1. Type 2 diabetes mellitus in the older patient Shokoufeh Bonakdaran Associate Professor of Endocrinology Mashhad university of medical sciences

3. Age Group 10 20 30 40 50 60

4. Risk of aging Increased risk of developing of macrovascular and microvascular complications and excess morbidity and mortality at high risk for polypharmacy, functional disabilities, cognitive impairment, depression, urinary incontinence, falls, and persistent pain

5. Diabetes in old age Hyperglycemia increases dehydration and impairs vision and cognition lead to functional decline and an increased risk of falling in older diabetic patients. older patients may tolerate relatively higher blood glucose levels before they manifest an osmotic diuresis, due to their lower GFRs hypoglycemia, can result in poor outcomes

6. Diabetes goals management of both hyperglycemia and risk factors avoidance of hypoglycemia, hypotension, and drug interactions due to polypharmacy management of coexisting medical conditions

7. Glycemic targets 7

8. 8

9. Target of glycemic control? The appropriate target for glycated hemoglobin (A1C) in fit older patients who have a life expectancy of over 10 years should be similar to those developed for younger adults (<7.0 percent).

10. the goal should be higher (≤8.0 percent) in frail older adults with medical and functional comorbidities and in those whose life expectancy is less than 10 years. Individualized goals for the very old may be even higher and should include efforts to preserve quality of life and avoid hypoglycemia

11. Avoiding hypoglycemia The risk of hypoglycemia is increased in older adults. older adults may have more neuroglycopenic manifestations of hypoglycemia (dizziness, weakness, delirium, confusion) compared with adrenergic manifestations (tremors, sweating). Hypoglycemic episodes in older individuals may also increase the risk of adverse cardiovascular events and cardiac autonomic dysfunction increased risk of developing dementia increase the risk of falls and fracture

12. CAUTION Insulin secretagogues such as sulfonylurea and meglitinides, as well all types of insulin, should be used with caution in frail older adults

13. nutrition medical nutrition evaluation Obese older adults with diabetes may benefit from caloric restriction and an increase in physical activity with a weight loss goal of approximately 5 percent of body weight Older adults are as much at risk for under- nutrition as for obesity. Weight loss increases the risk of morbidity and mortality in older adults

14. Pharmacologic therapy must be individualized based upon patient abilities and comorbidities. "Start low and go slow" is a good principle to follow For older patients who do not have contraindications, initiate therapy with metformin in patients with contraindications and/or intolerance to metformin, a short-acting sulfonylurea is an alternative option ( Glipizide). In a patient with chronic kidney disease who is intolerant of sulfonylureas, repaglinide could be considered as initial therapy

15. Metformin....but Increased risk of lactic acidosis. Older patients often have impaired renal function despite an apparently normal serum creatinine concentration. increased risk for myocardial infarction,stroke, cardiac failure, pneumonia Weight loss and gastrointestinal side effects may also be limiting factors

16. caution A calculated GFR >30 mL/min has been suggested as a safe level stop taking the drug immediately if they become ill for any reason, or if they are to undergo a procedure requiring the use of iodinated contrast material

17. Sulfonylurea usually well-tolerated. Hypoglycemia is the most common side effect and is more common with long-acting sulfonylurea drugs (eg, glibenclamide) avoid the use of long-acting sulfonylureas in older adults

18. Drug-induced hypoglycemia is most likely to occur After exercise or missed meals When they eat poorly or abuse alcohol When they have impaired renal or cardiac function or intercurrent gastrointestinal disease During therapy with salicylates, sulfonamides, fibric acid derivatives and warfarin After being in the hospital

19. Thiazolidinediones Pioglitazone improves insulin resistance, also may increase insulin secretion in response to glucose may be considered for some older patients, particularly those with lower initial A1C values and there are specific contraindications to sulfonylureas or if they are not able or willing to consider insulin. They can be given to patients who have impaired renal function should not be used in patients with class III or IV heart failure. limited experience, high cost, and concerns regarding fluid retention, congestive heart failure, MI, and fractures limit their usefulness, particularly in older adults

