Download - 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
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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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