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Diabetes Melitus Type 2 in People Over 65

Arief Zamir 030.06.034

FACULTY OF MEDICINE TRISAKTI UNIVERSITY JAKARTA 2011

history of impaired glucose regulation. .ABSTRACT Type 2 diabetes mellitus (DM) is far more common than type 1 DM among the elderly. or American Indian ethnicity. and black. insulin secretion is severely impaired and peripheral insulin resistance is mild or nonexistent. family history of DM. Hispanic. prevalence increases with aging. However. there are many elderly patients with type 2 DM who are not obese. In patients > 65. in these patients. sedentary lifestyle. Most patients with type 2 DM have both inadequate insulin secretion and increased peripheral resistance to insulin caused by age-related weight gain and increased body fat. risk factors include obesity. history of hypertension or dyslipidemia.

... 5 ……..... Definition …………………………………………………………………........ 6 VI..... Symptoms .................... 2 Table of Content Diabetes Melitus Type 2 I.... Diagnose …………………………………………………………………..... 8 Conclusion ........................ Physiology of aging ………………………………………………………..........TABLE OF CONTENT Abstract …………………………………………………………………………… 1 ……………………………………………………………………............... 3 …………………………………………………………………… 3 II........ Causes III................Therapy ………………………………………………………………….......................12 .................... 4 IV............................ 7 VII...........................…………………………………………………….. Risk Factor ……………………………………………………………… 8 VIII..... Pathogenesis V.............

whereas type 2 DM is heterogeneous group of disorders characterized by variable degree of insulin resistance. it may be present for years before it is detected. drugs (nicotinic acid. It is common among the elderly because of agerelated increases in body fat. endocrinopaties (acromegaly. disease of exocrine pancreas (chronic pancreatitis. stroke. when hyperglycemia has been severe enough and present long enough to cause symptoms. impaired insulin secretion. Causes Diabetes mellitus comprises a group of metabolic disorders that share the common phenotype of hyperglycemia.( 2 ) . cystic fibrosis. and increased glucose production. Other specific type include DM caused by genetic defects [maturity-onset diabetes of the young (MODY)]. peripheral neuropathy. the terms type 1 and type 2 DM have replaced insulin dependent diabetes mellitus (NIDDM). Hyperglycemia may be mild and is usually asymptomatic. Later complications include MI. In the elderly. and drugs that reduce glucose levels. Treatment is diet. respectively. symptoms may be nonspecific. exercise.DIABETES MELITUS TYPE 2 I. DM is currently classified on the basis of the pathogenic process that leads to hyperglycemia. peripheral arterial disease. hyperthyroidisme). pheocromocytoma. Definition Type 2 diabetes mellitus is variable degrees of peripheral insulin resistance and impaired insulin secretion leading to hyperglycemia. Diagnosis is by measuring plasma glucose. retinopathy. Cushing’s syndrome. nephropathy. protease inhibitors). thiazides. hemochromatosis).( 1 ) II. glucagonoma. including oral antihyperglycemics and insulin. Type 1 DM is characterized by insulin deficiency and a tendency to develop ketosis. Under the classification. glucocorticoid acids. and predisposition to infection.

changes such as confusion. incontinence. symptoms of cognitive impairment and long-term implications regarding dementia need to be researched. which may contribute to the reduction in autonomic warning symptoms. Part of the problem is that. because of the normal physiological changes associated with aging. there is no impairment in glucose-induced insulin release as seen by a normal second-phase insulin secretion among obese elderly patients. Dehydration is often more common with hyperglycemia because of elderly patients altered thirst perception and delayed fluid supplementation. Alterations in carbohydrate metabolism in the elderly include the loss of first-phase insulin release. It is said that at least half of the diabetic elderly population do not even know they have the disease. This suggests that the primary impairment in obese elderly patients is insulin resistance. Studies of healthy elderly patients have shown that glucose counterregulation involving glucagon. More often. it is important to remember that both type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes occur in the elderly. whereas lean elderly patients have impaired glucose-induced insulin release. In contrast to lean elderly and younger adults with diabetes. Lean elderly diabetic patients may even display features of autoimmune changes normally attributed to younger type 1 diabetic patients. Thus. and growth hormone responses to hypoglycemia are diminished. elderly diabetic patients rarely present with the typical symptoms of hyperglycemia. The initial surge in postprandial insulin does not occur in all elderly diabetic patients. Hypoglycemia is often a risk of diabetes treatment in the elderly. Physiology of aging Many age-related changes affect the clinical presentation of diabetes. epinephrine. Although classic overt symptoms of hypoglycemia may be absent. Polydipsia is usually absent because of decreased thirst associated with advanced age. or complications relating to diabetes are the presenting symptoms. . Islet cell antibodies and marked insulin deficiency are increasingly seen in lean elderly diabetic patients. The renal threshold for glucose increases with advanced age.III. These changes can make the recognition and treatment of diabetes problematic. and glucosuria is not seen at usual levels.

