Older Adults & Optimal Outcome

Individualizing Diabetes Management

Mary Moyer Janci BC-FNP BC-ADM CDETeaching Associate

Diabetes Care Center UWMC

What is Diabetes ?

• METABOLIC DISEASE

– Food breakdown (carbohydrates, proteins and fat)

– → fuel for the body ABNORMAL

2

3

GLUCOSE STIMULATEDINSULIN SECRETION

GLUCOSE UPTAKE BY MUSCLE & FAT

HEPATIC GLUCOSE

RESPONSE

NORMAL PLASMA GLUCOSE

Controlled glucose production.

Enters blood.

Controlled glucose clearance.

Enters peripheal tissue.

4

GLUCOSE STIMULATEDINSULIN SECRETION

GLUCOSE UPTAKE BY MUSCLE & FAT

Controlled glucose production.

Enters blood.

Controlled glucose clearance.

Enters peripheal tissue.

Diabetes Types

Type 1, 1.5, LADA

Type 2 Adult

Secondary Diabetes• Disease/injury to the pancreas

• - pancreatitis, pancreatectomy, CFRD

• Meds increased insulin resistance » STEROID INDUCED HYPERGLYCEMIA

T2DM Pathophysiology

• Peripheral insulin resistance in muscle and fat

• Decreased pancreatic insulin secretion

• Increased hepatic glucose output

– Risk fx: African Americans, Latinos, American Indians, Alaska Natives, Asian Americans, Pacific Islanders

–

• PEARL: oral agents or insulin

T1DMPathophysiology

• Decreased pancreatic insulin secretion

• Peripheral insulin resistance in muscle and fat

• Increased hepatic glucose output

• PEARL: only insulin

Haffner SM, et al. Diabetes Care, 1999

What makes older adults at risk for diabetes?

– Decreased beta cell function • with loss of first phase insulin shows up in post prandial blood glucose

– AND• Loss of muscle mass

• Decreased physical activity

• Increased adiposity

What factors affect quality of life?

• Changes in cognitive status

• Decrease ability to care for myself

• Increase in use of caregivers

• Decrease life expectancy

Huang et al. J AM Geriatr Soc 2005;53:306-311

How does glycemic control affect the body ?

Hypoglycemia Hyperglycemia

Increase in Hypoglycemia unawareness

Dehydration

Cognitive changes / confusion

Urinary incontinence

Need assistance to treat lows

Electrolytes

Falls & unsteady gait Dizziness/ falls

More admissions tohospital? Cardiac events

ACCORD, ADVANCE,

More admissions to hospital from HHS, infection

•

Recommendations for the Comprehensive Care of Older Patients With T2D:Consensus Panel Framework presented ADA conference 2012

Health Status Rationale

Reason-able

A1C Goal

Fasting or

Preprandia

l Glucose

(mg/dL)

Bedtime

Glucose

(mg/dL)

Blood

Pressure

(mm Hg) Lipids

Healthy Longer life expectancy <7.5% 90–130 90–150 <140/80

Statin (unless

contraindicated

or not tolerated)

Complex/

Intermediate

Health

Intermediate life

expectancy; high

treatment burden;

hypoglycemia

vulnerability; fall risk

<8.0% 90–150 100–180 <140/80

Statin (unless

contraindicated

or not tolerated)

Very Complex/

Poor Health

Limited life expectancy;

treatment benefit

uncertain<8.5% 100–180 110–200 <150/90

Consider

benefit

with statin;

(secondary

prevention >

primary)

13

Healthy: few coexisting chronic illnesses, intact cognitive and functional status.Complex/Intermediate Health: multiple coexisting chronic illnesses, or 2+ instrumental ADL impairments, or mild to moderate cognitive impairment.Very Complex/Poor Health: long-term care or end-stage chronic illnesses or moderate to severe cognitive impairment or 2+ activities of daily living dependencies.

Kirkman S et al. Diabetes Care. 2012;35(12):2650–2664.

What are we dealing with?1,2

Older adult stats:

• 65 years +

– 72.1 million 2030 ~ 19% population

• 85 years +

– 5.5 million 2007

– 6.6 million 2020

• Today ~ 26% adults > 65 years have diabetes

1. US Dept of Health Human Services, Admi on Aging. www.aoa.gov/aoaroot/aging_statistics/Profile2. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

What do most aging adults want?

