Case Study of Elderly patient with Long Standing Diabetes

Prof. Alaa Wafa

Mr. AH Mr. AH is a 70-year-old man who was diagnosed with T2DM 10 years

ago. He was initially treated with lifestyle management and metformin. 3 years later, his doctors advised him to add long acting basal insulin

analogue to metformin, reached to 40U/day . Other current medical conditions include: hypertension, hypothyroidism,

and mild osteoporosis without fracture history. Current medications; Metformin 1000 mg bid, long acting basal insulin

analogue 40U/day , Candesartan 16 mg qd, Alendronate 70 mg once weekly, Levothyroxine 100 mg qd.

Physical exam: BMI 26 kg/m2, BP 140/80 mmHg, otherwise unremarkable.

His current FPG 140 mg/dL and HbA1c 8.5%. Kidney and liver functions are normal.

Does his age should be a concern and why ?

What Kind of Care should this patient receive specifically ?

Q1. Based on the patient's age, physical examination, history, and laboratory values, what is an appropriate glycemic target for him?

A. 9.0%B. 8.0%C. 7.0%D. 6.5%E. 7-8%

Q2. Do you think increasing insulin dose is the best choice for Mr. A.H.?

A. YesB. No

Data Support Benefits of Vildagliptin in Newly Diagnosed Diabetes Or Patients with Short

History of Diabetes

Do you think that, Using Vildagliptin is useful with patient with longstanding diabetes?

It is a big Population...

7.5% of Population

Worldwide

Adapted from http://www.indexmundi.com/egypt/demographics_profile.html , https://www.cia.gov/library/publications/the-world-factbook/geos/eg.html , http://en.worldstat.info/World accessed 22-2-2014

0.22.1

7.9

17.6

14.9

02468

101214161820

12-19 20-39 40-59 60-74 ≥75

High prevalence of T2DM in the elderly population

National Health and Nutrition Examination Survey (NHANES) 2005-2006.T2DM=type 2 diabetes mellitus. Adapted from Cowie CC, et al. Diabetes Care. 2009; 32: 287–294.

%

Age (years)

Worldwide, the elderly population

in developed regions will nearly

double by 2050

Increasing in the proportions of older persons (60 years or older)

2013

≥60 Years ≤60 Years

International Diabetes Federation. Managing Older People with Type 2 Diabetes Global Guidelines. http://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Older%20People.pdf accessed 15-12-2013

2050

≥60 Years ≤60 Years

These changes present significant challenges to welfare, pension, and healthcare systems in both developing and developed nations

Diabetes-related complications are common in the elderly

• Diabetes-related complications are the major causes of morbidity, disability and mortality in older patients with type 2 diabetes:

• There is now overwhelming evidence that the level and duration of glycemia influences the development of diabetes-related complications

Sinclair 2004. Clinical guidelines for type 2 diabetes mellitus. EDWOP 2004

Microvascular: Neuropathy,Retinopathy,Nephropathy

Macrovascular: Cardiovascular disease, Stroke

Rates of Complications and Mortality in Older Patients With Diabetes Mellitus

(1/3)• The Diabetes and Aging Study:To contrast the rates of diabetes complications and mortality across age and diabetes duration categories.

• Design: This cohort study (2004-2010) included 72 310 older (60 years) patients with type 2 diabetes enrolled in a large, integrated health care delivery system.

Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study. 2013 Dec 9. [Epub ahead of print]

Rates of Complications and Mortality in Older Patients With Diabetes Mellitus

(2/3)

*Acu

te hy

pergl

ycem

ic ev

ent

*Acu

te hy

pogly

cemic

even

t

*End

-stag

e ren

al dis

ease

*Eye

dise

ase

*Peri

phera

l vas

cular

dise

ase

0

5

10

Age 60-69 yAge 70-79 yAge ≥80 y

Eve

nts p

er 1

000

Pers

on-y

ears

Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study. 2013 Dec 9. [Epub ahead of print]

*P Value < 0.0001All groups VS No morbidities

Rates of Complications and Mortality in Older Patients With Diabetes Mellitus

(3/3)

Corona

ry art

ery di

seas

e

Cerebro

vasc

ular d

iseas

e

Conge

stive

heart

failu

re

Mortali

ty0

20406080

100120

Age 60-69 yAge 70-79 yAge ≥80 y

Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study. 2013 Dec 9. [Epub ahead of print]

