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Diabetes in Elderly Adults

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Diabetes in Elderly Adults Frail older adult patients may have poor outcomes from even mild hypoglycemia. For example, injurious falls can lead to unintended ... – PowerPoint PPT presentation

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Title: Diabetes in Elderly Adults


1
Diabetes in Elderly Adults
2
Diabetes in Elderly Adults
  • By the age of 75, approximately 20 of the
    population are afflicted with this illness..

3
  • obese older patients have resistance to
    insulin-mediated glucose disposal .

4
  • delayed gastric emptying or gastroparesis is
    frequently reported for older adults with
    diabetes.

5
  • Lean older patients with type 2 diabetes had a
    marked impairment in glucose-reduced insulin
    secretion . It has recently been suggested that
    thin elderly diabetics have a syndrome
    intermediate between type 1 and 2 diabetes, which
    might properly be thought of as type 1 1/2
    diabetes.

6
  • 50 older persons with diabetes are unaware they
    have the illness, suggesting that symptoms of
    hyperglycemia are rarely present in this patient
    population.

7
  • This may be because the renal threshold for
    glucose increases with age, so that no sugar is
    spilled into the urine until the glucose level is
    markedly elevated. In addition, because thirst is
    impaired with normal aging, polydipsia is
    unlikely in elderly patients with diabetes, even
    if they are hyperosmolar as a result of marked
    hyperglycemia.

8
  • Often, diabetes presents for the first time in an
    elderly person who is hospitalized with a
    complication that may be related to diabetes,
    such as a myocardial infarction or a stroke. In
    frail elderly nursing home patients, nonketotic
    hyperosmolar coma may be the first sign of
    diabetes.

9
  • The goals of DM care in older adults, as in
    younger persons,
  • include control of hyperglycemia and its
    symptoms prevention, evaluation, and treatment
    of macrovascular and microvascular complications
    of DM DM self-management through education and
    maintenance or improvement of general health
    status.

10
  • Chronically ill, institutionalized patients
    with a short life expectancy do not require
    aggressive glucose control, but do require
    adequate control to facilitate healing and
    prevent
  • o Dehydration
  • o Symptoms of hyperglycemia or hypoglycemia
  • o Weight loss

11
Polypharmacy
  • Older adults with DM are at risk for drug side
    effects and drug-drug and drug-disease
    interactions. Polypharmacy is a major problem for
    older adults with DM, who may require several
    medications to manage glycemia, hyperlipidemia,
    hypertension, and other associated conditions.

12
  • Older adults tend to have less muscle than
    younger people and generally have a higher
    percentage of body fat. The elderly are generally
    less hydrated than younger individuals and thus
    tend to have less total body water .Blood flow to
    organs such as the kidneys and liver is
    diminished with age, which can lead to decreased
    metabolism and elimination of many drugs.

13
Polypharmacy
  • Clinicians should perform a careful review of
    each medication currently being used by the
    patient during the initial visit and at each
    subsequent visit and document whether the patient
    is taking each medication properly.

14
Urinary Incontinence
  • The older adult who has DM should be evaluated
    for symptoms of urinary incontinence during
    annual screening.

women with DM are at higher risk than the general
population for urinary incontinence.
15
  • The risk factors for urinary incontinence that
    are more common in older adults with DM include
    polyuria, overflow secondary to neurogenic
    bladder and autonomic insufficiency, urinary
    tract infection, candida vaginitis, and fecal
    impaction due to autonomic insufficiency. Urinary
    incontinence is commonly unreported by patients
    and undetected by providers.

16
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17
Glycemic Control
  • For older persons, target hemoglobin A1c (A1C)
    should be individualized. A reasonable goal for
    A1C in relatively healthy adults with good
    functional status is 7 or lower. For frail older
    adults, persons with life expectancy of less than
    5 years, and others in whom the risks of
    intensive glycemic control appear to outweigh the
    benefits, a less stringent target such as 8 is
    appropriate.

18
  • Chronically ill, institutionalized patients
    with a short life expectancy do not require
    aggressive glucose control, but do require
    adequate control to facilitate healing and
    prevent
  • o Dehydration
  • o Symptoms of hyperglycemia or hypoglycemia
  • o Weight loss

19
Monitoring
  • For the older adult with DM, a schedule for
    self-monitoring of blood glucose should be
    considered, depending on the individual's
    functional and cognitive abilities. The schedule
    should be based on the goals of care, target A1C
    levels, the potential for modifying therapy, and
    the individual's risk for hypoglycemia.

20
.Some older adults may not be able to perform
SMBG due to physical or cognitive impairment. In
such situations, the glycemic goals may need to
be adjusted to keep blood glucose levels higher,
and the regimen should be simplified to avoid
hypoglycemia for those at risk.
21
  • Start low and go slow with all medications
  • Consider drug-drug interactions carefully as
    most older adult patients are on multiple drugs
    as well as supplements.

22
  • Do not assume that because the creatinine is
    normal that kidney function is normal, since an
    older adult with decreased muscle mass can have
    normal creatinine levels with significant renal
    dysfunction as seen by low glomerular filtration
    rate (GFR).
  • Monitor liver and kidney function tests
    periodically even though diabetes medications,
    alone or in combination, are safe in older adult
    patients when selected carefully.