distribution. Elderly patients with peripheral insulin resistance and reduced glucose-induced insulin release are more likely to develop type 2 diabetes than those without. Thus. The specific genes responsible have not been discovered. there are often symptoms present with severe hypoglycemia (blood glucose levels <50 mg/dl) that are not present with moderate hypoglycemia. Pathogenesis A strong genetic predisposition to type 2 diabetes in middle-aged and elderly patients exists. Changes in drug absorption. Physiologic and environmental factors compound genetic predisposition. In elderly identical twins discordant for type 2 diabetes. fasting hepatic glucose production is normal in elderly patients with type 2 diabetes. Elderly individuals who have a high intake of fat and sugar and a low intake of complex carbohydrates are more likely to develop diabetes. ( 3 ) IV. Lower testosterone levels in men and higher testosterone levels in women are risk factors for diabetes development. and clearance must be considered when treating any condition in elderly patients. the epinephrine response is actually enhanced. subjects without diabetes have evidence of impaired glucose metabolism. . Other complicating aspects of the physiology of aging include changes in the pharmacokinetics of both insulin and oral medications.In elderly patients with diabetes. metabolism. Patients with a family history of diabetes are more likely to develop the illness as they age. Elderly type 2 diabetes patients have specific alterations in carbohydrate metabolism. the primary abnormality in obese elderly subjects is resistance to insulin-mediated glucose disposal. Unlike younger patients. These alterations affect individual drug choices and dosing decisions. Physical inactivity and central fat distribution predispose to diabetes in the elderly. The primary metabolic defect in lean elderly subjects is an impairment in glucoseinduced insulin release.

fatigue. Recently. type IV renal tubular acisodis Neurologic : distal symmetric polyneuropaty. Symptoms Common presenting symptoms of DM include polyuria. Insulin receptor number and affinity are normal in elderly patients. and poor wound healing. end-stage renal disease (ERSD). it has been demonstrated that non mediated glucose uptake (glucose effectiveness) is markedly impaired in elderly patients with type 2 diabetes. Acute complications of diabetes that may be seen on presentation include diabetic ketoacidosis (DKA) and non ketotic hyperosmolar state. weakness. erectile dysfunction. The glucokinase gene is the glucose sensor for the β-cell. The mechanism for this defect is unclear. polyradiculopathy. frequent superficial infections. have been shown to enhance glucose effectiveness in younger patients.Glucose uptake occurs by insulin-mediated and noninsulin-mediated mechanisms. Few studies have evaluated molecular biologic abnormalities in elderly patients with diabetes and more are required. Given that several interventions. these findings may have important therapeutic relevance for elderly patients with diabetes. blurred vision. but impaired glucose effectiveness is a contributing factor to elevated glucose levels in elderly diabetes patients. ( 4 ) V. mononeuropathy. Some studies have found that this gene acts as a marker for abnormal glucose tolerance in the elderly. but others have not. autonomic neuropathy • • Gastrointestinal : gastroparesis. female sexual dysfunction . polydipsia. including glucagon-like peptide 1 (GLP-1). diarrhea. but insulin receptor tyrosine kinase activity in skeletal muscle is reduced. weight loss. constipation Genitourinary : cystopathy. The chronic complications of DM are listed below : • • • Opthalmologic : nonproliverative diabetic retinopaty Renal : proteinuria.

