type 2 diabetes & the older adult in older adults.pdf6. ada. older adults: standards of medical...
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Type 2 Diabetes & The Older
Adult
Denise Soltow Hershey PhD, FNP-BCAssociate Professor
College of Nursing, Michigan State University
Objectives Identify risk factors that can lead to hypoglycemia
Develop and understanding of the diagnostic criteria and glycemic targets for older adults
Gain knowledge regarding medication management, including deintensification, simplification and deprescribing in older adults
Gain knowledge regarding management of diabetes at end of life.
Background
Diabetes is defined as:
FPG ≥ 126 mg/dl or A1c ≥ 6.5
Diabetes classified as either Type 1 (T1D) or Type 2 (T2D)
T1D – more likely to occur in younger adults
T2D occurs in 9% of adults
T2D occurs in 20 % of adults 65 y/o or older; accounts for 90 –95% of all diabetes cases in older adults.
Aging and T2D increases risk for:
Functional decline and disability
Development of frailty & muscle loss
Falls
Lower quality of life
Untreated T2D leads to the development of micro and macro vascular complications
Risk factors Genetic• Family history
• parent or sibling• Race
• Black, Hispanic/Latino, American Indian, Alaska Native and Asian-American, Native Hawaiian or Pacific Islander
Lifestyle• Inactivity• Diet
Comorbidities• Overweight or Obese
• Fat distribution• High Blood Pressure• Low HDL or high Triglycerides• History of heart Disease or stroke• Depression• Polycystic Ovary Syndrome
Aging• Decrease in exercise – loss of muscle mass - weight gain with age
Pathophysiology
Presentation in older adults
Different than younger adults
Older adults more likely to present with
Dehydration
Confusion
Incontinence
Diabetes complications
Neuropathy
Nephropathy
ADA Diagnostic Criteria for Prediabetes and Diabetes
Diagnostic Test
Pre-diabetes
Diabetes
OGTT 2-hour post
140 – 199 mg/dl
≥ 200mg/dl
Fasting Plasma Glucose
100 - 125 mg/dl
≥ 126 mg/dl
A1c 5.7 – 6.4 % ≥ 6.5%
Treatment Goals
ADA Framework for considering treatment goals for glycemia, blood pressure and dyslipidemia in older adults with diabetes ( 2019)
Patient Characteristics/Health Status
Rationale A1c Goal
Blood pressure Lipids
Healthy (few coexisting chronic conditions, intact cognitive and functional status)
Longer remaining life expectancy
< 7.5% <140/90 mmHg Statin unless contraindicated or not tolerated
Complex/Intermediate (multiple coexisting comorbidities or 2+ instrumental ADL Impairments, or mild to moderate cognitive impairment)
Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability, fall risk
<8.0% < 140/90 mmHg Statin unless contraindicated or not tolerated
Very complex/poor health (LTC or end-stage chronic illnesses, or moderate to severe cognitive impairment or 2+ ADL dependencies)
Limited remaining life expectancy makes benefit uncertain
<8.5% <150/90 mmHg Consider likelihood of benefit with statin
Management Considerations
Individualization is essential
• functional status, • risk for hypoglycemia• prevention of hospital admissions • Maintenance and/or improvement of functional
status
Goals based on:
• Hypertension• Hyperlipidemia• Obesity
Prevention of management of comorbidities
Prevention of Hypoglycemia
Hypoglycemia Increases risk for
Heart Failure
Dementia
Myocardial infarction
Stroke
Falls
Fractures
Death
Risk Factors for Hypoglycemia
Medications used in the treatment of T2D
Psychosocial factorsLiving aloneReduced food intake Depression
Cognitive issues memory loss and dementia
Sensory changes Hearing loss Visual impairmentDiminished taste
Motor changesDecreased dexterityReduced physical activityImpaired mobility
Comorbidities
Decreased Renal and hepatic function
Overall decreased awareness of symptoms associated with hypoglycemia
Medication selection
Metformin 1st line for those without contraindication
Selection of 2nd agent and insulin is dependent upon
patient’s health status and risk for hypoglycemia
Not uncommon for older adults to be on 2 – 3 agents.
If on sulfonylurea when insulin is introduced – sulfonylurea
needs to be tapered and discontinued.
