Rational Goal-Setting and Management

of Diabetes in the Elderly

Michael Shannon, MD

Medical Director, Physicians of Southwest Washington

Clinical Assistant Professor, University of Washington

Outline of Talk

Challenges of diabetes care in the elderly

Goal setting and A1c targets in elderly

Review of treatment options for elderly with

review of classes

Tools for older patients with specific needs:

grip, vision, memory, newer technology

Disclosure: Speaker and Consultant, Novo Nordisk

and BI/Lilly Alliance

Epidemiology of Diabetes in Elderly

Estimated at 26% for those aged 65+

Long term care (2007-13): multiple studies

cite 25-34% in LTC facilities (SNF and ALF)

Several Challenges in Managing These Patients

Hypoglycemia in the Elderly

Hypoglycemia in the Elderly

Psychomotor coordination deteriorates earlier

and greater in elderly erasing the usual 10–20

mg/dL difference between subjective

awareness and onset of cognitive dysfunction

Hypoglycemia recognized in far fewer elderly

Presentation overlaps other frailty syndromes

Confusion, word-finding errors, altered LOC

Tremors / dizziness

No one goes wrong getting a UA and Fingerstick

Hypoglycemia in the Elderly

Hypoglycemia in the Elderly

Hypoglycemia and cognitive impairment have

partial bidirectional relationship

Severe hypoglycemia linked to cognitive

impairment

Cognitive impairment increases hypoglycemia risk

Hypoglycemia increases risk of falls and

fractures (neuroglycopenic symptoms…)

Probably increases placement rates

Hypoglycemia in the Elderly

Limited ability to self-manage hypoglycemia

Limited vision/transfer ability to self-rescue

Increased fall risk, sedation from other medication

In institution, limited access to self-correction

Glucagon probably underutilized – arrival of

nasal glucagon will help caregivers of elderly

Hyperglycemia in the Elderly

Symptomatic hyperglycemia

Polyuria: glycosuria load, UTI risk

Dehydration (impaired thirst, impaired access)

Blurry vision (increased falls)

Impaired wound healing

Unlike hypoglycemia, these are more subtle

and slower to emerge -> need more vigilance

Polypharmacy and Complex PMH

Increases Hyperglycemia

Steroids

Antipsychotics

Infections / immobility

Increases Hypoglycemia

Sedative Agents (Alcohol)

Renal impairment

Poor nutrition

Cirrhosis (limited synthesis)

Diabetes Assessment in the Elderly

Goal-Setting for General Diabetes Plan

Physical Assessment

Nutritional Assessment

Physical Assessment

12

Nutritional Assessment

Malnutrition

Poverty / isolation

Dentition

WWII Widower

Depression

Cognitive Impairment

13

Physical Assessment

Ophthalmic

Higher rates of cataracts, glaucoma and macular

degeneration.

Dexterity/Hands:

Vials vs pens, choice of meters

General Home Safety Eval (cords, rugs, cats)

Diabetes Goals in the Elderly

Standards of

Medical Care in

Diabetes - 2018

A1C Goals in Adults: Recommendations (2)

• Less stringent goals (such as <8% [64 mmol/mol]) may

be appropriate for patients with a history of severe

hypoglycemia, limited life expectancy, advanced

microvascular or macrovascular complications, or long-

standing diabetes in whom the goal is difficult to achieve

despite diabetes self-management education,

appropriate glucose monitoring, and effective doses of

multiple glucose-lowering agents including insulin. B

Glycemic Targets:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S55-S64

Approach to the Management of Hyperglycemia

low high

newly diagnosed long-standing

long short

absent severeFew/mild

absent severeFew/mild

highly motivated, adherent, excellent self-care capabilities

readily available limited

less motivated, nonadherent, poor self-care capabilities

A1C

7%more

stringent

less

stringentPatient/Disease Features

Risk of hypoglycemia/drug adverse effects

Disease Duration

Life expectancy

Important comorbidities

Established vascular complications

Patient attitude & expected

treatment efforts

Resources & support system

Glycemic Targets:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S55-S64

Elderly DM Goals: My 3 Levels

For those with good functional status, same as

others post-ACCORD study (probably about

7.5% depending on CV disease)

For life expectancy ~5 years, < 8% or 8.5%

(weigh comorbidities, functional status, goals)

For palliative care patients: avoid symptoms

Glucose > 180 = glycosuria, dehydration, UTIs

Glucose over ~225 = poor wound healing,

increased decubitus ulcers

Diabetes: CV Outcome Trials

Landmark CV Trials for Elderly DM

DCCT: For DM1, enrolled people < 39 years of age

UKPDS: did not enroll past 59 years of age

Last round of trials without CV benefit include

ACCORD (mean age 62), VADT (mean age 60), and

ADVANCE (mean age 66) but few > 75 years old

No outcome trial focused on elderly (no HYVET)

No major trials at all for frail/institutionalized elderly

Pharmacologic Approaches to Glycemic Treatment:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85

ADA 2018: Pharmacologic

Therapy For DM2 and ASCVD

Lifestyle management and metformin

Subsequently, incorporate an agent proven to reduce

major adverse CV events and mortality (currently

empagliflozin and liraglutide) considering drug and

patient factors (Level A)

Canagliflozin may be considered (Level C)

EMPA REG by Age

LEADER - Analysis by Age

CANVAS – Analysis by Age

Neal B, et al. N Engl J Med. 2017;377:644-657.