it may actually miss 31% of cases in the elderly. ( 3 ) Criteria for diagnose according to Consensus Management and Prevention of Diabetes Melitus Type 2 in Indonesia 2006 : ( 6 ) Non DM <100 <90 <100 <90 Not sure DM 100 – 199 90 . examination of the filter can be done every 3 years. Although measuring fasting plasma glucose levels increases the detection of diabetes in the young. tests conducted each year. Diagnose The current diagnoses of diabetes in the elderly are the same as those of younger adults. Because it is also recommended that anyone over 45 years of age be screened. VII. The current American Diabetes Association (ADA) criteria for diagnosis of diabetes are: two fasting plasma glucose levels ≥126 mg/dl on two separate occasions. a 2-h OGTT may be useful in diagnosing diabetes if there is clinical uncertainty. Risk Factor . For those aged> 45 years without other risk factors. all elderly individuals should be screened annually for diabetes. congestive heart failure.199 100 – 125 90 . stroke ( 5 ) VI. a random plasma glucose ≥200 mg/dl with symptoms. In elderly patients. or a 2-h oral glucose tolerance test (OGTT) ≥200 mg/dl. peripheral vascular disease.• Cardiovascular : coronary artery disease. Recent literature from the DECODE trials that included elderly subjects are revealing that an OGTT ≥200 mg/dl increases the risk of all-cause mortality even in the presence of a normal fasting glucose.199 DM ≥200 ≥200 ≥126 ≥100 Random plasma Plasma vein glucose Fasting Capillary blood plasma Plasma vein Capillary blood glucose levels For high-risk group who did not show abnormal results.

Family history of diabetis 2. social and financial support. Research is lacking regarding the benefit of tight control in the oldest elders (>80 years of age). The mechanisms by which diabetes is associated with cognitive impairment remain unclear. . age 4. race/ethnicity 5. obesity (BMI >27kg/m2) 3. Inactivity VIII. and their own desires for treatment. although observational studies note improved cognitive functioning with lower HbA1c levels.1. undiagnosed depression. Often. elderly patients have cognitive impairments. limitations in their activities of daily living. The ideal HbA1c target of <7% may be difficult to achieve in the elderly. Diabetes is associated with lower levels of cognitive functioning and greater cognitive decline in elderly. and difficult social issues that need to be addressed. Prospective trials have not shown consistent improvements in cognition with tight control. but is recommended for all adults. A full geriatric assessment performed before establishing any long-term diabetes therapy may aid in identifying potential problems that could significantly impair the success of a given therapy. life expectancy. Therapy Goals of therapy for elderly diabetic patients should include an evaluation of their functional status. Major large prospective trials to date have not reported conclusive data on intensive blood glucose control and improved vascular endpoints for the geriatric population.

Dietary compliance is often not feasible for elders who exhibit difficulties with instrumental activities of daily living. Many nursing homes and long-term care facilities now offer exercise programs for the physically challenged. elimination of obesity. The risks of hypoglycemia are higher in the cognitively impaired. In frail elderly patients. dysphagia. Elderly patients often have impaired awareness of the autonomic warning symptoms of hypoglycemia even when they have been educated about them. may require a simplified approach to diabetes care. such as dementia or psychiatric illnesses. Alpha-glucosidase inhibitors (e. They may also have delayed psychomotor responses to intervene in the correction of hypoglycemia. smoking cessation. overall goals should aim at reduction of all cardiovascular risk factors. and diminished appetite.Therapy should be chosen based on the individual needs and issues of each patient.. a multidisciplinary approach to the evaluation and treatment of each patient will provide the most fruitful results.g. the following options are available. acarbose [Precose] and miglitol [Glyset]). and optimal control of hypertension. Exercise can improve insulin sensitivity and should be encouraged for those who are deemed able to participate after safety evaluations have been performed. because their functional capabilities may limit their ability to prepare basic meals. particular attention should be given to functional goals and to avoiding therapies that may cause loss of independence or early institutionalization. a consultation with a dietitian and home evaluations by social workers can provide some insight. As with any diabetic patient. Often. improvement in exercise. As with most of geriatrics. These agents delay digestion of complex carbohydrates and disaccharides. and therapy should be individualized accordingly. they should be considered in all elderly patients with mild . Coexisting health problems. each patient’s risk for hypoglycemia should be considered. Although less effective than other agents. For elderly patients who require medical therapy. Current options for therapy include diet and exercise as recommended by the ADA. 1. Therefore. Restricting caloric intake in long-term care patients should be done with much caution. Many already have insufficient caloric intake because of confusion.

