Diabetes in the elderly Chris MacKnight April 2, 2011
Disclosure I have no conflict of interest to report
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?
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?
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?
Outline Principles of frailty Diabetes treatment and falls The insulin-treated diabetic who develops dementia
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
What do we mean by frailty No good or commonly accepted definition Progressive weakness slowing up Vulnerability to poor outcomes, even from slight insults
Rockwood et al. CMAJ 1994
Theoretical Trajectories of Dying Lunney, J. R. et al. JAMA 2003;289:2387-2392. Copyright restrictions may apply.
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;173:489-495 Copyright 2005 CMA Media Inc. or its licensors
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
Copyright restrictions may apply. Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.
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?
British Geriatrics Society, 2009
J Am Geriatr Soc 2007;55:2041
Convenience sample >75 in Colorado with diabetes Looked at frailty, falls, HbA1c HbA1c <7% = 2.71 (1.10-6.67) OR for a fall
Diab Care 2008;31:391
Roughly 5 year longitudinal study in 446 diabetics, average age 73.6
What I Take From This Lower hemoglobin A1c may be dangerous Aim a bit higher in the frail elderly Avoid insulin if possible
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?
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...
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
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
Diab Care 2006;29:1794
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
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
Outline Principles of frailty Diabetes treatment and falls The insulin-treated diabetic who develops dementia
Resources Institute of Diabetes for Older People http://instituteofdiabetes.org/ 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