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Diabetes and the Older Adult

Diabetes and the Older Adult Tony Hampton, MD, MBA Disclosures Presenter disclosures, if any, listed here. Learning Objectives Define the present and future epidemiology of Diabetes and its complications in Older adults Discover screening, diagnostic, and prevention strategies for Diabetes in Older adults Discuss individualization of care and prevention of Diabetes in Older adults Identify best practices to involve patients in decisions related to Diabetes care in Older adults Epidemiology of Diabetes in Older Adults More than 25% of the US population over 65 has Diabetes Half over 65 have prediabetes Postprandial hyperglycemia is common in Older adults Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States.

• More lower extremity amputations • More nonretinopathy visual impairment ... Barthel Index (BI) Assesses the ability to perform 10 activities of daily living (ADL) ... functional outcome than MMSE : Requires ≥15 mins. to administer .

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Transcription of Diabetes and the Older Adult

1 Diabetes and the Older Adult Tony Hampton, MD, MBA Disclosures Presenter disclosures, if any, listed here. Learning Objectives Define the present and future epidemiology of Diabetes and its complications in Older adults Discover screening, diagnostic, and prevention strategies for Diabetes in Older adults Discuss individualization of care and prevention of Diabetes in Older adults Identify best practices to involve patients in decisions related to Diabetes care in Older adults Epidemiology of Diabetes in Older Adults More than 25% of the US population over 65 has Diabetes Half over 65 have prediabetes Postprandial hyperglycemia is common in Older adults Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States.

2 Atlanta, Georgia, Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. Kirkman MS. Diabetes in Older Adults ADA Consensus Report. Diabetes Care 2012. Onset 65 Years vs. Middle Age Shorter Diabetes duration lower mean A1C lower insulin use lower incidence of retinopathy Longer Diabetes duration Higher mean A1C Higher insulin use Higher incidence of retinopathy Older Onset Middle Age Onset No difference in prevalence of cardiovascular disease (CVD) or peripheral neuropathy Selvin E, et al. Diabetes Care 2006; 29:2415-19. Exponential Growth of Adults 65 in the US 020,000,00040,000,00060,000,00080,000,00 0100,000,0001900191019201930194019501960 197019801990200020102020203020402050 Year Population 65+ by Age: 1900 2050 Age65-74 Age75-84 Age85+ #age One out of every five Number of persons 65+ Know Your Patient Population: Recognize Disparities 051015202530354045 White menWhitewomenBlack menBlack womenAsian menAsian women45-6465-7475+Centers for Disease Control and Prevention.

3 Percent US Population with Diagnosed Diabetes , by Age, Race and Sex. 2011. Percent prevalence of T2DM Race and gender 2011 Diagnosis of Diabetes in All Adults Criteria do not change with age Diagnosis based exclusively on hyperglycemia Three methods used to determine dysglycemia HbA1c Fasting Glucose OGTT (2 hr. glucose) 126 mg/dL (7 mmol/L) 200 mg/dL ( mmol/L) 100 125 mg/dL ( mmol/L) 140 199 mg/dL ( mmol/L) < <100 mg/dL ( mmol/L) <140 mg/dL ( mmol/L) Sacks DB, et al. Clin Chem 2011; 57:147-9. NORMAL PREDIABETES Diabetes ADA recommends screening adults 45 years every one to three years Use FPG test, A1C, or oral glucose tolerance test Annual screening for early detection of mild cognitive impairment or dementia in adults 65 years of age Adults 65 years of age with Diabetes should be considered a high priority population for depression screening and treatment American Diabetes Association.

4 Diabetes Care 2017; 40(Suppl. 1):S99-104. Screening in Older Adults Highest Rates of Complications Li Y, et al. Diabetes Care 2012; 35:273-77. Centers for Disease Control and Prevention. Diabetes Public Health Resource. More cardiovascular disease More lower extremity amputations More nonretinopathy visual impairment More end-stage renal disease Hyperglycemic crisis death Age 65-74 More complications 2x rate of ER visits due to hypoglycemia Age 75+ also experience <3 chronic diseases No cognitive or significant visual impairment 0 or 1 of instrumental activities of daily living (IADL) dependencies RELATIVELY HEALTHY 3 chronic diseases Mild cognitive impairment Severe vision impairment 2 IADL dependencies DIFFICULT TO IMPLEMENT Moderate to severe cognitive impairment 2 IADL dependencies Residence in a long-term nursing facility LIMITED BENEFIT Heterogeneity of Older Adults with Diabetes Blaum C, et al.

5 Medical Care 2010; 48(4):327-34. Vision/hearing impairment Gait problems and falls Depression Cognitive impairment Diabetes and Geriatric Syndromes Laiteerapong N, Karter AJ, Liu JY, et al. Diabetes Care 2011; 34:1749-53. Worsening functional Impairments and Disability Polypharmacy Diabetic eye disease Diabetic foot disorders Obesity Depression High blood pressure Low education level Low income level Greater disability Delayed recovery Hospitalization Nursing home stays ASSOCIATED CONDITIONS functional Impairment Diabetes and functional Impairment NAME CONTEXT STRENGTHS LIMITATIONS 10 Meter Walk Test (10 MWT) Tests short duration walking speed; tests gait and functional mobility Easy/quick to administer (<5 mins.) Assistive devices can be used Not for patients who cannot walk without caretaker assistance Timed Up & Go Test (TUG) Assesses mobility, balance, walking ability, and fall risk Easy/quick to administer (<5 mins.)

