Diabetes Mellitus in Elderly

Supriyanto Kartodarsono
Divisi Endokrinologi dan Metabolik
Departemen Penyakit Dalam
RSUD Dr Moewardi/FK UNS

SURAKARTA
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◆ High prevalence diabetes in elderly is inevitable
◆ Hyperglycaemia in ederly is benign
◆ Reduced life expectancy
◆ Older adult are less capable of self-monitoring their blood
glucose

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 Pathogenesis hyperglycamia in elderly

Coexisting illness

Reduced insulin
Poor nutrtion secretion

Genetic
Increased adipose
tissue

Reduced physical
Medication activity

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 Diabetes in elderly
◆ 50% underdiagnosed à WHY ?
◆ Early sign: metabolic abnormalities
◆ Early symptoms (if any)
v Often gradual onset
v Commonly mistaken for sign of normal
aging

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 Aging and Diabetes
◆ Poor diabetic control exaserbates the
aging process
◆ Poor diabetes control cause age
related disease to develop earlier
◆ Poor diabtes control make co-morbid
condition worse and harder to manage

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 Diabetes assesment in Older Adult

v Physical assesment
v Mobillity/physical activity
v Nutrtional assement
v Cardiovascular assesment
v Neurological assement
v Optlamic assesment
v Renal assement
v Auditory assement
v Immune system
v Psychososial assement
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 Case of mistaken identity

Sign of aging Sign of Diabetes

◆ Needing glasses ◆ Blurred vision
◆ More frequent urination ◆ Polyuria and nocturia
◆ Can’t do things like you did ◆ Fatigue
when you were 20 ◆ MI and CVA’s 2 time more
◆ Atherosclerosis common
◆ High blood pressure ◆ High blood pressure
◆ Change in gait ◆ Neuropathy and food deformities
◆ Restlessnessm, confusion, slower ◆ Restlessness/confussion with
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cognition hihg and low blood sugar
 Common Geriatric Syndrome

◆ Depression
◆ Polypharmasi
◆ Cognitive Impairment
◆ Urinary incontinence
◆ Injurious falls
◆ Persitent pain

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Accelarated aging
Chronic diabetic complications
DIABETES Comorbidities
MELLITUS
Multiple contributor

Geriatric syndrome

Frailty
Dependency
Poor quality of life
Poor DM care
 Treatment Recomendations

◆ Glycaemic control
◆ Hypertension
◆ Lipid
◆ Tobacco cessation
◆ Eye care
◆ Foot care
◆ Nephropathy
◆ Diabetes self management training
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 Treatment Recomendations

◆ When and how to prioritize intervention?

◆ Stratifiying older adult
Ø Comorbidities
Ø Complications
Ø Risk and benefit of (intensive) tjheraphy

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 Glycaemic control

◆ A1c
Ø < 7% in healthy adults with good functional status
Ø < 8% appropriate in:
§ Frail older adult
§ Life expectancy less than 5 years
§ Those whom risk of intesive glycaemic control
outweighs benefits
Ø Frequency

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 Risk of intensive glycaemic control

◆ Hypoglycaemia
◆ Polypharmacy
◆ Drug to drug interaction
◆ Drug to disease interaction

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 Who benefits most from intensive Glycaemic
control

◆ Older adult in good health

◆ Those with microvascular complications
◆ Frail elderly without microvascular complications will
probably not live long enough to develop them

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 Medical Therapy in elderly with Diabetes

◆ Follow th same hierarchy of chosing a glucose lowering therapy as recommended

for younger adult

◆ Non-insulin drug
Ø Metformin is the drug of choice
Ø DPP4 inhibitors are preferred owing to the lower risk of hypoglycamia
Ø Modern sulfonylurea (glyclacid &glimepiride) may be used in low dose.
Glibenclamid should be avoided
Ø Pioglitazone should bne avoided because of the risk of fracture and heart
failure
Ø SGLT2 inhibitor maybe used in otherwise healthy persons
Ø GLP1 receptor agonis maybe used

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 Medical Therapy in elderly with Diabetes

◆ Insulin therapy
Ø Indication for insulin therapy similar in adults of all age
group
Ø If basal insulin is required, prefer preparation with low risk of
hypoglycaemia
Ø If prandial coverage is necessary, prefer premix insulin
analog with low risk of hypoglycaemia

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 Hyperglycaemia

v Can cause
v Delirium
v Mood swing and irrationality
v Appetide changes
v Sleep disturbances
v Increased risk for:
v Diabetic ketoacidosis
v HHS

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 Hyperglycaemia
◆ Impair cognitive function
◆ Reduce energy
◆ Impairs memory
◆ Decreased wound healing
◆ Increased risk of HHS
◆ Increases urine output à Increased risk opf UTI
◆ Impairs immune system

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 Hypoglycaemia

◆ Aging increased risk of hypoglycaemia

Ø Reduce hormonal counter regulation
Ø Renal and hepatic changes
Ø Hydration status
Ø Inadequate or irregular nutrition
Ø Decreased intestinal absorption
Ø Autonomic neuropathy
Ø Polypharmacy
Ø Use of alcohol, other sedating meds

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 Hypoglycaemia

◆ May cause
Ø Heart arrytmias
Ø Increased risk of falls
Ø Sign and symptomes maybe mask by co-morbidities
io.e. Parkinson’s
Ø Impairs concentration and cognition
Ø Impairs reaction time

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 Diabetes Self-Mangement Training

◆ More likely to include family members and/or other

caregivers
◆ Essential topics:
◆ Hypoglycemia prevention and treatment
◆ Benefits of MNT and physical acitvity
◆ Medication review
◆ Evaluation of foot care- amputation prevention
◆ Evaluate Geriatric Conditions

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 CONCLUSION

◆ Functionally independent older people with diabetes who have a

life expectancy of greater than 10 years should be treated to
achieve the same glycemic, BP and lipid targets as younger
people with diabetes
◆ A higher A1C target may be considered in older people with
diabetes taking antihyperglycemic agent(s) with risk of
hypoglycemia
◆ In the older person with diabetes and multiple comorbidities
and/or frailty, strategies should be used to strictly prevent
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hypoglycemia
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Terima