Care of Diabetes in Older Adults

Dr. Zuhayer AhmedHMO

Dept. of EndocrinologyDMCH

Older Adults

•Young Old: –65-75 years

•Older Old:– >75 years

Older Adults are special!

•20% of over 65 years

•Premature death

•Functional Disability

•Co-existing illness:–Hypertension–Coronary Heart Disease–Stroke

Diabetics more vulnerable!

•More prone to geriatric syndromes:

–Polypharmacy

–Cognitive impairment

–Urinary incontinence

–Injurious falls

–Persistent pain

Presentation Focus

• Treatment Targets

• Glycemic Goals

• BG Control

• Minimizing Complications

Treatment Targets

•Symptom free

•Prevent short term complications

•Prevent long term complications

•Quality of life =Lifestyle focus

Health Status

HbA1c Fasting(mg/dl)

Bedtime(mg/dl)

“Healthy” <7.5% 90-130 90-150

Complex <8.0% 90-150 100-180

Very Complex

<8.5% 100-180 110-200

Glycemic Goals

• BG level should be individualized

•“Very Complex” groups are pretty relaxed in glycaemic goals to avert hypoglycaemia

•Glycaemic goals at a minimum should avoid acute compliocations

Controlling blood sugar levels

Exercise/Activity

•Increased insulin sensitivity

•Decreased insulin requirements

•Weight reduction

•Lipid control

•Blood pressure control

Healthy Eating

• Regular carbohydrate

• High in fibre

• Low in fat (particularly saturated fat)

• Low in added sugar

• Adequate energy /protein/fluids/vits and mins

Blood Pressure and Lipid Profile

•Blood pressure –Healthy: 140/90 mmHg–Complex: 140/90 mmHg–Very Complex: < 150/90 mmHg

•Lipid profile:–No definite level

•Assessment:–3-6 monthly if normotensive

Kidneys, Eyes & Feet

Renal Function

•Assess annually –3-6/12 if positive

(microalbuminuria/protein)

•Creatinine annually

Eye Examination

• Assess at diagnosis and every 2 years

•If retinopathy present, assess annually

Foot Assessment

• Assess annually• •3-6/12 for high risk feet

Cognitive capacity•Capacity/desire to learn

•Capacity for self care

•Eyesight/hearing

•Literacy level

•Poor memory

Assess with MMSE:(score = 30, 18-26 suggests dementia, <10

severe dementia)

Nutrition Assessment

•Distribution and intake of carbohydrates important

•Weight loss not recommended unless > 20% above weight range

Pharmacologic Approach

• Limited Alcohol• No smoking• Hypoglycaemic agents:

–Need to consider comorbidities, contraindications and side effects especially hypoglycemia

• Antihypertensive therapy: –For All

• Lipid lowering therapy & Aspirin:–No established benefit in very complex

status

Drug Name Reasons of Caution

Metformin Renal InsufficiencySignificant Heart Failure

TZDs CCFIncreased risk of fractures

Insulin Secretogogues HypoglycaemiaInsulin HypoglycaemiaDPP4 Inhibitors Costs

Heart FailureGLP-1 Agonists Costs

Hypoglycemia

•Higher risk:

–Insulin overdose

–Progressive renal insufficiency

–Cognitive impairment:•Difficulty in complex self-care activities

Hypoglycemia

• Specific education to the elderly and carergivers

•Changes in OHA & other medications

• Increase BG testing frequency

• Caution with prescribing diabetes tablets /insulin treatment

In conclusion the aim in elderly people with diabetes is to…

•Relieve symptoms of high glucose levels•Avoid low glucose levels•Achieve agreed blood glucose levels•Monitor diabetes complications•Encourage health and fitness habits•Ensure older people are actively involved in setting goals for their diabetes management

Life Expectancy

•Variable, but often LONGER!!

Thank you!