Even

ts p

er 1

000

Pers

on-y

ears

*P Value < 0.0001All groups VS No morbidities

Conclusion: Duration of diabetes and advancing age independently

predict diabetes morbidity and mortality rates

56% of health care expenditure attributed to diabetes is incurred by the

elderly populationCost in US$ millions

Institutional care Outpatient care Outpatient medicines and supplies

<45 years 45-64 years ≥65 years

American Diabetes Association. Diab Care 2008;31:596-615

Good glycemic control reduces the risk of long-term complications of diabetes

1. Stratton et al. BMJ 2000 ; 321 : 405-12 2. Turner et al. JAMA 1999 ; 281 : 2005-12

-43%-37%

-21%

-50%

-40%

-30%

-20%

-10%

0%

Reduction in long-term complication with every 1% reduction in HbA1c

Reductionin peripheral

vascular disease

Reductionin Microvascular

disease

Reductionin death related

to type 2 diabetes

The management of T2DM in the elderly is challenging

Ageing, diabetic microvascular and macrovascular complications, hyperglycaemia, hypoglycaemia, multiple morbidity and lack of

social support are risk factors for the geriatric syndromesT2DM=type 2 diabetes mellitus.Araki A, Ito H. Geriatr Gerontol Int. 2009; 9: 105–114.

Ageing

Diabetescomplications

Comorbidity

Lack of social support

Hyperglycaemia

Hypoglycaemia

Increasedmortality

Depression

Disability

Malnutrition

Urinary incontinence

Cognitive impairment

Falling

Risk factors Geriatric syndromes

Cognitive decline

Depression

Intoleranceto side effects

The achievement of good glycemic control in the elderly is challenging

Poor

Gly

cem

ic C

ontr

ol

“Frailty”

Co-morbidities

Poly-pharmacy

Compromised renal function

1. Gregg et al. Arch Intern med 2000 ; 160 : 174-80; 2. Ott et al. Diabetologia 1999 ; 53 : 1937-423. Rockwood et al. Drugs Aging 2000 ; 17 : 295-302; 4. Wolff et al. Arch Intern med 2002 ; 162 : 2269-765. Shorr et al. Arch Intern med 1997 ; 157 : 1681-6

Hypoglycaemia is a major challenge in the treatment of diabetes in the

elderly

• Advanced age• Recent hospitalization• Intercurrent illness• Chronic liver, renal or

cardiovascular disease• Endocrine deficiency

(thyroid, adrenal, pituitary)• Loss of normal counter-

regulation• Hypoglycaemic

unawareness

SU=sulfonylurea.Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.

I. Patient risk factors • Poor nutrition or fasting• Prolonged physical

exercise• Alcohol (ethanol)

• Use of SU and / or insulin• Drug interactions with SUs

III. Drug risk factors

II. Lifestyle risk factors

Severe hypoglycaemia accounts for almost 20% of all hospitalizations for

T2DM in the elderly

T2DM=type 2 diabetes mellitus.Greco D, et al. Exp Clin Endocrinol Diabetes. 2010; 118: 215–219.

Decompensated diabetes

39%

Intercurrent illness14%

Acute cardiovascular

events13%

Chronic complications

of diabetes1

Severe hypoglycaemia

17%

The risk of hypoglycaemia can increase due to drug interactions with

SUs

MAOI=monoamine oxidase inhibitor; SU=sulfonylurea.Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.

Displacement of SUs from the

plasma proteins

Reducing the hepatic

metabolism of SUs

Decreasing the urinary excretion

of SUs or their metabolites

The consequences of hypoglycaemia

Cardiovascularcomplications3

Weight gain by defensive eating5

Coma3

Increased risk of car accident6

Hospitalisation costs4

Loss of consciousness3

Increased risk of seizures3

Death2,3

Increased risk of dementia1

1Whitmer RA, et al. JAMA. 2009; 301: 1565–1572; 2Bonds DE, et al. BMJ. 2010; 340: b4909; 3Barnett AH. Curr Med Res Opin. 2010; 26: 1333–1342; 4Jönsson L, et al. Value Health. 2006; 9: 193–198;5Foley JE, Jordan J. Vasc Health Risk Manag. 2010; 6: 541–548; 6Begg IS, et al. Can J Diabetes. 2003; 27: 128–140; 7McEwan P, et al. Diabetes Obes Metab. 2010; 12: 431–436.

Reduced quality of life7

Hypoglycaemia

So, Management challenges can lead to cautious prescriptions

in the elderly

1. Market research, data on file, Novartis.2. Cryer PE. Diabetes 2008; 57: 3169-76

Hypoglycemia

Other factors

Glycemic targets

Man

agem

ent c

halle

nges

?• Glycemic targets for elderly with long-standing or

more complicated disease should be less ambitious than for the younger, healthier individuals

• If lower targets cannot be achieved with simple interventions, an HbA1c of 7.5–8.0% may be acceptable, transitioning upward as age increases and capacity for self-care decline

> 65 Years

Older adults who are functional, cognitively intact, and have significant life expectancy

should receive diabetes care with goals similar to those developed for younger

adults. (E)

Glycemic goals for some older adults might reasonably be relaxed, using

individual criteria, but hyperglycemia leading to symptoms or risk of acute

hyperglycemic complications should be avoided in all patients. (E)

ADA 2014: Treatment Goals according to health status