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Diabetes Core Update
Diabetes in Older Adults Consensus Statement
00:27:33
Diabetes Core Update is a monthly podcast that presents and discusses the latest clinically relevant articles from the American Diabetes Association’s four science and medical journals – Diabetes, Diabetes Care, Clinical Diabetes, and Diabet
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- [00:01]
A
Welcome to the American Diabetes Association Core Update. While we usually go over the most important articles from the core journals published by the American Diabetes association, today we will cover a recent consensus report published in Diabetes Care on diabetes in older adults. Joining us today will be our usual host, Dr. Neal Skolnick, as well as a member of the consensus committee, Dr. Mary Kordkowski.
- [00:28]
B
Dr. Skolnick, today we're going to go over the recent physician statement on diabetes in older adults published online in November of 2012, and in the December 2012 edition of Diabetes Care. The reason this topic is important is because more than 25% of the United States population age 65 and older have diabetes. Both in number of individuals over 65 and the proportion of them with diabetes is expected to increase for the foreseeable future. Diabetes in older adults is linked to higher mortality, reduced functional status and an increased risk of institutionalization. Heterogeneity of health status of older adults and the relatively small amount of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. The risk benefit of intensive treatment and the increase in side effects typically experienced by the elderly make decisions about treatment challenging ones. To address these issues, the American Diabetes association put together a consensus development conference on diabetes and older adults. The position statement that was the result of this conference is what we're going to talk about today. Joining us today is one of the members of the committee that developed the consensus report, Dr. Mary T. Kortakowski. Dr. Kortakowski is a professor in the Division of Endocrinology at the University of Pittsburgh. Welcome, Dr. Kortakowski.
- [02:12]
A
Oh, thank you. My pleasure.
- [02:15]
B
Since we only have about 20 minutes to discuss the consensus statement, we'll restrict our discussion to the highlights of the statement and we'll encourage our listeners to go to the American Diabetes association website@www.diabetesjournals.org to download and read the full statement. For a first question, can you tell us about the epidemiology and consequences of diabetes in older adults?
- [02:43]
A
Well, as you mentioned in your opening statement, one out of every four people above the age of 65 has diabetes. There are several reasons for this, some of which are related to the prevalence of overweight and obesity among the American population, particularly those who are older, as well as the increasing tendency to more sedentary lifestyle and behaviors as people get older and as they move away from exercise. But there's also pathophysiologic factors at play that are associated with an age related loss of muscle mass as well as inefficiencies in energy metabolism that accompany aging. But there's also an age related decline in the function of beta cells that has also been reported. Now, among those who have diabetes, about a third of those are not aware of the diagnosis. And this is important. The consequences of not knowing that you have diabetes can be serious. We know that older adults with diabetes have the highest rates of lower limb amputations, heart attacks, visual problems, kidney failure, and rates are even higher for those above age 75. Much of this can be prevented with good control of blood glucose values as well as other metabolic measures such as blood pressure or lipids that accompany the management of type 2 diabetes and type 1 diabetes. Now, one of the reasons why these people don't know they have diabetes is it has a relatively insidious onset. As people get older. People may experience symptoms of feeling fatigued at night to urinate, often attributing these symptoms to normal aging or what to expect as they get older, and not necessarily being aware that this could be due to something that is treatable.
- [04:49]
B
Let's now discuss some of the evidence for preventing and treating diabetes and its common comorbidities in older adults, as well as the guidelines of the American Diabetes association that have been drawn from the evidence. If we can start with the discussion of screening for the elderly.
