Diabetes, hypertension and a lot more `in the elderly` JORIS SCHAKEL INTERNIST- CLINICAL GERIATRICIAN

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1 Diabetes, hypertension and a lot more `in the elderly` JORIS SCHAKEL INTERNIST- CLINICAL GERIATRICIAN

2 IT`S HARD TO GIVE GENERAL ADVICE!

3 ``The Elderly`` Heterogeneous group ;widely varying physiologic profiles, functional capabilities, and life expectancy Although the elderly are sometimes classified as youngold (age 65 80) and old-old (80+),-> too simplistic for clinical decision-making. Consensus: A continuum somewhere from age of 65 characterized by slow progressive decline in function.

4 Diabetes differs in the elderly Diabetes Prevalentie Incidentie Heterogeneity

5 Incidence and prevalence of diabetes Source: National Health Interview Survey estimates projected to the year 2010.

6 SOME BACKGROUND

7 For fluids do not remain in the body, but use the body only as a channel through which they may flow out. Life lasts only for a time, but not very long. For they urinate with pain and painful is the emaciation. For no essential part of the drink is absorbed by the body while great masses of the flesh are liquefied into urine. (Translated by Eugene J. Leopold)

8 Leonard Thompson ( )

9 Timeframe that carbohydrate-restricted diets prolong the lives of animals with experimental diabetes, and went on to show the same in humans.

10

11 Trials

12

13

14 THE COMING PANDEMIC

15 Pandemic Diabetes: 29 million (U.S) have diabetes aged 20 years or older (12.3% of the adult population), and 1 in 4 do not know it. This number has increased from 26 million in 2010 Prediabetes: 86 million people more than 1 out of 3 people aged 20 years and older have prediabetes. without weight loss and moderate physical activity, 15-30% of people with prediabetes will develop type 2 diabetes within 5 years

16 Sedentary lifestyle + Carbohydrates = Diabetes

17 Sedentary lifestyle + Carbohydrates = Diabetes

18

19

20 Scientists discover the Couch Potato gene Scientists in China and Aberdeen have made a key discovery which could explain why some people are 'couch potatoes'

21

22

23

24 AGING EFFECTS ON DIABETES

25 Pathogenesis of hyperglycemia in the elderly

26 Pathogenesis of hyperglycemia in the elderly Intrinsic effects: -Aging is associated with declining beta cell function. -Lower blood insuline levels independent of insulin resistance. Extrinsic effects: cytokines, polypharmacy EdelsteinSL, Predictors of progression from impaire glucosetolerance to NIDDM Diabetes 1997

27 Pathogenesis of hyperglycemia in the elderly Co-morbidity Nutritional state Decline insulin secretion Genetic Increase fat tissue Medication Physical activity

28

29 SYMPTOMS ARE OFTEN NONSPECIFIC

30 Aging versus Diabetes AGING Need glasses Frequent urination Not feeling a teenager Atherosclerosis High blood pressure Different walking pattern Worse sleep DIABETES Blurry vision Polyuria en polydipsia Tiredness MI and CVA s 2x High blood pressure Neuropathy and foot deformations Restless with high and low glucose levels

31 Why is it important?

32 Side-effects of hyperglycemia elderly Uncontrolled diabetes accelerates the aging proces Age specific disabilities occur earlier (Mild) cognitive disturbances. Other diseases are more difficult to regulate when having high HbA1C.

33 Complications Shortterm Longterm. 2 x higher risk kidneyfailure, neuropathy and retinopathy 10x risk of amputation 50 % ->cardiac causes CVA 2-4 x elevated rr.

34 INDIVIDUALIZED MANAGEMENT IS BEST

35

36 Use your ABC! A: HbA1c, Micro Albuminuria B: Blood Pressure C: Cholesterol D: Diet, Do not smoke E: Execercise

37 In practice treating the elderly Recommendations should be more closely-aligned with individual characteristics: 1. functional status, 2. presence of frailty and dependency, 3. comorbidity profiles, 4. life expectancy. These are likely to influence treatment goals, the care model adopted, and how the clinician plans on-going care.

38 Guidelines

39 Frailty

40 3 Functional stages

41 3 Groups JAGS 2012:Diabetes in Older Adults: A Consensus Report

42 Life expectancy

43 Glucose/ HbA1c

44

45 What is the evidence: glucose treatment? The UK Prospective Diabetes Study (UKPDS) the Action to Control Cardiovascular Risk in Diabetes [ACCORD] trial the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation [ADVANCE] trial and the Veterans Affairs Diabetes Trial [VADT] CONCLUSIE: No hard evidence improvement on macro vascular endpoints Microvascular prevention nephropathy Intensive treatment group increased mortality and hypoglycemias Time to benefit 8 years. Hemmingsen B, Lund SS, Gluud C et al. Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev

46 Blood pressure

47

48 Wat is de evidence : RR treatment? Multipele trials on hypertension in the elderly. Not specific for diabetes, but were included the Action to Control Cardiovascular Risk in Diabetes [ACCORD] BP trial CONCLUSION: There is consistent evidence that lowering bloodpressure from high to moderate reduce Cardiovascular risk Different subclasses of antihypertensives are effective Time to benefit 2 jaar Cigolle CT, et al. Diabetes and cardiovascular disease prevention in older adults. Clin Geriatr Med 2009;25: ,

49 Wat is de evidence : lipid lowering?

50

51 Wat is de evidence : lipid lowering? -There are no large lipid lowering trials in the elderly with diabetes. Data is extra polated CONCLUSIE: Most show reductions in morbidity and mortality in primary and secondary prevention Fibrates seems to be ineffective. Time to benefit 1-2 jaar Baigent C,et al. Efficacy and safety of cholesterol-lowering treatment: Lancet 2005;366:

52 COMPLICATIONS TREATMENT

53 Co-morbidities. Cognitive function/ dysfunction Pharmacologic: interactions, polypharmacy, hypoglycemia

54 Co-morbidities. Cognitive function/ dysfunction Pharmacologic: interactions, polypharmacy, hypoglycemia

55

56

57

58 Prevent Hypoglycemia!

59 Autonomic symptoms Neuroglycopenic symptoms Hypoglycemia unawareness Baseline Hypo Recovery ** Older ( 65 years) Baseline Hypo Recovery * Middle-aged (39-64 years) Bremer JP et al. Diabetes Care. 2009; 32 (8):

60

61 Key points Pandemic. Prevention by life style Comprehensive approach not only glucose. AND Its not only about the cardiovascular risk!!

62 thanks for your attention!

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