–INDEPENDENCE For ADLsExploratory study T2DM 65+ n=2871% ranked Independence and ADLS as top priority

– What takes away independence?

• Polypharmacy “too many meds to manage” LEADS TO increased side effects

• Higher risk of hypoglycemia due to length of time with DM• Increased CVD • Decreased kidney function

Huang et al. J AM Geriatr Soc 2005;53:306-311

Treatment Goals

• Improving quality of life & quality of care

• Allowing choices in daily living

• Assisting individuals to make informed health decisions

ADA. Older adults. Sec. 10. In Standards of Medical Care in Diabetes-2016. Diabetes Care 2016.:39 (Suppl.1):S81-S85

Recommendations for the Comprehensive Care of Older Patients With T2D: Consensus Panel Framework

Health Status Rationale

Reason-

able A1C

Goal

Fasting or

Preprandial

Glucose

(mg/dL)

Bedtime

Glucose

(mg/dL)

Blood

Pressure

(mm Hg) Lipids

Healthy Longer life expectancy <7.5% 90–130 90–150 <140/80

Statin (unless

contraindicated or

not tolerated)

Complex/

Intermediate

Health

Intermediate life

expectancy; high

treatment burden;

hypoglycemia

vulnerability; fall risk

<8.0% 90–150 100–180 <140/80

Statin (unless

contraindicated or

not tolerated)

Very

Complex/

Poor Health

Limited life expectancy;

treatment benefit

uncertain

<8.5% 100–180 110–200 <150/90

Consider benefit

with statin;

(secondary

prevention >

primary)

17

Healthy: few coexisting chronic illnesses, intact cognitive and functional status.Complex/Intermediate Health: multiple coexisting chronic illnesses, or 2+ instrumental ADL impairments, or mild to moderate cognitive impairment.Very Complex/Poor Health: long-term care or end-stage chronic illnesses or moderate to severe cognitive impairment or 2+ activities of daily living dependencies.

Kirkman S et al. Diabetes Care. 2012;35(12):2650–2664.

Case Study- What to do?Use our tools

• Interview patient in decision-making.

– MMSE

• Individualize Patient Goals

– Adjust target A1C based on chronic conditions, lifespan, mental capability

• Prioritize targets: BP, Lipids, A1C

• Customize treatment plan: meds, diet, exercise, caregiving

Inzucchi S E et al. Dia Care 2012;35:1364-1379

2nd TOOL:RANKING

More or less

stringent glucose control?

A1c

3rd TOOL: Priorities

Physiologic Parameter

Time to see benefit of tx

Outcome

Blood glucose 8 years Reduced microvascular disease

Reduced CV dx

Lipids 2-3 years Reduced stroke and MI morbidity and mortality

Blood pressure 2-3 years Reduced stroke and MI morbidity and mortality

Kirkman S et al. Diabetes Care. 2012;35(12):2650–2664.

Physiologic Parameter

Length of time needed to see benefit of tx

Outcome Research

Blood glucose 8 years 1. ↓ microvascular disease, mortality & MIs

2. Neutral CVD, MI stroke ↑𝑚𝑜𝑟𝑡𝑎𝑙𝑖𝑡𝑦

3. Neutral CVD, ↓ kidney disease

4. Neutral CVD, ↓𝑎𝑙𝑏𝑢𝑚𝑖𝑛𝑢𝑟𝑖𝑎

1. UKPDS

2. ACCORD (stop 3 yrs)

3. ADVANCE

4. VADT

Lipids 2-3 years Reduced stroke

mortality

No large trials

Meta-analysis of smaller studies

Blood pressure 2-3 years 1. Reduced stroke

2. Reduced mortality

1. ACCORD-BP

2. VADT

A1c 8..2%

LDL 128

BP 138/64

Recommendations for the Comprehensive Care of Older Patients With T2D: Consensus Panel Framework

Health Status Rationale

Reason-

able A1C

Goal

Fasting or

Preprandial

Glucose

(mg/dL)

Bedtime

Glucose

(mg/dL)

