Diabetes%20in%20the%20older%20person

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Diabetes in the older person
Terry Aspray Tuesday pm
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Diabetes in the older person

• Diabetes A future epidemic?
• New drugs and old people
• Old drugs and old people
• Can we prevent complications?

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A Future Epidemic? Old Age
Population millions

• Older population in UK growing
• Demographics
• Projections year 2000-2051
• Aged 65 to rise by 80
• Aged 85 to rise by 255
• Source Joseph Rowntree foundation 2005
  http//www.jrf.Org.uk/knowledge/findings

65
85
Year
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A Future Epidemic? Diabetes

• In the UK
• Of people with diabetes
• 50 aged 65
• 25 aged 75

Source Diabetes UK 2004
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A Future Epidemic? Diabetes Death
Melton Mowbray Survival- Aged 75 Yrs

• Community study
• Population aged 75
• Diabetic subjects
• Mortality x4.5

Survival ()
Croxson et al Diab Med. 1994
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A Future Epidemic? Frailty Care Homes
Cost billions
Residents thousands

• Frail population in UK growing
• Care homes
• 450,000 residents
• Cost 13 billion (2000)
• 1,130,000 residents
• Cost 55 billion (2051)

Source Joseph Rowntree foundation 2005
Http//www.jrf.Org.uk/knowledge/findings
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A Future Epidemic? Diabetes Care Homes

• 1630 Residents
• 1275 had blood tests
• Diabetes in at least 19.9
• 105 new cases
• 186 already diagnosed
• EMI Care
• Undiagnosed Diabetes common

(plt0.001)

Aspray et al (2006) Diabetes Care Aspray et al
(2006) Public Health
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A Future Epidemic?

• ?Diabetes-all ages
• Especially in the old
• ?Co-morbidities
• Age
• Diabetes
• Frailty with diabetes
• e.g. Nursing homes

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A Future Epidemic?

• Watch out for Diabetes in 2050
• ?Diabetes-all ages
• Especially in the old
• ?Co-morbidities
• Age
• Diabetes
• Frailty with diabetes
• e.g. Nursing homes

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Case Based Discussion 1.

• Age 89 F. in a NH
• Gliclazide 120mg
• Metformin 1.5g
• Pioglitazone 30mg
• BP 152/72
• HbA1c 5.3
• Urea 7.5 creat 156
• TC 5.5
• Hb10g/dl

• Questions
• Any concerns?
• Would you change the treatments?

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Case Based Discussion 1.

• Age 89 F. In a NH
• Weight 49 kg
• Gliclazide 120mg
• Metformin 1.5g
• Pioglitazone 30mg
• Bp 152/72
• HbA1c 5.3
• Urea 7.5 creat 156
• TC 5.5
• Hb 9.8g/dl

• Concerns
• Low HbA1c
• Any hypos?
• Mild anaemia
• Interpreting HbA1c
• Glitazone
• Renal impairment
• Metformin
• Changes
• Stop metformin?
• Stop Pioglitazone?
• Cut gliclazide dose?

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Can We Prevent Complications? UKQOF
Glucose Points
Record of HbA1c in last 15months 3
HbA1c is 7.4 or less in the past 15 months 16
HbA1c is 10 or less in the past 15 months 11
BP
HbA1c is 10 or less in the past 15 months 3
BP 145/85 or less in the past 15 months 17
Lipids
Record of Cholesterol in last 15months 3
Cholesterol lt5mmol in the past 15 months 6
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Can We Prevent Complications? QOF Glucose

• Not just about bringing down glucose
• No lower limit in QOF for HbA1c
• Safety first?
• Avoiding Osmotic symptoms and Hypos
• Ensure regular and consistent meals.
• Consider withdrawal of treatment!
• Target HbA1c ??1 at 7.5-8.5

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Hypoglycaemia Elderly

• Unawareness in old
• ?counter-regulatory response
• Take longer to recover.
• Misdiagnosis
• CVA, TIA
• Fit
• Confusion ?cause.

• Therefore-.
• Careful prescribing.
• Ensure regular and consistent meals.
• Consider withdrawal of treatment!