glipizide [Glucotrol]. Thiazolidinediones are comparatively expensive drugs. Diabeta.g. Biguanides (e.g.g. in the absence of exogenous glucose. rosiglitazone [Avandia] and pioglitazone [Actos]). It does not cause hypoglycemia. insulin release is lessened with repaglinide. repaglinide [Prandin] and nateglinide [Starlix]). Nateglinide is unrelated to the sulfonylureas and repaglinide. all elderly patients should have their creatinine clearance calculated. Metformin should not be administered if the creatinine clearance is <60 mg/dl. insulin secretagogues should be used with caution in patients . Traditional sulfonylureas are still widely used as first-line therapy. Although sulfonylureas can cause hypoglycemia in the elderly. With the exception of nateglinide. metformin [Glucophage]). which may lessen the risk of hypoglycemia. Repaglinide is unrelated to the sulfonylureas but also promotes insulin secretion from pancreatic β-cells. Sulfonylureas (e.. 2.g. Thiazolidinediones (e.. but this has not been a clinical problem. However. 3. they are potentially very useful. but for elderly patients who can afford them. but it also acts on pancreatic β-cells as an insulin secretagogue. These are true insulin sentisitizers and enhance insulin effects by activating the PPAR alpha receptor. Both repaglinide and nateglinide are used around meal times and are short-acting.. it should be avoided in patients with heart failure. Liver functioning may be impaired at high doses. Glynase]) and other types of secretagogues (e. However. Before starting therapy. Gastrointestinal side effects may limit therapy or may benefit those who suffer from constipation. it is used with caution in the elderly because it can cause anorexia and weight loss. Rosiglitazone has been shown to be safe and effective in elderly patients.diabetes. Serum creatinine is a poor correlate because of low muscle mass in the elderly. The benefit of metformin in the elderly is that it does not cause hypoglycemia when used independently. 4. Unlike with sulfonylureas. glyburide [Micronase. First-generation agents such as chlorpropamide should be avoided in the elderly because of their long half-life and increased propensity for hypoglycemia in the elderly. the incidence is relatively low if shorter-acting agents are used.

Ride smaller sessions spread range.Lose excess pounds. 5. Motivate yourself by remembering the benefits of losing weight. The risk of severe hypoglycemia associated with insulin increases with age. To keep your weight in a healthy permanent changes to your eating and exercise habits. If you're overweight. Eat healthy foods.000 calories you at least 14 grams of fiber. (3) So the best treatment for a type 2 diabetes geriatric patients is to keep healthy lifestyle. Aim for 30 minutes of moderate physical activity a day.Biguanides. The recommended and also safe about 20-30 minutes every morning. For every 1. consume.Get more physical activity. focus on self-esteem. Choose foods low Focus on fruits. and diet and exercise. A complete geriatric assessment should be performed first to assure that patients can comply with their regimens and to identify potential complicating factors. Insulin should be watched clearly to prevent the side effect that may happen in elderly patients.Initiation of insulin in elderly type 2 diabetic patients should be done with the involvement of a multidisciplinary team. vegetables and whole grains. not smoke or alcohol. All insulin secretagogues should be avoided in those with liver disease. If there are identified caregivers. such as a healthier heart. because fiber helps control blood sugar your bike. do in fat and calories. break it up into throughout the day. If you can't fit in a long workout. Thiazolidinediones. Take a 10 percent of your body weight can reduce the risk of diabetes. try to have brisk daily walk. more energy and improved . Sulfonylureas. Swim laps. And the medication given such as Alpha-glucosidase inhibitors .with renal dysfunction. provisions for adequate respite programs should be offered to avoid caregiver burnout. Insulin. losing 5 to exercise is jogging levels.

social workers. diabetologists. Successful diabetes care in the aging population requires an understanding of the physiology of aging. pharmacists.CONCLUSION Ideal geriatric care requires a multidisciplinary approach. diabetes educators. When prescribing insulin or oral agent regimens for this population. recognition of the special issues facing the elderly. and dietitians to ensure the most efficacious treatment. and interaction with geriatricians. More research is needed to help us understand the full impact of diabetes on this expanding and complex segment of our population. . providers should pay special attention to possible side effects and drug interactions.

p 7-8 . chap.2011 4. 2011 2. Sidartawan et al.am. 15th edition. http://clinical. 4. Mc Graw Hill. Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2006. accessed at : January 17. Eugene et al.diabetesjournals.com. Braunwald. Mc Graw Hill. Clinical Management of Diabetes in Elderly.2011 5. p 786 3. http://www.merck. http://www. Braunwald. Diabetes Mellitus Harrison’s Manual of Medecine.org. Soegondo.Merk Manual of Geriatric. Diabetes Mellitus Harrison’s Manual of Medecine. Eugene et al. 64 accessed at : January 17.health. PB PERKENI. p 787 6. 15th edition. Pathogenesis of Diabetes Mellitus in the Elderly. Type 2 Diabetes Mellitus.p 172-175 . October 2001 vol. accessed at : January 17.REFERENCES 1. 19 no.