- [05:06]
A
Well, the American Diabetes association recommends that all adults over the age of 45 be screened every one to three years with either a fasting glucose, a hemoglobin A1C, or an oral glucose tolerance test. In reality, we actually rarely perform oral glucose tolerance tests and many patients become nauseated during these tests and find them time consuming and uncomfortable. So usually we'll use a fasting glucose, a postprandial glucose, or an A1C. Because the prevalence of diabetes is so common in those above age 65. As we previously mentioned, screening someone with a fasting glucose once a year would not be unreasonable in the population above the age of 65. Now, why screen these patients? Well, again, it's to identify the disease as early as possible as a way of intervening to prevent some of the diabetes related complications that can impact both the duration of life as well as the quality of existing life. So can diabetes be prevented? Well, certainly we know there are people at high risk, such as those who are overweight or who have a positive family history. People who have high cholesterol or high triglycerides can have underlying diabetes as well as those with elevated blood pressures. There was a diabetes prevention program that was conducted in a group of high risk individuals for type 2 diabetes that was recently published and this cohort has been followed. One of the randomization arms in this study was therapeutic lifestyle intervention, which was caloric restriction to try to lose 10 to 15% of body weight and regular exercise, meaning at least 30 minutes of exercise five days per week. What was interesting about the study is that the participants who were over age 60 had a greater response to the lifestyle intervention than the younger participants. They had a less robust response to metformin, which is often used for treating pre diabetes. This cohort of patients has now been followed up for 10 years, meaning that a lot of these people are well over the age of 70 now. And it was shown that there was a legacy effect of this intensive lifestyle intervention with again a greater reduction in progression to diabetes. Among those who were randomized to the intensive lifestyle intervention of reduction of 50% compared to reductions of about 30% for those less than age 65.
- [08:04]
B
That's pretty remarkable. I just want to point that out that for me that was a surprising result and it's in some ways paradoxical that in a group that you don't think of as necessarily able to change their habits easily, and you might not ordinarily think of as able to sustain exercise and lifestyle changes, in fact, it was more effective than in younger people.
- [08:29]
A
Right? It's a very good point and it probably speaks to the underlying pathophysiology of the disorder of diabetes in the elderly population with this reduction in muscle mass, meaning they're more likely to become insulin resistant. So if they exercise and improve energy metabolism, they have a better response to exercise.
- [08:54]
B
When we move on to patients with established diabetes, how do we approach setting glycemic goals in the elderly?
- [09:01]
A
Well, I think this is where some of the biggest questions come up for what to do with the elderly population. As you're aware of, you know that the American Diabetes association recommends that we try to achieve A1C levels of about 7% or below 7% in the majority of people with type 2 diabetes. However, this recommendation is not absolute and there are many contingencies included, such as those who are at high risk for hypoglycemia or who have limited life expectancy or who have other comorbid conditions, which can describe many of those in the population of individuals over 65. So what happened with this consensus statement is that patients were actually put into categories. It's very difficult to make recommendations for glycemic control based on age alone. But looking at age together with functional status, presence or absence of other comorbid conditions or diabetes related complications as well as the severity of these other comorbid conditions or complications can help guide therapy. When those who are listening go to the website, they'll find that there's a very nice table within the paper that describes different levels of recommended glycemic control depending on where someone falls in this assessment. For those who are very healthy and doing well regardless of age, aiming for an A1C of less than 7.5% is reasonable. And if they do well with an A1C of 6.5%, that's also fine. But for those who have more comorbid illnesses or more complications, maybe aiming for a level of less than 8% would be reasonable, while those who have the most frail or the most severe comorbid illnesses, aiming for an A1C of less than 8.5% is reasonable. And this goes along with some published data that has demonstrated these U shaped curves between mortality and morbidity and A1C levels, where those at the very low end of A1C of less than 6%, at least for people with diabetes, had higher mortality and morbidity at the low end as well as those with a 1Cs at the higher end, while those with a 1C's between 7 to 8% had the lower levels. The nice thing about aiming for less than 8.5 is it also is saying not to avoid bringing these people under control and definitely to still use targeted management, but just allowing your targets to be a little higher.
- [12:24]
B
That's fantastic. So there really is. We've moved from a one size fits all approach to more individualization of target goals based on someone's both age and comorbid illnesses. How about for lipid lowering?
- [12:41]
A
Well, that's also. That's another good point. Although we have less data to support particular recommendations in older adults with type 2 diabetes, but we do have data for older adults and have extrapolated from that population to the diabetic population. So even among subjects above the age of 70, the use of statin medications have been shown to reduce the risk of cardiovascular disease by approximately 20%, similar to what would be observed in those below the age of 70. So in each of those first two groups, both at the healthy elderly as well as those with some comorbid conditions but who are still doing okay, statin therapy is generally recommended, while those who have very poor health or have multiple more severe comorbid illnesses, I think it has to be looked at in the context of their overall health status and life expectancy.
