Diabetes in the elderly. Chris MacKnight April 2, 2011

Transcription

1 Diabetes in the elderly Chris MacKnight April 2, 2011

2 Disclosure I have no conflict of interest to report

3 Show of Hands 87 yo woman with diabetes and multiple other comorbidities, on multiple medications. Hx of falls 87 yo woman with diabetes and hypertension, on 3 medications, no falls. Do you treat them differently?

4 Show of Hands 87 yo woman with diabetes and multiple other comorbidities, on multiple medications. Hx of falls 87 yo woman with diabetes and hypertension, on 3 medications, no falls. Do you treat them differently? How so?

5 66 yo man with diabetes, managed with insulin for over 20 years. Currently on 2 injections of basal insulin and 3 meal-time doses/day adjusts doses himself. Lives with his wife. Develops dementia. What do you need to plan for and change over the next few years?

6 Outline Principles of frailty Diabetes treatment and falls The insulin-treated diabetic who develops dementia

7 Outline Principles of frailty Diabetes treatment and falls The insulin-treated diabetic who develops dementia Relevant to hospital medicine Transitions of care and discharge planning Appropriate treatment goals

8 What do we mean by frailty No good or commonly accepted definition Progressive weakness slowing up Vulnerability to poor outcomes, even from slight insults

9 Rockwood et al. CMAJ 1994

10

11 Theoretical Trajectories of Dying Lunney, J. R. et al. JAMA 2003;289: Copyright restrictions may apply.

12 Fig. 1: Kaplan-Meier curves, adjusted for age and sex, for study participants (n) over the medium term (5-6 years), according to their scores on the CSHA Clinical Frailty Scale Rockwood, K. et al. CMAJ 2005;173: Copyright 2005 CMA Media Inc. or its licensors

13 Care of the Frail Patient Manage symptoms Minimize medications Support for the patient & caregiver Attention to bowel and bladder function Attention to mobility Attention to ADLs

14 Copyright restrictions may apply. Holmes, H. M. et al. Arch Intern Med 2006;166:

15 Diabetes and falls 87 yo woman with diabetes and multiple other comorbidities, on multiple medications. Hx of falls 87 yo woman with diabetes and hypertension, on 3 medications, no falls. Do you treat them differently?

16 British Geriatrics Society, 2009

17 J Am Geriatr Soc 2007;55:2041

18 Convenience sample >75 in Colorado with diabetes Looked at frailty, falls, HbA1c HbA1c <7% = 2.71 ( ) OR for a fall

19 Diab Care 2008;31:391

20 Roughly 5 year longitudinal study in 446 diabetics, average age 73.6

21

22 What I Take From This Lower hemoglobin A1c may be dangerous Aim a bit higher in the frail elderly Avoid insulin if possible

23 66 yo man with diabetes, managed with insulin for over 20 years. Currently on 2 injections of basal insulin and 3 meal-time doses/day adjusts doses himself. Lives with his wife. Develops dementia. What do you need to plan for and change over the next few years?

24 Dementia Memory loss Other cognitive loss (language, praxis, executive function) Impact on function Tends to be slowly progressive Early functional losses are high-level skills Banking, driving, cooking...

25 and diabetes management Very little data on prevalence/impact Records of insulin taken/glucometer results may be incomplete or false Times may be incorrect Intake and activity may become more erratic The spouse/caregiver may be unaware

26

27 A case-control study of diabetics vs nondiabetics drawn from general practices in Wales Diabetics did worse on average on MMSE and clock-drawing task

28

29

30

31 Diab Care 2006;29:1794

32

33 What I take from this Be vigilant for cognitive impairment in diabetics Poor compliance in a previously wellcompliant patient Diabetic control and reports of compliance not adding up Involve the family/caregiver in diabetic training

34 When cognitive impairment occurs Simplify diabetic management Oral agents as much as possible The formal health care system will have difficulty providing more than one or two supervised injections at home each day Concentrate on risk-avoidance hypoglycemia or extreme hyperglycemia Long-term outcomes less important

35 Outline Principles of frailty Diabetes treatment and falls The insulin-treated diabetic who develops dementia

36 Resources Institute of Diabetes for Older People Neumiller et al. Am J Geriatr Pharmacother 2009;7:324 Schwartz et al. Diab Care 2008;31:391 Nelson et al. J Am Geriatr Soc 2007;55:2041 Chen et al. Ageing Research Reviews 2010;9S:S18 Abbatecola et al. Drugs Aging 2009;26S1:53 Sinclair et al. Diab Res Clin Pract 2000;50:203 Munshi et al. Diab Care 2006;29:1794