BiguanidesMetformin
Usual dose is 850 – 1000mg Bid po
1 – 2 % A1c reduction
GI effects are common – can be dose related
Considerations in older adults:• Recommended initial therapy• Low risk for hypoglycemia• Reduce cardiovascular events and mortality• Do not use if eGFR< 30.• Avoid in patients with decompensated HF
SulfonylureasGlyburide, Glipizide, Glimepiride
PO daily med, dose dependent on specific agent
1 – 2% A1c reduction
Adverse events• Risk for hypoglycemia,• weight gain • increased risk of CV mortality
Use with caution• Glyburide is not recommended in older adults• Glipizide and Glimepiride needs to be used very cautiously
Thiazolidinediones Pioglitazone & Rosiglitazone
Daily, oral
Dose dependent on agent
1 – 2% reduction in A1C
Adverse effects:• Fluid retention• Weight gain• Fracture risk• Bladder cancer (pioglitazone)• Increased LDL (rosiglitazone)• Increased risk for MI ( rosiglitazone)
Considerations in older adults• Do no use in patients with renal impairment• Use cautiously in hepatic insufficiency, HF and CAD• Avoid in patients who are a fall risk or at high risk for fractures
Α-Glucosidase inhibitors
Arcarbose
50 – 100mg TID po
A1c reduction 0.4% - 0.9%
Side effects:• Flatulence• Diarrhea• Abdominal pain
Considerations for older adults:• CV events decreased in patients with impaired
glucose tolerance• Do not use in patients with comorbid liver or
bowel disease or if serum creatine > 2 mg/dl
Melitnides Repaglinide, Nateglinide
Dose dependent on regimen, administered TID orally
0.4% - 0.9% A1c reduction
Adverse events:• Weight gain• Peripheral edema• Hepatotoxicity• GI disturbances• Risk of hypoglycemia
Considerations for Older Adults• CV events decreased in patients with impaired glucose
tolerance• Do no use in patients with comorbid liver or bowel disease or if
serum creatinine > 2 mg/dl
Amylin mimetics
Pramlintide
120 μg before meals, sub-q
Adverse Events:• N/V• Risk hypoglycemia when used with insulin
Considerations for older adults• Should not be used in patients with an A1c >
9%• Avoid use in patients with decreased
hypoglycemia awareness• Avoid in patients with history of poor
adherence
GLP-1 receptor agonist
Exenatide, Liraglutide, Lixisenatide
Dose dependent on modality, sub-q
A1c reduction 1 – 1.5%
• Weight loss• N/V/D• Risk for acute pancreatitis• Injection site reactions• Increased risk of hypoglycemia when taking sulfonylureas
Adverse events:
• Increased risk of side effects in patients with renal insufficiency• Exenatide not indicated with eGFR < 30• Caution when using lixisenatide• Liraglutide may provide some CV benefits• Good motor skills and visual acuity needed due to being an
injectable
Considerations in older adults
DPP-4 inhibitors Sitagliptin, Saxagliptin, Linagliptin, Alogliptin,
Dose dependent on regimen, Oral daily
A1c reduction: 0.5 - 0.8%
Adverse effects:• Join pain• Skin lesions• Potentials risk of acute pancreatitis
Considerations for use in older adults• Can be used in renal impairment• Renal dose adjustment required for linagliptin
SGLT2 inhibitors
Dapglifozin, Canagliflozin, Empaglifozin
Dose dependent on modality, daily, po
A1c reduction .5% - .7%
• Weight loss• Blood pressure lowering• Vulvovaginal candidiasis• Urinary tract infection• Risk of euglycemic diabetic ketoacidosis• Risk of amputation and fractures with canagliflozin• Increased LDL cholesterol
Adverse effects:
• May lead to abnormalities in renal function• Avoid in older patients with preexisting renal impairment• Avoid when eGFR <60
Considerations for older adults
Insulin Novolog, Humalog
Individualized, sub-q
A1c reduction – no limit
Adverse events• Hypoglycemia• Weight gain
Considerations for use in older adults• Dosing errors can occur with functional and
cognitive changes in older adults• Can challenge self-management capacity• Lower dose may be required in patients with
lower eGFR
Management of Comorbidities
•Minimizes both macrovascular and microvascular complications
Effective diabetes management also
includes management of lipids and blood pressure
•Important in order to decrease risk of frailty and functional status
Nutritional status assessment
•90% of T2D patients are obese•Weight loss in fit older patients can be beneficialObesity –
•Target systolic of 140 or less should be goal•Systolic less than 130 has shown few benefits, increases risk of falls, cognitive decline and frailty.