Blood

Pressure

(mm Hg) Lipids

Healthy Longer life expectancy <7.5% 90–130 90–150 <140/80

Statin (unless

contraindicated or

not tolerated)

Complex/

Intermediate

Health

Intermediate life

expectancy; high

treatment burden;

hypoglycemia

vulnerability; fall risk

<8.0% 90–150 100–180 <140/80

Statin (unless

contraindicated or

not tolerated)

Very

Complex/

Poor Health

Limited life expectancy;

treatment benefit

uncertain

<8.5% 100–180 110–200 <150/90

Consider benefit

with statin;

(secondary

prevention >

primary)

21

Healthy: few coexisting chronic illnesses, intact cognitive and functional status.Complex/Intermediate Health: multiple coexisting chronic illnesses, or 2+ instrumental ADL impairments, or mild to moderate cognitive impairment.Very Complex/Poor Health: long-term care or end-stage chronic illnesses or moderate to severe cognitive impairment or 2+ activities of daily living dependencies.

Kirkman S et al. Diabetes Care. 2012;35(12):2650–2664.

4th TOOL: Use the Medication Chart

Diabetes Medication

Target Population

Benefits Risks Dose Adjustment for CKD Stage 3-5Dialysis

COST

Sulfonylureas- glipizide, glyburide, glimeperide

T2DM < 5 years

↑ insulin secretion↓ 𝑚𝑖𝑐𝑟𝑜𝑣𝑎𝑠𝑐𝑢𝑙𝑎𝑟

(UKPDS)

More hypos; weight gain

Glimeperide: decrease dose; 1 mg/day recommendedGlipizide: no decrease in doseGlyburide: avoidDIALYSIS- GLIPIZIDE ONLY

LOW

Meglitinides-repaglinide,netaglinide

Recent diagnosisT2DM,Elevated PPG

Short acting, lesshypoglycemiqFlexible dosing based on size of meal,

More hyposWeight gainFrequent dosing

Repaglinide: no decrease in doseNateglinide: start at low dose of 60 mgDIALYSIS- REPAGLINIDE ONLY

MOD-HI

Biguanides-metformin, glucophage

Overweight, obese, IR

No wt gain, less hypoglycemia

↓ 𝐶𝑉𝐷 𝑒𝑣𝑒𝑛𝑡𝑠𝑈𝐾𝑃𝐷𝑆

GI side effects, rare lactic acidosis

Contraindicated: males SCr > 1.5 mg/dl; females: SCr> 1.4 mg/dl

Consider s crt 1.7/egfr<30 dose reductionDIALYSIS- AVOID

LOW

TZDs- ***rosiglitazone, pioglitazone

Overweight, obese, IR

↑ 𝑖𝑛𝑠𝑢𝑙𝑖𝑛𝑠𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑖𝑡𝑦

No hypos↑ 𝐻𝐷𝐿

Weight gain/fluidretention, slow onset, Bone fx

No dose adjustment for either med

DIALYSIS OK

LOW

DPP-4 ***SitagliptinSaxagliptinVildaliptinAlogliptinLinigliptin

↑ 𝑖𝑛𝑠𝑢𝑙𝑖𝑛↓ 𝑔𝑙𝑢𝑐𝑎𝑔𝑜𝑛

No hypoglycemia

Angioedema, urticarial,? Pancreatitis?HF

↓ 25% GFR 30-50↓ 50% GFR < 30 DIALYSIS OK

HI

Diabetes Medication

Target Population

Action/ Benefits Risks Dose Adjustment for CKD Stage 3-5 Dialysis

COST

GLP-1 RA ***Exenatide/ ERLiraglutideAbiglutideLixsenatideDulaglutide

Overweight,obese

No hypoglycemiaWt loss

↓ 𝑃𝑃 𝑔𝑙𝑢𝑐𝑜𝑠𝑒↓ 𝑠𝑜𝑚𝑒 𝐶𝑉 𝑟𝑖𝑠𝑘 𝑓𝑥

GI side effectsInjectablePancreatitis?Change thyroid tumors in animals

Avoid eGFR <30 HI

Alpha-glucosidase inhibitor-acarbose,miglitol

No hypoglycemia↓ 𝑃𝑃 𝑔𝑙𝑢𝑐𝑜𝑠𝑒 Elevated post meal glucoseSlow intestinal carbdigest/absorp

