dm in elderly

8/8/2019 DM in Elderly

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DiabeteDiabetes ins in elderlyelderlyPresented by

Dr. Yunus Tanggo, SpPD, PhD

Internal medicine of FK UKI


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Physiologies changes in elderly

Adams in 1981 propose a theory :

Cell ageing process : disturbance of recovery,catabolism and multiplication

Immunity alteration : autoimune process,

infections, degenerative disease

Genetic components : biological clock in

nuclear cell


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Loss of Endocrine function is due to

age-related cell loss

fibrosis lymphosit infiltration

hormone receptor disturbance and changes of

cell permeability


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Pathogenesis of HyperglycemiaPathogenesis of Hyperglycemia

in Elderlyin Elderly

Poor Nutrition

Coexisting IllnessReduced Insulin

Secretion

Increased AdiposeTissue

Decreased PhysicalActivity

Medications

Genetics


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Prevalence of DiabetesPrevalence of Diabetes


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Diabetes in OlderAdultsDiabetes in OlderAdults

50% under-diagnosed WHY??

Early signs: Metabolic Abnormalities

Insulin resistance 1st phase insulin release

PPG with normal FPG

Early symptoms: (if any)

Often gradual onset

Commonly mistaken for signs of normalaging


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Associated problem in

managing DM in elderly Cerebral aging : senile dementia

Atherosclerotic changes : increase risk of stroke

Compromise cardio-respiratory reserve

Blunting in hormone profile

Poorhepatic glycogen reserve

Cataract

Neuropathy

Cerebro-vascular disease

NKHS and hyponatremia

7


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Case of Mistaken IdentityCase of Mistaken Identity

Blurred Vision

Polyuria and nocturia

Fatigue

MI and CVAs 2 times

more common

High Blood Pressure

Neuropathy and foot

deformities

Restlessness/confusion

with high and low BG.

Needing glasses

More frequent urination

Cant do things like you

did when you were 20

Atherosclerosis

High Blood Pressure

Change in gait

Restlessness, confusion,

slower cognition.

Signs of DiabetesSigns of DiabetesSigns of AgingSigns of Aging


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Diabetes AssessmentDiabetes Assessment

in the OlderAdultin the OlderAdult

Physical Assessment

Mobility/ Physical Activity

Nutritional Assessment

Neurological Assessment

Psychosocial Assessment

OtherAreas


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Diabetes AssessmentDiabetes Assessment

in the Older

Adultin t

he Older

Adult

Common Geriatric Syndromes

Depression

Polypharmacy Cognitive Impairment

Urinary incontinence

Injurious falls

Persistent pain


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Physical AssessmentPhysical Assessment

Ophthalmic

Higher rates of cataracts, glaucoma and

macular degeneration.

Auditory

Renal

Thickening of basement cell membranes.

Immune system Flu, herpes zoster, cancer


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Physical AssessmentPhysical Assessment

Cardiovascular System

Reduction in CVD risk factors may have

greatest impact on morbidity and mortality

Hypertension

Lipids

Increased risk of CVAs and MIs.

Heart rate in response to exercise reduced. Thickening of basement cell membranes.

50% of newly diagnosed people with T2DM

have CVD.


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Physical AssessmentPhysical Assessment Dexterity/coordination

History of injurious falls

Mobility/

Physical

Activity Joint disease/ Bone mass

Aerobic capacity

Lean body mass

Fat mass Activity

Current level?

Limitations, preferences


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Nutritional

Assessment

Nutritional

Assessment

Nutritional status Change in nutrient needs

Change in body composition

Hydration status

Alcohol use/abuse

Supplement/herbal use

Gastrointestinal tract Absorption Gastroparesis

Appetite


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Neurological AssessmentNeurological Assessment

Cognitive Impairment

Increased rate in PWD

Mini-mental status exam recommended Check for reversible causes:

B12 levels

Thyroid hormone Neuroimaging

Depression screening

B

lood glucose control


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Neurological AssessmentNeurological Assessment Autonomic and peripheral neuropathies:Heart

IncontinenceSexual function

Protective sensation

Hypoglycemia unawareness Body Temperature regulation

Reduced ability to sense:

Thirst, Smell, Taste


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Psychosocial AssessmentPsychosocial Assessment

Depression

Support systems

Loss of peers

Change in family role

Healt

hB

eliefs Locus of Control

Internal vs. External


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OtherAreas ofAssessment

Co-morbidities

Pain

Polypharmacy Diabetes medications appropriate?