20. Pioglitazone is preferred because of the greater concern about atherogenic lipid profiles and a potential increased risk for cardiovascular events with rosiglitazone. increased risk for bladder cancer

21. Meglitinides Repaglinide are short-acting glucose-lowering drug similar risk for weight gain as sulfonylureas but possibly less risk of hypoglycemia repaglinide could be considered as initial therapy in a patient with chronic kidney disease

22. alpha-glucosidases inhibitors Acarbose inhibits the gastrointestinal alpha- glucosidases ( slowing the absorption of glucose and results in a slower rise in postprandial blood glucose concentrations) Is safe and effective. The main side effects are flatulence and diarrhea

23. DPP4 inhibitors moderately effective as monotherapy or when used in combination relatively weak agents and usually lower A1C levels by only 0.6 percent. have no risk of hypoglycemia and are weight- neutral Safe? relatively expensive. The dose of DPP-IV inhibitors should be adjusted in patients with renal insufficiency.

24. GLP1 agonists as monotherapy or as an adjunct to diet and exercise or in combination with oral agents no risk of hypoglycemia significant reduction in weight. The most common adverse events are nausea, vomiting, and diarrhea acute pancreatitis and deterioration in renal function in patients taking GLP-1 therapies should not be used in patients with a creatinine clearance below 30 mL/min

25. Insulins long-acting insulins whether or not the patient is physically and cognitively capable of using an insulin pen or drawing up and giving the appropriate dose of insulin, monitoring blood glucose, and recognizing and treating hypoglycemia?

26. Insulin metabolism is altered in patients with chronic renal failure, so that less insulin is needed when the GFR is below 50 mL/min.

27. glycemic goals are not met…. difficulty adhering to the medication, side effects, or poor understanding of the nutrition plan

29. monitoring A1C twice yearly in older patients who are meeting treatment goals quarterly in patients whose therapy has changed or who are not meeting glycemic goals The effectiveness of self-monitoring of blood glucose in patients with type 2 diabetes is less clear than for type 1 diabetes self-monitoring of glucose may not be necessary at all, ( for older patients with type 2 diabetes who are diet-treated or who are treated with oral agents not associated with hypoglycemia.)

30. Accuracy of HbA1C? may not be accurate anemia and other conditions that impact red blood cell life span chronic kidney disease, recent transfusions and erythropoietin infusions chronic liver diseases

31. Retinopathy The prevalence of retinopathy increases progressively with increasing duration of diabetes poor vision can lead to social isolation, an increased risk of accidents, and impaired ability to measure blood glucose and draw up insulin doses. A complete ophthalmologic examination should be performed at the time of diagnosis and at least yearly thereafter. The purpose is to screen not only for diabetic retinopathy but also for cataracts and glaucoma

32. Nephropathy all patients with diabetes be screened for increased urinary albumin excretion annually. increased urinary albumin excretion increases in the older population for reasons unrelated to diabetic nephropathy. For older patients who are already taking an ACE inhibitor or ACE receptor blocker, it may not be necessary or helpful to continue testing for increased urinary albumin excretion on an annual basis.

33. Diabetic foot more than 30 percent of older diabetic patients cannot see or reach their feet older diabetic patients should their feet examined at every visit A detailed neurologic examination and assessment for peripheral artery disease should be performed at least yearly.

34. CHD is by far the leading cause of death in older patients Risk reduction should be focused upon the following areas: Smoking cessation Treatment of hypertension Treatment of dyslipidemia ASPIRIN therapy Exercise

35. summary The appropriate target for glycated hemoglobin (A1C) in fit older patients who have a life expectancy of over 10 years should be similar to those developed for younger adults (<7.0 percent). The goal should be somewhat higher (≤8.0 percent) in frail older adults with multiple medical and functional comorbidities and in those whose life expectancy is less than 10 year

36. Summary 2 The risk of hypoglycemiais substantially increased in older adults. avoidance of hypoglycemia is an important consideration