- [13:49]
B
That makes sense. And then how about with regard to.
- [13:52]
A
Blood pressure well, similar there, although we do have a little more data again in populations with and without diabetes. But the ACCORD trial, which was published within the past couple of years and demonstrated that there was really no benefit to pushing for normalization of A1C in a population of patients with underlying cardiovascular disease and long term diabetes, also had a blood pressure arm to the study. And in the blood pressure arm they compared two systolic targets with one of less than 120 millimeters of mercury and the other of less than 140 millimeters of mercury. And they found no difference in cardiovascular outcomes between those two groups. And of course, over treating blood pressure in the elderly can result in lightheadedness, dizziness, fatigue and even syncope with falls. So here the recommendations for blood pressure are for the healthiest category to aim for blood pressures less than 140 over 80. The same would hold for those in the intermediate group, while those with more severe comorbid illnesses to aim for blood pressures less than 150 over 90. In part as a way of avoiding the polypharmacy the that is necessary. Often patients need three or four medications in order to bring their blood pressure to a desired range.
- [15:38]
B
That's a great point. And particularly in the frail elderly, polypharmacy is a critical issue. The other issue that comes up a lot is decisions about aspirin. What does the consensus statement say about use of aspirin?
- [15:53]
A
Well, the consensus statement says that it is reasonable to use low dose aspirin therapy as primary prevention for men above the age of 50 and women above the age of 60, provided there are no contraindications to its use. Certainly it can be used for secondary prevention at even lower ages in those with already a stage cardiovascular disease. But the issues to consider with the elderly would be the risk of bleeding. And there is not a lot of data showing that bleeding is any greater in the elderly than it would be in the younger populations. So again, it would just be sort of putting it in context of what the overall health status is of the patient. Again, for those who are the healthiest, older adults, and those who are sort of in the intermediate category, it's probably reasonable to continue to use aspirin therapy, while in those who have more complex or more severe disease, it's not necessarily contraindicated, but some thought should be given to whether it's safe to continue to use it in a particular person.
- [17:15]
B
Another issue that comes up a lot is older adults are generally at increased risk for adverse drug reactions from the medicines they take. Their pharmacokinetics are different than that of younger adults due to factors such as decreased renal clearance of medicines. They're often more sensitive to the effects of medicines and specifically they are at increased risk of hypoglycemia with medications used for diabetes. Can you discuss some of the specific aspects of drug therapy we should be aware of with regard to pharmacotherapy in older adults?
- [17:47]
A
Right. That is a very good point. There are now several different classes of medications to choose from and there are really no absolute contraindications to any particular therapy for type 2 diabetes with the exception of glyburide. Glyburide is a sulfonylurea that has been around for a long time, but it is the sulfonylurea that has the highest risk of hypoglycemia in young adults, but even greater in older adults. And I would suggest that glyburide and this consensus statement actually makes a point that glyburide should not be used at all in older adults. Similar to the guidelines for younger people with type 2 diabetes, there is a recommendation for initiation of metformin. Metformin together with therapeutic lifestyle intervention at the time of diagnosis of diabetes in elderly populations. That does raise the issue of renal function because we also know that just like diabetes increases with increasing age, the prevalence of chronic kidney disease also increases with increasing age. And while creatinine may be normal, the EGFR may be below 60 in some of our elderly patients. There was a recent consensus paper printed about metformin and EGFR in diabetes care recently, sort of looking at recommendations by diabetes associations in other countries in addition to the United States States, suggesting that it may be safe to continue to use metformin in those with EGFR as low as 45ml min and below, that maybe other medications should be used. Another issue that I think gets overlooked a lot with metformin is that it interferes with the absorption of B12. And given that B12 deficiency also increases in an elderly population, it's probably reasonable to either monitor B12 levels or to start low dose supplements with B12. In these patients, sulfonylureas are often used. These are insulin secretagogues as probably the second most commonly used drugs for older and younger people. Here what's really important to inform patients about is that the major risk factor for these agents