Care of Diabetes in older adults
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Care of Diabetes in Older Adults
Dr. Zuhayer AhmedHMO
Dept. of EndocrinologyDMCH
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Older Adults
•Young Old: –65-75 years
•Older Old:– >75 years
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Older Adults are special!
•20% of over 65 years
•Premature death
•Functional Disability
•Co-existing illness:–Hypertension–Coronary Heart Disease–Stroke
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Diabetics more vulnerable!
•More prone to geriatric syndromes:
–Polypharmacy
–Cognitive impairment
–Urinary incontinence
–Injurious falls
–Persistent pain
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Presentation Focus
• Treatment Targets
• Glycemic Goals
• BG Control
• Minimizing Complications
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Treatment Targets
•Symptom free
•Prevent short term complications
•Prevent long term complications
•Quality of life =Lifestyle focus
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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
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• 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
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Controlling blood sugar levels
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Exercise/Activity
•Increased insulin sensitivity
•Decreased insulin requirements
•Weight reduction
•Lipid control
•Blood pressure control
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Healthy Eating
• Regular carbohydrate
• High in fibre
• Low in fat (particularly saturated fat)
• Low in added sugar
• Adequate energy /protein/fluids/vits and mins
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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
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Kidneys, Eyes & Feet
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Renal Function
•Assess annually –3-6/12 if positive
(microalbuminuria/protein)
•Creatinine annually
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Eye Examination
• Assess at diagnosis and every 2 years
•If retinopathy present, assess annually
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Foot Assessment
• Assess annually• •3-6/12 for high risk feet
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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)
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Nutrition Assessment
•Distribution and intake of carbohydrates important
•Weight loss not recommended unless > 20% above weight range
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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
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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
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Hypoglycemia
•Higher risk:
–Insulin overdose
–Progressive renal insufficiency
–Cognitive impairment:•Difficulty in complex self-care activities
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Hypoglycemia
• Specific education to the elderly and carergivers
•Changes in OHA & other medications
• Increase BG testing frequency
• Caution with prescribing diabetes tablets /insulin treatment
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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
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Life Expectancy
•Variable, but often LONGER!!
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Thank you!