•Frail individuals BP target should be 145 –160/90
HTN
•Managed until the age of 80, some studies show benefit until age 85
•Statins are recommended class of medications•Statins should be stopped in older adults with severe morbidity and/or limited life expectancy
•Fibrates can be used in healthy adults, no recommended in frail older adults
Hyperlipidemia
Inappropriate Polypharmacy
T2D puts older adults at risk for inappropriate polypharmacy
The use of multi antidiabetic meds and medications for other comorbidities increases risk
Need to consider if intensifying treatment is necessary
Questions to be asked:
Can other medications be reduced or eliminated as new medications are added?
What adverse effects need to be considered? (hypoglycemia, weight gain etc)
Will some of these effects be increased by the addition of new medication?
What are the patient preferences?
What is the patients and care givers capacity? Are they capable to follow the plan and monitor for side effects?
May need to consider either simplification and/or deintensification of regimen.
Deintensification – Deprescribing
Patient health status Simplification Deintensification/deprescribing
Healthy (few comorbidities, functional & cognitive status intact)
• Severe or recurrent hypoglycemia (if on insulin)
• Wide glucose excursions• Decline in cognitive or functional
status
• Severe or recurrent hypoglycemia on non-insulin therapy
• Wide glucose excursions• Inappropriate polypharmacy is
present
Complex/Intermediate(multiple comorbidities, 2+ instrumental ADL impairment or mild to moderate cognitive impairment)
• Severe or recurrent hypoglycemia (if on insulin)
• Unable to manage complexity of insulin regimen
• Significant change in social circumstances (loss of caregiver, financial difficulties, change in living situation)
• Severe or recurrent hypoglycemia on non-insulin therapy
• Wide glucose excursions• Inappropriate polypharmacy is
present
Community-dwelling(receiving care in a skilled nursing facility for short-term (ST) rehab)
• If treatment regimen was escalated during recent hospitalization, the reinstating of prehospital regimen is appropriate during rehab
• If hospitalization resulted in weight loss, anorexia, ST cognitive decline and/or loss of physical functioning
Very complex/poor health(long-term (LT) care, end stage chronic disease, moderate to severe cognitive impairment or 2 + ADL dependencies)
• On Insulin and patient desires to decrease number of injections and finger sticks
• inconsistent eating pattern
• On hypoglycemic agents with high risk of hypoglycemic events
• Taking medications without clear benefit
EOL • Pain or discomfort caused by treatment
• Excessive caregiver stress due to treatment complexity
• Taking medications that do not have any clear benefit of improving symptoms &/or comfort
ADA 2019 recommendations for deintensification and simplification of treatment regimens in older adults with T2D
Management at End of Life
Goal
Decreasing symptomsImprove comfort
Prevention of hypoglycemic and hyperosmolar hyperglycemic events
(polydipsia and polyuria)
Discussions regarding diabetes
Focus on frequency of glucose testingContinuation or stoppage of medications
Monitoring of glycemic control
EOL Management Changes
Weeks to monthsMaintain glucose levels between 180
and 360 mg/dlTarget levels based on patient’s
preferences and risk for development of hyperosmolar hyperglycemic
eventsRequirements for self blood glucose
monitoring reduced from daily to every 3 days
A1c’s no longer requiredMedications may need to be adjusted based on patients' symptoms and risk
for hyperosmolar events
Days to liveMain goal prevention of hypoglycemia
Oral medications can be stoppedGlucose monitoring only when
patients are exhibiting symptoms of hypo or hyperglycemia
Short acting insulin is appropriate in patients who are conscious and
experiencing hyperglycemic events.
Conclusions: Implications for Practice
Management plans take into consideration:
Patients functional and cognitive status Mutual preferences and values
Are collaboratively developed and include shared decision making and mutual goal
setting
Goals need to consider
Current functional statusPrevention of hypoglycemia
Prevention of unnecessary hospital admissions
Focus on improving functional healthReduction of disability
Adjusted as patient moves across the aging trajectory
Questions
References
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