Drug interactions

A

bility to administer medications Safety

Finances


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Treatment Recommendations

Glycemic Control

Hypertension

Lipids

Tobacco cessation

Eye care

Foot care Nephropathy

Diabetes Self-Management Training


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Glycemic ControlGlycemic Control

A1c-


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Risks of Intensive GlycemicRisks of Intensive Glycemic

ControlControl

Hypoglycemia

Polypharmacy Drug to drug interactions

Drug to disease interactions


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HyperglycemiaHyperglycemia Can cause:

Delirium

Mood swings and irrationality Appetite changes

Sleep disturbances

Increases risk for: Diabetic Ketoacidosis

Hyperglycemic Hyperosmolar State (HHS)


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HyperglycemiaHyperglycemia

Impairs cognitive ability

Reduces energy

Impairs memory

Decreased wound healing

Increased risk of HHS

Increases urine output

Impacts incontinence/dehydration

Increased risk ofUTI

Impairs immune system23


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Aging increases risk ofhypoglycemia:Aging increases risk ofhypoglycemia:

Reduced hormonal counter regulation

R

enal andhepatic c

hanges

Hydration status

Inadequate or irregular nutrition

Decreased intestinal absorption

Autonomic neuropathy

Polypharmacy

Use of alcohol, other sedating meds

HypoglycemiaHypoglycemia


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HypoglycemiaHypoglycemia

May cause:

Heart arrhythmias

Increased risk of falls Signs and symptoms may be masked by

co-morbidities (i.e. Parkinsons)

Impairs concentration and cognition Impairs reaction time


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HypertensionHypertension

Goal: Less than 140/80 if tolerated

Less than 130/80 may produce further

benefit Blood pressure reduction should be done

gradually to minimize complications (no more

than 20mm/hg reduction in systolic BP/3 mo)


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Hypertension:Hypertension:

Medication PrecautionsMedication Precautions

ACE-I orARB Therapy

MonitorK 1-2 weeks after initiating therapyand with each dose increase

ACE-I associated with decreased renal

function in elderly

Hyperkalemia common at moderate and high

doses


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Hypertension:Hypertension:

Medication PrecautionsMedication Precautions

Thiazide or loop diuretic

Check electrolytes within 1-2 weeks ofinitiation and at least yearly

Hypokalemia associated with ventricular

arrhythmias.


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LipidsLipids

Secondary to overall health statusassessment

Goals: LDL< 100mg/dl

HDL > 40 men, 50 womenTG < 150mg/dl

LDL 130 pharmacologic therapy + lifestyleintervention


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Lipids: Medication PrecautionsLipids: Medication Precautions

Increased side effects

Myalgias and myositis

Rhabdomyolysis

Elevated liver function? Niacin or Statin: Measure ALT w/in 12 weeks of

initiation or dosage change

Fibrate: evaluate liver enzymes at least annually

Precaution with reduced renal function


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Retinopathy ScreeningRetinopathy Screening

Dilated eye exam at diagnosis

High risk (symptoms of eye disease,

retinopathy, glaucoma, cataracts, A1c>8, T1DMorBP>140/80mm/hg):

at least yearly follow-up exams

Low(-er) risk : every 2 years


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Foot ScreeningFoot Screening

At least annual comprehensive foot examand at all non-urgent outpatient visits.Assess changes in:

Skin integrity

Loss of protective sensation

Early detection of neuropathy

Decreased perfusion Bone deformity


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Nephropathy ScreeningNephropathy Screening

Screen for microalbumin and GFR at

diagnosis and (at least) annually


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THANK YOU

for your attention

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dm in elderly

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