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Benefits of Glucose Control 2008 trials

• Intensive glucose control x3
• Target HbA1c 6.0-6.4
• Little CVS benefit?
• Already diagnosed DM
• Over age 60
• Up to 6 years f.u.
• ?Risk severe hypos
• ?Risk Death (ACCORD)

• Thanks to Gillian Hawthorne
• BGS Spring Meeting 2009

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Benefits of Glucose Control 2008 trials

• Legacy Studies x2
• Long Term benefit
• New cases T2DM
• Urine micro albumin
• Despite moderate control in long term
• HbA1c 8 at 10yrs

• Intensive glucose control x3
• Target HbA1c 6.0-6.4
• Little CVS benefit?
• Already diagnosed DM
• Over age 60
• Up to 6 years f.u.
• ?Risk severe hypos
• ?Risk Death (ACCORD)

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Thiazolidinediones Old People

• ADOPT (4351 subjects)
• Also Pioglitazone (Takeda)
• Rosiglitazone
• Metformin
• Sulphonylurea
• Hand, humerus, foot
• NOT hip or spine

• Other risks
• Cardiovascular (Rosi)
• Fluid retention/heart failure
• Anaemia

women
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Case based discussion 2.

• 79yrs T2DM 15 yrs
• Retinopathy
• Neuropathy
• BP 188/90
• Glargine/metformin
• Bendrofluazide
• Lisinoprol
• Amlodipine
• Atenolol

• Why is her BP poorly controlled?
• What side effects do you think she suffers from?
• What is the target BP?

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Case based discussion 2.

• 79yrs T2DM 15 yrs
• Retinopathy
• Neuropathy
• BP 188/90
• Glargine/metformin
• Bendrofluazide
• Lisinoprol
• Amlodipine
• Atenolol

• BP
• Drug adherence
• Side effects
• Diuretic
• Ca antagonist
• Combinations
• Target BP
• Evidence supports Rx at all ages but

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Can We Prevent Complications? BP

• BHS for Diabetes
• start at gt140/90 target lt130/80 Achievable?
• HOT 140/81
• UKPDS. 144/82
• PROGRESS Post stroke- 138/82- half normotensive
• HYVET target lt150/80- achieved in 48
• Side effects of treatment.
• e.g. Orthostatic Hypotensionfalls!

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Case Based Discussion 3.

• 88 year old with T2DM for 30 yrs
• Living with daughter
• Needs help feeding
• Incontinent
• No longer takes tablets as was getting hypos
• Cholesterol 5.6mmol

• How should you manage her?
• Any risks to treatment?

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Case Based Discussion 3.

• 88 year old with T2DM for 30 yrs
• Living with daughter
• Requires help with feeding
• Incontinent
• No longer takes tablets as was getting hypos
• Cholesterol 5.6mmol

• Statin?
• Risks benefits of treatment?

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Can We Prevent Complications? Lipids

• Should we give statin?
• CVS events ?by 7-10 at 7 years in the old
• Dementia no benefit
• (Cochrane 2009)

• HPS
• 5 reduction in 5yrs

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Can We Prevent Complications? Lipids

• Statin safety
• 1.5x MSK symptoms
• Mosshammer D 2009
• Only 10 monitor LFTs correctly
• Leaver 2009

• High dose Atorva is safe up to age 78
• Koren MJ 2009
• Dementia no benefit
• (Cochrane 2009)

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Case Based Discussion 4.

• Age 72 F.
• Diabetes for 7 years
• Gaining weight
• Gliclazide 320mg
• Metformin 1.5g
• Pioglitazone 45mg
• BP 152/72
• HbA1c 9.5
• Urea 4.5 creat 111

• Questions
• How about insulin?
• What if she refuses?

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Case Based Discussion 4.

• Age 71 F.
• Diabetes for 7 years
• Gliclazide 320mg
• Metformin 1.5g
• Pioglitazone 45mg
• BP 152/72
• HbA1c 9.5
• Urea 4.5 creat 111

• Insulin
• Once daily
• Twice daily
• Four times daily
• With or without OHA
• Newer Drugs?

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New Drugs Incretins

• Insulin release
• Response to glucose
• Orally gt I.V.

• Incretins
• Secreted from small bowel
• Stimulate beta cells to produce more insulin.