Diagnosis is a fairly soft endpoint,

but death is unequivocal.

Edwin AM Gale, Lancet 2003

The Diabetes Toolbox 2018

Drug Class (First in Class) FDA Approval

Insulin (subcutaneous) 1922 (first use)

Sulfonylurea (chlorpropamide) 1958

Biguanide (metformin) 1995

Alpha-glucosidase inhibitors (acarbose) 1995

Thiazolidinedione (troglitazone) 1997

Meglitinide (repaglinide) 1997

Incretins (pramlintide, exenatide) 2005

DPP-IV Inhibitors (sitagliptin) 2006

Bile acid sequestrant (colesevelam) 2008 (DM)

Dopamine agonist (bromocriptine QR) 2009

SGLT-2 inhibitor (canagliflozin) 2013

The Toolbox in 2018

Metformin: great – with new GFR guidance –

please use metformin ER

Sulfonylureas: cheap, but risk of

hypoglycemia; no more glyburide (and its evil

metabolite norglyburide cleared through

kidneys) -> now $4 monthly glimepiride

TZDs: no hypoglycemia but risks of edema,

CHF, and possibly fractures and malignancies

Available for Q&A: colesevelam, bromocriptine

Metformin

FDA (April 2016): “We have concluded

from the review of studies published in the

medical literature that metformin can be

used safely in patients with mild impairment

in kidney function and in some patients with

moderate impairment in kidney function.”

Label update: now “contraindicated” if

eGFR is <30mL/min/1.73m2

2014 update from the International Society

of Nephrology: metformin may still be

appropriate for eGFR 14-29mL/min/1.73m2

if kidney disease is stable

GLP-1 Agonists

Modest benefit in HbA1c 0.7-1.1% and some

weight loss as well but some nausea

Safety warnings about pancreatitis and

medullary thyroid cancer

Cardiovascular studies complete for several

Can be used in combination with basal insulin

at same time of day, for probably best efficacy

with reasonably low risk of hypoglycemia

DPP-IV Inhibitors

Sitagliptin, saxagliptin, linagliptin, alogliptin

Modest decrease in HbA1c of 0.5% - 0.8%;

Minimal side effects (possible more minor

infections) except saxagliptin showed increased

congestive heart failure (seen in ADA guideline)

SGLT-2 Inhibitors

Approved starting in 2013; blocks renal re-

absorption of glucose and lowers blood sugars

Associated with similar modest HbA1c decrease

of 0.5% - 0.7%) as DPP-IV inhbitors (UTDOL)

Risks: infections and dehydration, DKA

Independent of resistance (can use with insulin)

but limit dose eGFR 45-60 and don’t use <

eGFR 45 or with hepatic impairment

CV Studies: EMPA REG, CANVAS

Final Words on Newer Agents

None of these have been in wide use for long

Lessons of rosiglitazone: hemoglobin A1c is

a surrogate endpoint, not the true goal of care

All the new drugs cost upwards of $10/day

Final Words on Newer Agents

None of these have been in wide use for long

Lessons of rosiglitazone: hemoglobin A1c is

a surrogate endpoint, not the true goal of care

All the new drugs cost upwards of $10/day

For elderly, hypoglycemia safety probably is

main reason to use, or dosing convenience,

with possible exception of empagliflozin and

liraglutide b/c cardiovascular outcome study

Indications for Insulin Therapy

Severe hyperglycemia at diagnosis

Hyperglycemia despite maximum doses of

non-insulin agents

Decompensation of other organ systems that

limits use of other oral agents

Early potent treatment with safety other than

hypoglycemia

Combination Injectable Therapy in T2DM

Pharmacologic Approaches to Glycemic Treatment:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85

The Medicare Test Strip Quandry

1-2 tests/day x 12 weeks, 6 tests/day x 1 week w notes

Tools for Limited Sight/Grip

Insulin Pens = KEY for many elderly

Much easier to get nowadays, somewhat more $

Occupational therapist may be able to help grip

Certain meters good for low vision

Prodigy Voice: endorsed by AFB, NFB

FORA series

Tools for Limited Memory

For oral meds: mediset or blister packs

Once weekly GLP1 may be a tool for those

with VNS and/or family member

Newer meters with memory function:

Echo, Memoir, and Timesulin cap

Newer “smart pens” integrated with software

Intensive insulin may require higher level of

placement (DM1, wound issues, etc)

To Infinity and Beyond

Insulin Pens = KEY for elderly (easier than

ever: CTS, visual impairment, neuropathy)

Insulin pumps appropriate if motivated and

fulfill strict Medicare criteria

Continuous monitors approved for Medicare

specific to two compan – work in progress

AMDA has excellent LTC guidelines for also

incorporating multidiscipinary team

Conclusion

Diabetes is common in the elderly and care of

these individuals is more challenging

ADA and AACE have slightly different goals

of care and toolbox can be viewed with focus

on elderly

The EMPA REG and LEADER study showed

cardiovascular and all-cause mortality

reduction with empagliflozin and liraglutide

Questions and Appreciation