Diabetes dan usia

lanjut
Sasaran Belajar
Describe an approach to the clinical care of diabetes and
comorbid conditions in older adults

Assess the special needs of diabetes management in
the elderly

Indicate the drug selection criteria for older adults with
diabetes
1972

2010

2020
5.3 million
(4.48% of the total
population)

23.99 million
(9.9% of the total
population)

28.82 million
(11.34% of the total
population)
1. Indonesian Ministry of Social Affairs. 2002.
2. ADA. Complete Nurses Guide to Diabetes Care. Second Edition. 2009.

Age is a risk factor for developing diabetes
2


Undiagnosed and untreated diabetes is more common
in the elderly than in any other age group
2


Trend in Older Population in Indonesia
(Age 60+)
1

0
2
4
6
8
10
12
14
15 - 24 th 25 - 34 th 35 - 44 th 45 - 54 th 55 - 64 th 65 - 74 th 75 keatas
0,6%
1.8
5
10.5
13.5
14
12.5
PREVALENSI DM PERKOTAAN BERDASARKAN KELOMPOK UMUR
(RISKESDAS 2007)
4,9%
6,4%
PREVALENSI DM PERKOTAAN BERDASARKAN JENIS
KELAMIN (RISKESDAS 2007)
Laki-laki
Perempua
n
DM PREVALENCE BY AGE GROUP
DM PREVALENCE BY GENDER
Men
Women
Older Adults with Diabetes: Risks
Higher rates of premature death, functional disability,
coexisting illness (e.g. hypertension, CHD, stroke)

Greater risk for polypharmacy, depression, cognitive
impairment, urinary incontinence, injurious fall, and
persistent pain

Standards of Medical Care in Diabetes. Diabetes Care 2012;35(suppl 1) Jan 2012.
Diagnosis: Long-term vs. recent, substantial vs. no
complications, with range of physical and cognitive
functioning

Can have significant functional impairment or be very
active with no complications

Life expectancies variable but often longer than
clinicians realize
Older Adults with Diabetes:
Not All the Same
Standards of Medical Care in Diabetes. Diabetes Care 2012;35(suppl 1) Jan 2012.
CDC. Available at: http://www.cdc.gov/diabetes/statistics/dmany/fig4.htm.
0-44 years
45-64 years
65-74 years
75+ years
500
600
700
800
900
1000
0
100
200
300
400
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03
Year
R
a
t
e

(
p
e
r

1
0
0
0

D
i
a
b
e
t
i
c

P
o
p
u
l
a
t
i
o
n
)

Risk of Hospitalization Among People
with Diabetes Increases with Age
Most elderly patients with diabetes have T2DM

Pathogenesis of T2DM in older patients is similar to
other age groups
Pathophysiology and Rationale for
Treatment
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Coexisting
illness
Age-related
decreased
insulin secretion
Age-related
insulin
resistance
Adiposity
Decreased physical
activity
Genetics
Drugs
Factors
predisposing
the elderly to
diabetes
Factors Predisposing Older Adults to the Development of Diabetes
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Approach to Therapy
Goal: Prevent metabolic decompensation + control risk
factors for CVD
Control hypertension, lipid disorders, smoking

Treat severe hyperglycemia
To control fatty acid mobilization and oxidation, protein
catabolism/muscle wasting, excessive glucose production,
urinary loss of calories in the form of glucose

Standards of Medical Care in Diabetes. Diabetes Care 2012;35(suppl 1) Jan 2012.
Considerations
Patients life expectancy
Patient commitment
Availability of support services
Economic issues
Coexisting health problems
Complexity of medical regimen




ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition.
2009
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Healthy adult with reasonable life expectancy:
FG 100-130 mg/dl
PG <180 mg/dl
A1C <7 %

Older patient with advanced complications:
FG 140 mg/dl
A1C <7.5-8 %
Approach to Therapy:
Control of Hyperglycemia
Standards of Medical Care in Diabetes. Diabetes Care 2012;35(suppl 1) Jan 2012.
Nutrition Therapy
Weight reduction = better control of hyperglycemia

