Diabetes Dan Usia Lanjut

8/11/2019 Diabetes Dan Usia Lanjut

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Diabetes dan usialanjut


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Sasaran Belajar

Describe an approach to the clinical care of diabetes and

comorbid conditions in older adults

Assess the special needs of diabetes management in

the elderly

Indicate the drug selection criteria for older adults with

diabetes


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1972 2010 2020

5.3 million

(4.48% of the total

population)

23.99 million

(9.9% of the total

population)

28.82 million

(11.34% of the total

population)

1. Indonesian Ministry of Social Affairs. 2002.

2. ADA. Complete Nurses Guide to Diabetes Care. Second Edition. 2009.

Age is a risk factor for developing diabetes2

Undiagnosed and untreated diabetes is more commonin the elderly than in any other age group2

Trend in Older Population in Indonesia

(Age 60+)1


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0

2

4

6

8

10

12

14

15 - 24 th 25 - 34 th 35 - 44 th 45 - 54 th 55 - 64 th 65 - 74 th 75 keatas

0,6%1.8

5

10.5

13.514

12.5

PREVALENSI DM PERKOTAAN BERDASARKAN KELOMPOK UMUR

(RISKESDAS 2007)

4,9%

6,4%

PREVALENSI DM PERKOTAAN BERDASARKAN JENIS

KELAMIN (RISKESDAS 2007)

Laki-laki

Perempua

n

DM PREVALENCE BY AGE GROUP

DM PREVALENCE BY GENDER

Men

Women


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Older Adults with Diabetes: Risks

Higher rates of premature death, functional disability,

coexisting illness (e.g. hypertension, CHD, stroke)

Greater risk for polypharmacy, depression, cognitiveimpairment, urinary incontinence, injurious fall, and

persistent pain

Standards of Medical Care in Diabetes. Diabetes Care2012;35(suppl 1) Jan 2012.


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Diagnosis: Long-term vs. recent, substantial vs. no

complications, with range of physical and cognitive

functioning

Can have significant functional impairment or be very

active with no complications

Life expectancies variable but often longer than

clinicians realize

Older Adults with Diabetes:

Not All the Same



7/39CDC. Available at: http://www.cdc.gov/diabetes/statistics/dmany/fig4.htm.

0-44 years

45-64 years

65-74 years

75+ years

500

600

700

800

900

1000

0

100

200

300

400

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03

Year

Rate(per

1000Diabetic

Population)

Risk of Hospitalization Among People

with Diabetes Increases with Age


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Most elderly patients with diabetes have T2DM

Pathogenesis of T2DM in older patients is similar to

other age groups

Pathophysiology and Rationale for

Treatment

ADA. Therapy for Diabetes Mellitus and Related Disorders. 5thEdition. 2009.


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Coexisting

illness

Age-related

decreased

insulin secretion

Age-related

insulin

resistance

Adiposity

Decreased physical

activity

Genetics

Drugs

Factors

predisposing

the elderly to

diabetes

Factors Predisposing Older Adults to the Development of Diabetes



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Approach to Therapy

Goal: Prevent metabolic decompensation + control risk

factors for CVD

Control hypertension, lipid disorders, smoking

Treat severe hyperglycemia To control fatty acid mobilization and oxidation, protein

catabolism/muscle wasting, excessive glucose production,

urinary loss of calories in the form of glucose



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Considerations

Patients life expectancy

Patient commitment

Availability of support services

Economic issues Coexisting health problems

Complexity of medical regimen

ADA. Therapy for Diabetes Mellitus and Related Disorders. 5thEdition.

2009ADA. Therapy for Diabetes Mellitus and Related Disorders. 5thEdition. 2009.


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Healthy adult with reasonable life expectancy:

FG 100-130 mg/dl

PG


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Nutrition Therapy

Weight reduction = better control of hyperglycemia

Barriers: Lifelong dietary habits; changes in taste, smell,

vision; neurological or muscular disorders; chewing and

swallowing difficulties; cost

Poor eating habits due to cost and difficulty shopping are

common



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Nutrition Therapy

Goal of MNT: Meet nutritional needs; keep blood

glucose, blood pressure, blood lipids as close to normal

as possible

Dietician can be helpful to set up and maintain

appropriate diet

MNT= medical nutrition therapy

ADA. Complete Nurses Guide to Diabetes Care. 2ndEdition. 2009.


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Exercise in Older Diabetic Patients

Exercise is beneficial in all ages

Recommend: Exercise tolerance test, supervision,

proper footwear

Important to minimize risk of hypoglycemia

ADA. Therapy for Diabetes Mellitus and Related

Disorders. 5thEdition. 2009



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Exercise in Older Diabetic Patients

Intensity must match patients physical fitness level

Stationary bike

Walking

Water aerobics

Exercise videos Armchair fitness

ADA. Complete Nurses Guide to Diabetes Care.

Second Edition.2009

ADA. Complete Nurses Guide to Diabetes Care. 2ndEdition. 2009.


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Physiologic Changes in the Elderly

Neurological

Ophthalmologic

Body composition

Gastrointestinal

Hepatic

Renal

Endocrine

ADA. Complete Nurses Guide to Diabetes Care.

Second Edition.2009

ADA. Complete NursesGuide to Diabetes Care. 2ndEdition. 2009.