Incretin effect
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New Drugs Incretins

• Incretins new class of drugs
• GLP-1 exenatide
• Metabolised by DPP4
• DPP4- inhibitors
• Oral Gliptins

• Range of effects
• ?Glucose dependent insulin secretion
• ?glucagon secretion
• Slow gastric emptying
• ? Food intake
• ? ?-cell mass in rats
• ? Insulin sensitivity
• ? Glucose disposal

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Incretins in older people

• Exenatide NICE 3rd line
• Injection
• HbA1c ?1
• Weight ? 1.5- 5.5kg
• Insulin ?weight!
• Gliptins NICE 2nd line
• Tablet
• HbA1c ?1
• Weight ? 1.5- 5.5kg

• Incretins for older patients
• Theoretically?ß cell mass less effect
• Not licensed monotherapy
• Exenatide
• Benefit into 7th decade
• Gliptins
• Safe and well tolerated
• Efficacy maintained Glycaemia and Weight

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Case Based Discussion 4.

• Age 66 M.
• Diabetes for 21 years
• Poor control for 5 years
• BD mix insulin 40/30
• Metformin 1.5g
• Very irritable
• Poor concentration
• Nostalgic for the old days
• Diabetes advice going nowhere

• Could there be an underlying cause?
• What do you do?

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Case Based Discussion 4.

• Age 66 M.
• Diabetes for 21 years
• Poor control for 5 years
• BD mix insulin 40/30
• Metformin 1.5g
• Very irritable
• Poor concentration
• Nostalgic for the old days
• Diabetes advice going nowhere

• Could there be an underlying cause?
• Hypoglycaemia???
• BM 9.2 then what?

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Complications Dementia

• Epidemiological Evidence
• Risk with diabetes
• Alzheimers Dementia x2-4
• Vascular Dementia x3
• Diabetes for gt15 yrs x3

Gregg (2000) Arch Int Med 160 174-180 Katzmann
(1989) Ann Neurol 25 317-24 Leibson (1997) Am J
Epidemiology 145 301-8 Yoshitake (1995)
Neurology 451161-68
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Can We Prevent Complications? Dementia

• Evaluation
• Index of suspicion
• Is it hypoglycaemia?
• MTS (10 item)
• MMSE (30 item)
• Clock drawing test
• Draw a clock
• Put in the numbers
• Set hands at 10-to-3

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Can We Prevent Complications? Dementia
Age Adjusted Incidence of dementia /10,000
person yrs

• HypOglycaemia associate with dementia
• Kaiser Permanente
• 1980-2002
• 16,667 patients
• Mean Age 65yrs
• Hypo 8.8
• Dementia 11
• Hypo Dementia 17
• Link has dose response

Whitmer et al. JAMA. 2009301(15)1565-1572
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Can We Prevent Complications? Dementia

• HypERglycaemia
• ?HbA1c ?cognition
• Digital skills substitution test (DSST)
• Visuo-motor speed learning
• MMSE
• Global screening test
• Memory score (Rey)
• Memorise/retrieve words
• Stroop
• Executive skill response time

Plt0.0001 Plt0.0001
ACCORD-MIND Diabetes Care 2009 baseline data
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Case Based Discussion 4.

• Age 66 M.
• Diabetes for 21 years
• Poor control for 5 years
• BD mix insulin 40/30
• Metformin 1.5g
• Very irritable
• Poor concentration
• Nostalgic for the old days
• Diabetes advice going nowhere

• Could there be an underlying cause?
• Needs Dementia work up
• Consider depression
• Consider psychological impairment

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Conclusion Diabetes in older people

• We have an epidemic
• Old People Diabetes
• Drugs
• Old drugs
• Benefits- Legacy
• Risks of tight control
• New drugs
• Glita-bones Concerns
• Incretins Just as effective in the old?

• Complications
• Risks of treatment
• Orthostatic Hypotension
• Hypoglycaemia awareness
• Dementia
• Lack of clinician awareness
• Dysglycaemia causal?
• Benefits from statins

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Conclusion Diabetes in Older People

• Complications
• Risks of treatment
• Orthostatic Hypotension
• Hypoglycaemia awareness
• Dementia
• Lack of clinician awareness
• Dysglycaemia causal?
• No benefits from statins

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