Barriers: Lifelong dietary habits; changes in taste, smell,
vision; neurological or muscular disorders; chewing and
swallowing difficulties; cost

Poor eating habits due to cost and difficulty shopping are
common


ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Nutrition Therapy
Goal of MNT: Meet nutritional needs; keep blood
glucose, blood pressure, blood lipids as close to normal
as possible

Dietician can be helpful to set up and maintain
appropriate diet

MNT= medical nutrition therapy
ADA. Complete Nurses Guide to Diabetes Care. 2
nd
Edition. 2009.
Exercise in Older Diabetic Patients
Exercise is beneficial in all ages

Recommend: Exercise tolerance test, supervision,
proper footwear

Important to minimize risk of hypoglycemia



ADA. Therapy for Diabetes Mellitus and Related
Disorders. 5
th
Edition. 2009
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Exercise in Older Diabetic Patients
Intensity must match patients physical fitness level
Stationary bike
Walking
Water aerobics
Exercise videos
Armchair fitness



ADA. Complete Nurses Guide to Diabetes Care.
Second Edition.2009
ADA. Complete Nurses Guide to Diabetes Care. 2
nd
Edition. 2009.
Physiologic Changes in the Elderly
Neurological
Ophthalmologic
Body composition
Gastrointestinal
Hepatic
Renal
Endocrine




ADA. Complete Nurses Guide to Diabetes Care.
Second Edition.2009
ADA. Complete Nurses Guide to Diabetes Care. 2
nd
Edition. 2009.
Hypoglycemic Drugs Other than Insulin
Start with small dose and increase slowly

Combination therapy: Limited evidence in older patients;
weigh benefits versus risks and adherence problems


ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Hypoglycemic Drugs Other than Insulin
Oral drugs can cause hypoglycemia

Renal and hepatic insufficiency risk factors for severe
hypoglycemia

If hypoglycemia occurs, observation required, especially
with long-acting agents
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Hypoglycemic Drugs Other than Insulin
Sulfonylureas: Risk for hypoglycemia low if nutrition is
good and no major renal and hepatic insufficiency

Avoid chlorpropamide and glyburide because of
hypoglycemia risk
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Approach to Therapy
Metformin contraindicated with renal insufficiency or
significant heart failure

TZDs can cause fluid retention (contraindicated in CHF)

Sulfonylureas, other insulin secretagogues, and insulin
can cause hypoglycemia



Standards of Medical Care in Diabetes. Diabetes Care 2012;35(suppl 1) Jan 2012.
CHF= congestive heart failure

Approach to Therapy
Biguanide: Contraindicated with elevated serum
creatinine (men 1.5mg/dl; women 1.4 mg/dl)

DPP4 Inhibitors: Dosage adjustment needed in renal
dysfunction

Incretins: No special considerations known

ADA. Complete Nurses Guide to Diabetes Care. 2
nd
Edition. 2009.
Insulin
Consider insulin when goals not met by weight reduction,
exercise, or other glucose-lowering drugs

Simple insulin regimen preferred

No contraindications to use






ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Insulin
Insulin use requires good visual, motor, and cognitive
skills
Can the patient administer insulin?
If not, can caregiver administer?
Insulin pen?

Patient and/or caregiver must be trained in self-
monitoring of BG

ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Impaired autonomic nervous system function
Impaired counter-regulatory responses
Poor nutrition
Cognitive disorder
Use of alcohol or sedating agent
Polypharmacy
Kidney or liver failure
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition.
2009
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5
th
Edition. 2009.
Potential Risk Factors for Hypoglycemia
in Older Patients
After age 60, patient visits often decrease because there
is no one to take the patient to the doctor
More homecare services by primary care doctors are
needed to address this gap in care:
Determine goals of therapy
Monitor glucose control
Special Issues: Access to Care
Older adults who are functional, cognitively intact and/or
with significant life expectancies should receive diabetes
care using goals developed for younger adults