GI side effects, low impact of A1c Avoid SCr > 2 mg/Dl

DIALYSIS AVOID

MOD

SGLT2 inhibitors ***CanagliflozinDapagliflozinEmpagliflozin

Block glucosereabsorption

↑ 𝑔𝑙𝑦𝑐𝑜𝑠𝑢𝑟𝑖𝑎No hypos

↓ 𝑤𝑡↓ 𝐵𝑃

No hypos

Euglycemic DKA

GU infectionsPolyuriaHypotension/volume depletionDizziness

Adjust dose in egfr <59 Avoid in egfr < 30

HI

New Insulins HyposInjectable needs training

Adjust dose by 25-50% in patients with decreased kidney function

HI

Insulin & Older Adults

• US Public Health survelliance data of people ≥ 65 𝑦𝑒𝑎𝑟𝑠

– Insulin was one of top meds ADRs → ER visits

– 40% of these pts were hospitalized

– What do we learn?• careful selection of patients, training for insuln and smbg, regular follow up

– Budnitz et al. N Engl J Med. 2011:365:2002-2012

Case Study- Lifestyle Changes and Education

• Lifestyle changes– Exercise– Nutrition Education 1:1

• Blood Glucose Monitoring– Testing daily in the fasting state– 2 hour post meal testing after the largest meal

• Diabetes Core Classes– 10 hour program focusing on diabetes, meds, nutrition– ADA certified– Individualized Training. Bring a family member or caregiver.

Nutrition

• Older adults at risk for poor nutrition & weight loss– Causes: loss of smell, taste, hormonal changes that control satiety

• American Dietetics Association– Refer to RD for individualized care plan

– Involve patient, family, team members in choices

– Base on patient’s condition & life span

– Some changes may include:• Less restrictive diet

• More carbohydrate beverages

Position of the ADA Assoc; Ethical and legal issues in nutrition, hydration, and feeding.J Am Diet Assoc. 2008; 108:873-882

Research to support lifestyle changes

• DPP & Look AHEAD1

– Found wt loss & physical activity ↓ glucose – older adults had > wt loss & more physical activity than younger pts and not

associated with intensity of exercise. – So bottom line: don’t have to run a marathon or be on ‘Biggest Loser’ TV show

• Exercise & healthy eating for planned weight loss2

– Increases muscle mass– Improves functional status– Improves depression– ? decrease urinary incontinence– ? improve CV risk factors1. Espelnad et all. JAGS: 61:912-922, 2013. 2. American Heart Asso. 2014 . http://www.heart.org

Update Case Study 5 years later 87 yo

• Patient returns to clinic with A1c 9%.

– CABG with 2 vessel bypass, HTN, Hyperlipidemia, developing cognitive impairment

– Now living in ALF

• TREATMENT PLAN: changing the meaning of optimal ? Options?• Decreased risk of hypos with meds; changed target to A1c <8.5%• Added basal insulin in AM & stopped DPP4 due to $$$- ??? Now low dose TZD or NPH?• Continue metformin?• Add sulfonylurea?

Palliative Care Proposed Recs

Goals: comfort, symptom control, prevention of pain, hyperglycemia/hypoglycemia, dehydration; preservication of diginity and quality of life (1)

Patient has the right to refuse testing & treatment

Stable patient: focus on preventing hi/lo bgs (2)

Organ failure patient: focus on preventing bg lows; (2)tx highs with hydration as tolerated. T1DM require insulin but may simplify.T2DM my titrate off insulin.

• 1. J Am Med ir Assoc 2012, 13:497-502• 2. J Palliat Med 2011; 14:83-87

Summary

REMEMBER INDIVIDUALIZE DIABETES GOALS IN OLDER ADULTS

– USE TOOLS• Interview for patient priorities• Set medical priorities

– Lipids, BP, A1c• Set target A1c / bg control by using ranking scales• Use diabetes med chart • Add lifestyle changes• Re-evaluate routinely• Re-adjust diabetes goals based on patient / family priorities,

physical and mental condition, lifespan