is hypoglycemia and patients should be made aware of what a low blood sugar reaction feels like so that they don't mistake it for something else and not treat it appropriately. Not only do we have patients monitor for hyperglycemia, but also for hypoglycemia. And many elderly patients with diabetes don't necessarily feel that well when their blood Sugars are below 80 to 90. So that's an important consideration. The short acting insulin secretagogues like ripaglinide and nutaglinide cause meal related increases in circulating insulin levels. But when looked at in comparison to sulfonylureas, they also are associated with risk for hypoglycemia. So even with these agents, patients need to be informed. Some of the other agents, the thiazolidine diones, have been around for a while, but their use has really plummeted with evidence of risk for cardiovascular risk in the elderly with rosiglitazone. Risk for congestive heart failure with both rosiglitazone and pioglitazone, as well as the observation that these are associated with reductions in bone density in both men and women, with an increase in fracture risk in women. So that definitely has implications for the elderly. Also, glucosidase inhibitors are not used very frequently in the United States. If they are used, probably using them in low doses with the largest meal of the day can be helpful in some patients. And then there's the newer agents that adjust the incretin system. These are agents that augment insulin secretion via the action of the hormone glucagon, like peptide 1. These are injectable agents of exenatide and liraglutide, or there are agents that inhibit the enzyme dipeptide that can be taken orally and they prolong the duration of action of endogenously secreted GLP1. There really is no data specific to elderly populations with either of these drugs, although there's no evidence that they would be harmful to use in the elderly. The main side effect with the injectable GLP one agonist is nausea and vomiting with a reported risk for pancreatitis. So patients need to know about that. The dipeptidylpepeptidase 4 inhibitors seem to be generally well tolerated and carry a low risk for hypoglycemia when used alone. I think the main issue with these latter two agents is cost. They're very expensive agents and that's often an issue for many elderly patients. Insulin is not contraindicated in the elderly and it's often necessary, as I mentioned earlier, that there is a decline in beta cell function with aging, particularly in those at risk for or with diabetes. So if necessary, addition of a basal insulin alone in those who have gradual deterioration, deteriorations in glycemic control or in a regimen of a long acting basal insulin in combination with premedal insulin may become necessary for those who have more severe deteriorations in glycemic control. So age is not a contraindication to basal bolus insulin therapy.
- [24:32]
B
Those are really helpful practical points about medical therapy in the elderly. How about particular issues regarding the care of patients with diabetes in long term care facilities?
- [24:43]
A
Well, there are and that population has probably been the least well studied even though there's a prevalence of diabetes in residents of long term care facilities is higher than it is in the general community. Of the few studies that have been done in this population, it seems like sliding scale insulin is the most used method for treating diabetes. And we know that that's probably the least effective method for treating diabetes. These patients also have a higher risk of falls. They have more functional impairments and more cognitive impairments than those who don't live in these facilities. Also, their meal consumption may be more erratic and more irregular. So overall in these patients it's important to avoid hypoglycemia as well as hyperglycemia because they can with impaired thirst mechanisms, they can become dehydrated and can develop severe hyperglycemia. So the recommendations currently are that these patients have their blood glucoses monitored regularly while they're hospitalized or in these long term facilities and that agents that would be associated with a low risk of hypoglycemia that also are effective at avoiding hyperglycemia may be preferable. This could be metformin. If their renal function is adequate and they tolerate this. This could be a single daily dose of a basal insulin with correction insulin only if their blood sugars go above a certain level. But we really don't have data to support one treatment approach over another.
- [26:42]
B
Dr. Kurtajkowski, we really covered a lot of material. We talked about individualization with regard to glycemic goals. We talked about goals with regard to lipid lowering blood pressure and aspirin. Then we discussed details about the different medications and their particular benefits and risks in the elderly. I thank you for taking the time to share the information from the position statement with our listeners. For more information, our listeners can go to www.diabetesjournals.org for the American Diabetes Association, I'm Dr. Neal Skolnick. Thanks for listening. LA.