Glycemic goals for those not meeting the above criteria
may be relaxed, but avoid hyperglycemia leading to
symptoms or risk of acute hyperglycemic complications

Recommendations: Older Adults
Standards of Medical Care in Diabetes. Diabetes Care 2012;35(suppl 1) Jan 2012.
Greater reductions in morbidity and mortality may result
from the control of CVD risk factors rather than tight
glycemic controls alone

Evidence supports treatment of hypertension; less
evidence for lipid-lowering and aspirin therapy

Individualize screening for diabetes complications with
attention to those leading to functional impairment (e.g.
visual, lower extremity complications)

Recommendations: Older Adults
Standards of Medical Care in Diabetes. Diabetes Care 2012;35(suppl 1) Jan 2012.
A schedule of blood glucose self-monitoring should be
considered, depending on:
Functional and cognitive abilities
Goals of care
Target A1C levels
Potential for modifying therapy
Risk of hypoglycemia

California Healthcare Foundation/American Geriatrics Society Panel on Improving
Care for Elders with Diabetes. J Am Geriatr Soc 2003;51:S265-S280.
Blood Glucose Monitoring in the Older
Adult with Diabetes
The measurement of A1C may not be accurate in
older adults due to:
anemia and other conditions that impact red blood cell
lifespan
chronic kidney disease
recent transfusions and erythropoietin infusions
recent acute illness or hospitalizations
chronic liver diseases
Blood Glucose Monitoring in the Older
Adult with Diabetes
http://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-elderly-patient
Integrated geriatric services in hospitals and community
health services (PUSKESMAS)

Home-based care centres & Centre for Family
Assistance (PUSAKA)

National Plan of Action for Elderly Welfare
Health of the Elderly in South-East Asia. WHO
2004
Programs for the Elderly in Indonesia
Health of the Elderly in South-East Asia. WHO 2004.
Verify comprehension:

E.g.: Tell me your understanding of how and when to take your
medications.

Clarify treatment benefits:

E.g.: When people take their insulin, they notice that their
blood glucose control improves, and they have more energy.
Do you notice that?
Strategies for Improving Adherence in
the Older Patient
Rubin RR. Am J Med 2005;118 Suppl 5A:27S-34S.
Goals of diabetes care in the elderly:
Control of hyperglycemia
Prevention and treatment of macro- and microvascular complications
Self-management through education
Maintenance or improvement of general health status

.
Summary
Case Study 1
Patient profile:
82-year-old woman with mild dementia
To be cared at home after brief stay in hospital for
pneumonia
Medical history:
CAD (MI 5 years ago), CHF, COPD, HTN, T2DM
Case Study 1 (contd)
Physical exam
BP: 130/84; Weight 105 lbs
Medications
Lisinopril 10 mg/day
Simvastatin 40 mg/day
Fluticasone/salmeterol inhaler bid
Insulin:
Glargine 15 units/day
Lispro 3 units before each meal
Case Study 1: Discussion
What is your A1C goal for this patient?
What are your recommendations for her insulin regimen?
Case Study 1: Follow-up
A month later, the nurses tell you the patient is
belligerent and tries to avoid receiving her insulin or
checking her BG
BG monitoring results are 140-190 fasting and 160-220
postprandial

What are you recommendations for the continued
management of this patient?
Case Study 2
70-year-old male with history of T2DM
HTN, hyperlipidemia
Routine physical exam:
Alert and interactive
BP 136/84; pulse 72;
Height 155 cm (5 1); Weight 66 kg (145 lbs); BMI 27.5
Labs: A1C=7.8%; Cr: 1.1
Medications:
Metformin 500 mg bid; Glipizide 10 mg qd
Case Study 2: Discussion
What is your A1C target for this patient?
What is your glycemic management plan for this patient?
Would you make any changes to his current
medications?