23
  • In general, a creatinine clearance estimated at lt
    60 ml/min warrants dose adjustments of most
    renally cleared medications. In an older woman
    (68 years) weighing 60 Kg with a serum creatinine
    of 1.0, this would translate to an estimated
    creatinine clearance of 51 ml/min, just under
    this threshold.

24
Medications
  • Sulfonylureas

o Use with caution in older adult patients
because of the risk of hypoglycemia. o Avoid
agents like chlorpropamide and glyburide because
of their prolonged length of action. o Shorter
acting agents like glipizide, or the
non-sulfonylurea insulin secretagogues
repaglinide and nateglinide, can be useful to
avoid nocturnal hypoglycemia, or to avoid
hypoglycemia in patients with erratic oral
intake.
25
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26
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27
Metformin
  • o Use with caution in the older adult with
    diabetes because of an increased risk of lactic
    acidosis in patients with impaired renal
    function.
  • o Measure serum creatinine and liver function
    tests (LFTs) periodically in the older individual
    who receives metformin, and with any increase in
    dose.
  • o Measure creatinine clearance with a timed urine
    collection at least annually and with increases
    in dosage of metformin in frail older adults, or
    those with decreased muscle mass.
  • o Avoid initiating in patients 80 years of age
    unless creatinine clearance is within normal
    limits.
  • .

28
Thiazolidinediones (TZDs
  • o TZDs are well tolerated by older adults as they
    do not cause hypoglycemia. Side effects of fluid
    retention and leg edema can be limiting factors
    in using this class of medications in the older
    adult.
  • o TZDs should be avoided in patients with Class
    III and Class IV congestive heart failure.

29
  • Alpha-Glucosidase Inhibitors
  • o Alpha-glucosidase inhibitors are less effective
    than other agents and may cause gastrointestinal
    side effects.

30
Insulin
  • Elderly subjects often make errors when trying to
    mix insulin on their own. The accuracy of insulin
    injections has been shown to be improved in older
    patients when they are treated with premixed
    insulin.

31
  • In these situations, it is beneficial to use
    simpler insulin regimens with fewer daily
    injections, such as pre-mixed insulin
    preparations, pre-measured doses, and easier
    injection systems (e.g., insulin pens with easy
    to set dosages).

32
  • Recommend equipment that is easy to hold, easy
    to read and requires the least amount of steps.
    Insulin pens and pre-filled syringes may be
    easier for older patients to use than a syringe.
    Syringe magnifiers are available if vision is a
    problem.

33
Hypoglycemia
  • Older adult patients commonly exhibit
    neuroglycopenic manifestations of hypoglycemia
    that include confusion,
  • delirium, dizziness, weakness or falls as
    compared to adrenergic symptoms. It is important
    that older adult patients and their caregivers
    recognize these symptoms as hypoglycemia and
    treat appropriately.

34
  • Frail older adult patients may have poor
    outcomes from even mild hypoglycemia. For
    example, injurious falls can lead to unintended
    consequences such as institutionalization. In
    addition, hypoglycemia can exacerbate existing
    conditions (e.g., coronary artery disease or
    cerebrovascular disease).

35
  • The older adult with DM who is on an ACE
    inhibitor or ARB should have renal function and
    serum potassium levels monitored within 1 to 2
    weeks of initiation of therapy, with each dose
    increase, and at least yearly.

36
  • The older adult with DM who is prescribed a
    thiazide or loop diuretic should have
    electrolytes checked within 1 to 2 weeks of
    initiation of therapy or of an increase in dosage
    and at least yearly.

37
Management of Hyperlipidemia
  • The targets of therapy, interval of lipid
    profile screening, and choice of medications for
    treatment of hyperlipidemia in older adult
    patients with diabetes are the same as those in
    younger adults.
  • When an individual does not have evidence of
    CVD and has a life expectancy that is determined
    by the provider to be three years or less,
    relaxation of the goals of therapy may be made.

38
Eye and Foot Care
  • Recommendations for eye and foot examinations
    and treatment in older adults with diabetes are
    the same as those for younger individuals. Older
    adults may require additional education and
    devices such as mirrors to examine their feet due
    to decreased mobility and dexterity.

39
Nutrition
  • The current trend is to distribute the
    patients carbohydrate intake as evenly as
    possible throughout the day. Education regarding
    the importance of consistency in carbohydrate
    intake and the timing of meals can help avoid
    large fluctuations in blood glucose levels.

40
  • Every effort should be made to minimize the
    complexity of meal planning and to engage the
    spouse, or others living with the patient, in
    creating a home environment that supports
    positive lifestyle change.
  • In chronic care settings, there is no need for
    a rigid and restrictive meal plan. A regular diet
    with consistent, moderate carbohydrate intake may
    be sufficient and may help to avoid under
    nutrition.

41
Physical Activity
  • Types of physical activities that may be
    appropriate for the older adult include
  • o Walking
  • o Swimming or water aerobics
  • o Bicycle riding
  • o Yoga
  • o Gardening
  • o Household chores
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