1. Review treatment options in caring for older patients with diabetes
2. Understand risks of hyperglycemia and hypoglycemia in older patients
3. Appreciate importance of cardiovascular risk reduction in older patients with diabetes by treating hypertension and hyperlipidemia
4. Gain awareness of association: diabetes, HTN, and vascular risk factors with dementia
5. Discuss the Treatment-Risk Paradox and how this applies to medical management in older patients
Treatment options and goals
Risks of longstanding diabetes
Reducing cardiovascular events: treating hypertension and dyslipidemia
Dementia: association with cardiovascular risk factors; ?can we prevent it?
The Treatment-Risk Paradox: Paper review
Case Study #1
78 y/o nursing home resident presents for evaluation of recurrent severe hypoglycemia. Diagnosed age 65 , treated with sulfonylurea without response, subsequently treated with insulin, currently 70/30 14 u in AM, 10 u QHS. Logs: 4-6 readings/day, ranging from 30’s (usually in afternoon or early AM) to mid 500’s, average 195.
92 year old woman comes to you on glyburide at 10 mg a day. She, after much discusssion, is unable to check her own glucose. She is very afraid of having a hypoglycemic reaction as she lives alone. Her Hgb A1C is currently 9.8%. She is otherwise healthy, on no other medications, and is completely active and independent.
Case # 2
What is the goal of treatment in this woman?
What are the risks and the benefits of “tight” control for this patient?
What should her goal A1C be?
Describe some barriers to self monitoring for older patients.
Is Metformin contraindicated?
Case # 3
You are following a 75 year old woman in the nursing home who has a severe dementia that is probably mixed alzheimers/vascular type, complicated by diabetes, hypertension and hyperlipidemia.
PE: weight 95 lbs
Case # 3…
How tight should control be for this patient? What would be an optimal HgbA1C?
How should her diet be managed? Is there any evidence for dietary restrictions in this setting?
What are the risks and benefits of optimizing her blood pressure control?
Case # 4
A healthy, active, independent 85 year old woman with DM presents to you for care. She is concerned because her sister has a severe dementia. Other than a blood pressure of 170/70, her PE is unremarkable.
Case study 4
Is her risk of dementia higher with an underlying diagnosis of diabetes?
What is the significance of isolated systolic hypertension in the elderly? Should this be treated?
What is the average life expectancy of a healthy 80 –85 year old woman?
Aging of America
Average life expectancy 72-79
At age 65, average life expectancy 82!
At age 85, average life expectancy 90
Fasting growing segment: over 85
Almost 5% of population by 2050
Prevalence of Diabetes
Prevalence of Cardiovascular disease
Prevalence of Dementia
Aging of America
Prevalence of Diabetes
Over 20% those over 65 (NHANES 1994)
Framingham Data: Diabetes or impaired glucose tolerance (fasting glucose 120-139) in nearly 40% those over 65
Three times more common in older patients with diabetes (11% vs 3.8%)
More common in older patients with DM (38% vs 16%)
Association with more rapidly progressive posterior capsule cataracts …
Over 50% in those over 80
Not always due to Diabetes
1/3 older patients cannot see/reach feet
Importance of caregiver education
Special Population: The FRAIL
Not all older patients are FRAIL
Frailty as increasingly recognized diagnosis
Associated diseases such as Diabetes
Stressors that precipitate
Hip fractures, pneumonia, depression, stroke
Treatment of the Frail
Care with any dietary restrictions
Significant number nursing home residents with weight loss, at risk for malnutrition
Tight control likely not goal
Still consider treatment of cardiovascular risk factors to reduce risk of CHF, stroke and morbidity
Big Goal: Prevention of Cardiovascular Events…
Common diseases: Diabetes, Hypertension, Hyperlipidemia
Common outcomes: Stroke, CHF/CAD, Dementia
No evidence that aggressive treatment of DM prevents/ changes these outcomes, but DM often seen in patients with HTN and hyperlipidemia, and mounting evidence that treatment of these risk factors can modify the risk of CAD, CHF, stroke and possibly even dementia in this group
Diabetes: CV equivalent
Patients with type 2 diabetes without prior hx of heart attack have same risk of MI compared to patients with prior hx of MI