6 Excellent test-retest reliability and correlation with other assessments May demonstrate less reliability among patients suffering from cognitive impairment Barthel index (BI) Assesses the ability to perform 10 activities of daily living (ADL) Easy/quick to administer (<5 mins.) for self-report; 20 mins. for observation Widespread familiarity contributes to its interpretability Not for use with people who have Communication deficits and changes in their mental status Four Step Square Test (FSST) Test of dynamic balance; clinically assesses ability to change directions while stepping Easy/quick to administer (<5 mins.) Preferred by Older adults they feel it is relevant to daily life Can be difficult for impaired patients to perform Assessments for Physical Function Rehabilitation Measures Database. Vision and Hearing Impairment Johnson CE, et al.

7 Eye 2009; 58(9):471-7. Ophthalmologic examination at the time of diagnosis and at least yearly thereafter to screen for diabetic retinopathy, cataracts, glaucoma Symptomatic patients with prediabetes and Diabetes can benefit from screening for hearing loss Ask, Do you have a hearing problem now? Refer to audiologist for thorough audiological evaluation and appropriate recommendations for aural rehabilitation NAME CONTEXT STRENGTHS LIMITATIONS Clock Drawing Test/ Mini Cog Assessment Tests executive functioning Easy/quick to administer (<5 mins.) Not for patients with visual impairment or who can t hold a writing tool Confusion Assessment Method (CAM) Diagnoses delirium with altered mental status Clearly defined clinical features Does not identify the cause of delirium Digit Span Test Tests attention and immediate recall Easy/quick to administer (<5 mins.)

8 Only tests attention and immediate recall Folstein Mini-Mental State Exam (MMSE) Tests multiple cognitive domains Widely used; assesses several cognitive domains Age, education, cultural background affect the score; insensitive to change over time Modified Mini Mental Status Examination (3MS) Tests multiple cognitive domains Higher sensitivity, similar specificity, better predictor of functional outcome than MMSE Requires 15 mins. to administer Assessments for Cognitive Function Screen for cognitive dysfunction at initial work-up Periodic screening at subsequent appointments Simplify self-care regimen Interview and involve caregivers Cognitive Status Whitmer RA, et al. JAMA 2009; 301:1565-72. Cukierman T, et al. Diabetologia 2005; 48: 2460-69. Approximately 20% of Older adults with Diabetes have undiagnosed CI Alzheimer s-type and multi-infarct dementia are two to three times as likely in an Older Adult population with Diabetes T2DM is associated with medial temporal lobe atrophy and poor performance on tests of executive function, speed, memory and attention, language and praxis Verdelho A, et al.

9 The LADIS Study. J Neurol Neurosurg Psychiatry 2007; 78(12):1325-30. Yoshitake T, et al. Neurology 1995; 45:1161-68. Ott A, et al. Neurology 1999; 53:1937-42. Diabetes and Cognitive Impairment Novak V, et al. Diabetes Care 2012; 34(11):2438-41. Lauder LJ, et al. ACCORD Study. Lancet Neurol 2011; 10:969-77. Whitmer RA, et al. JAMA 2009; 301:1565-72. Cukierman T, et al. Diabetologia 2005; 48:2460-69. Cognitive Function Hypoglycemia Hyperglycemia Insulin resistance Insulin insufficiency Diabetes and Cognitive Impairment Depression in Older Adults with Diabetes Depression and Diabetes are synergistic earlier onset of negative outcomes than either factor alone: -Poor glycemic control -Poor self-care -Accelerated rates of coronary heart disease -Higher occurrence of dementia -Higher mortality -Greater disability and complications Katon WJ, et al.

10 Arch Gen Psychiatry 2012; 69:410-17; Katon WJ, et al. Diabetes Care 2005; 28:2668-72. Lin EH, et al. Diabetes Care 2004; 27:2154-60; Black SA, et al. Diabetes Care 2003; 26:2822-8. Treating Diabetes in Older Adults Management Rules of Diabetes in Older Adults Rule # 1: Individualize targets Rule # 2: Avoid hypoglycemia Rule # 3: Individualize medications Individualization of Glycemic Targets Diabetes Care 2017; 40(Suppl 1): S53. Framework for Individualizing A1C Targets in Older Adults Reasonable A1C goal for healthy Older adults <7% May be appropriate if it can be safely achieved in healthy Older adults with few comorbidities and good functional status < Appropriate for Older adults with multiple comorbidities, poor health, and limited life expectancy Potential harm in lowering A1C to < in Older adults with type 2 and comorbidities Brown AF, et al.


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