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Hypoglycemic Drugs Other than Insulin

Start with small dose and increase slowly

Combination therapy: Limited evidence in older patients;

weigh benefits versus risks and adherence problems



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Oral drugs can cause hypoglycemia

Renal and hepatic insufficiency risk factors for severe

hypoglycemia

If hypoglycemia occurs, observation required, especially

with long-acting agents



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Sulfonylureas: Risk for hypoglycemia low if nutrition isgood and no major renal and hepatic insufficiency

Avoid chlorpropamide and glyburide because of

hypoglycemia risk



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Approach to Therapy

Metformin contraindicated with renal insufficiency orsignificant heart failure

TZDs can cause fluid retention (contraindicated in CHF)

Sulfonylureas, other insulin secretagogues, and insulincan cause hypoglycemia


CHF= congestive heart failure


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Insulin

Consider insulin when goals not met by weight reduction,exercise, or other glucose-lowering drugs

Simple insulin regimen preferred

No contraindications to use



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Insulin

Insulin use requires good visual, motor, and cognitiveskills

Can the patient administer insulin?

If not, can caregiver administer?

Insulin pen?

Patient and/or caregiver must be trained in self-

monitoring of BG



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Impaired autonomic nervous system function

Impaired counter-regulatory responses

Poor nutrition

Cognitive disorder

Use of alcohol or sedating agent

Polypharmacy

Kidney or liver failure

ADA. Therapy for Diabetes Mellitus and Related Disorders. 5thEdition.

2009ADA. Therapy for Diabetes Mellitus and Related Disorders. 5thEdition. 2009.

Potential Risk Factors for Hypoglycemia

in Older Patients


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After age 60, patient visits often decrease because thereis no one to take the patient to the doctor

More homecare services by primary care doctors are

needed to address this gap in care:

Determine goals of therapy

Monitor glucose control

Special Issues: Access to Care


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Older adults who are functional, cognitively intact and/or

with significant life expectancies should receive diabetes

care using goals developed for younger adults

Glycemic goals for those not meeting the above criteria

may be relaxed, but avoid hyperglycemia leading to

symptoms or risk of acute hyperglycemic complications

Recommendations: Older Adults



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Greater reductions in morbidity and mortality may result

from the control of CVD risk factors rather than tight

glycemic controls alone

Evidence supports treatment of hypertension; less

evidence for lipid-lowering and aspirin therapy

Individualize screening for diabetes complications with

attention to those leading to functional impairment (e.g.

visual, lower extremity complications)

Recommendations: Older Adults



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A schedule of blood glucose self-monitoring should beconsidered, depending on:

Functional and cognitive abilities

Goals of care

Target A1C levels Potential for modifying therapy

Risk of hypoglycemia

California Healthcare Foundation/American Geriatrics Society Panel on ImprovingCare for Elders with Diabetes. J Am Geriatr Soc2003;51:S265-S280.

Blood Glucose Monitoring in the Older

Adult with Diabetes

Bl d Gl M i i i h Old


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The measurement of A1C may not be accurate in

older adults due to:

anemia and other conditions that impact red blood cell

lifespan

chronic kidney disease

recent transfusions and erythropoietin infusions

recent acute illness or hospitalizations chronic liver diseases

Blood Glucose Monitoring in the Older

Adult with Diabetes

http://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-elderly-patient


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Integrated geriatric services in hospitals and communityhealth services (PUSKESMAS)

Home-based care centres & Centre for Family

Assistance (PUSAKA)

National Plan of Action for Elderly Welfare

Health of the Elderly in South-East Asia. WHO2004

Programs for the Elderly in Indonesia

Health of the Elderly in South-East Asia. WHO 2004.

St t i f I i Adh i


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Verify comprehension:

E.g.: Tell me your understanding of how and when to take your

medications.

Clarify treatment benefits:

E.g.: When people take their insulin, they notice that their

blood glucose control improves, and they have more energy.Do you notice that?

Strategies for Improving Adherence in

the Older Patient

Rubin RR.Am J Med2005;118 Suppl 5A:27S-34S.


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Goals of diabetes care in the elderly:

Control of hyperglycemia

Prevention and treatment of macro- and microvascular complications

Self-management through education

Maintenance or improvement of general health status

.

Summary


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Case Study 1

Patient profile:

82-year-old woman with mild dementia

To be cared at home after brief stay in hospital for

pneumonia

Medical history:

CAD (MI 5 years ago), CHF, COPD, HTN, T2DM


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Case Study 1 (contd)

Physical exam BP: 130/84; Weight 105 lbs

Medications

Lisinopril 10 mg/day

Simvastatin 40 mg/day

Fluticasone/salmeterol inhaler bid

Insulin:

Glargine 15 units/day

Lispro 3 units before each meal


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Case Study 1: Discussion

What is your A1C goal for this patient?

What are your recommendations for her insulin regimen?


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Case Study 1: Follow-up

A month later, the nurses tell you the patient is

belligerent and tries to avoid receiving her insulin or

checking her BG

BG monitoring results are 140-190 fasting and 160-220

postprandial

What are you recommendations for the continued

management of this patient?


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Case Study 2

70-year-old male with history of T2DM

HTN, hyperlipidemia

Routine physical exam:

Alert and interactive

BP 136/84; pulse 72;

Height 155 cm (5 1); Weight 66 kg (145 lbs); BMI 27.5

Labs: A1C=7.8%; Cr: 1.1

Medications:

Metformin 500 mg bid; Glipizide 10 mg qd


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Case Study 2: Discussion

What is your A1C target for this patient?

What is your glycemic management plan for this patient?

Would you make any changes to his current

medications?

Documents

Diabetes Dan Usia Lanjut