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Finding the Sweet Spot: DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) Belinda.

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Presentation on theme: "Finding the Sweet Spot: DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) Belinda."— Presentation transcript:

1 Finding the Sweet Spot: DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) Belinda Setters, MD, MS, AGSF March 6, 2014 Kentucky Cardiopulmonary Rehab Symposium

2 The Sweet Spot: DM II treatment update
Disclosures Acting Associate Chief of Staff , Geriatrics & Extended Care Director, Acute Care for Elders & Transitional Care Programs Robley Rex VAMC, Louisville, Ky Associate Clinical Professor University of Louisville Depts. of Internal and Family & Geriatric Medicine No financial (or other) incentives, stock or compensation

3 The Sweet Spot: DM II treatment update
Learning Objectives Review updated guidelines for DM II treatment Identify pitfalls of treatment in post acute (rehabilitation) care Understand unique features of elderly patients that complicate treatment Understand the importance of individualized care

4 The Sweet Spot: DM II treatment update
Just the stats m’am. . . 25.8 million diabetics (all ages) = 8.3% of population > 65 yo, increases to 27% of population (10.9 million) 7 million undx patients DM II associated with 2 x higher disability 42% of persons > 65 yo have at least one disability = 14 million people American Diabetes Association: CDC: NIH:

5 The Sweet Spot: DM II treatment update

6 The Sweet Spot: DM II treatment update
From Dr. Samuel E. Dagogo-Jack:

7 The Sweet Spot: DM II treatment update

8 The Sweet Spot: DM II treatment update

9 The Sweet Spot: DM II treatment update
Treatment goals . . . Fasting blood glucose < 140 mg Hemoglobin A1C < 7 If can push to get better #s, without side effects (hypoglycemia), then ok to do so in adult patients Post acute care (“rehabilitation”) guidelines follow those of non-critical care acute recommendations J Clin Endocrinol Metab 2012, 97(1):16-38

10 The Sweet Spot: DM II treatment update
Treatment goals Short term concerns Minimize adverse effects of high glucose Wound healing & infection Confusion/MS change Fatigue = decr. participation in therapy Falls Minimize HYPOglycemia Minimize “pill burden” Transition patient to home

11 The Sweet Spot: DM II treatment update
Treatment goals Options. Glucose >140 DX: DM II Current RX Adjust RX No DM II Monitor BS hrs ( + ) ( --) d/c monitoring

12 The Sweet Spot: DM II treatment update
Recommended therapy: Insulin Long Acting Insulin (Daily) Short Acting Insulin (with Meals) OR Intermediate acting (Twice Daily)

13 The Sweet Spot: DM II treatment update
Insulin types Action Onset Peak Duration Name Brand Rapid 15 min 1 hr 2-4 hrs Glucine Lispro Aspart Apidra Humalog Novolog Regular / “short” 30 min 2 hrs 3-6 hrs Lispro R Novolin R Humalog R Novolgo R Intermediate 2 -4 hrs 4-12 hours 12-14 hrs NPH Humulin N Novulin N Long hrs (aprox 6) None 24 hrs Detemir Glargine Levemir Lantus

14 The Sweet Spot: DM II treatment update
Insulin types “the slide” Sliding Scale Insulin Good for short term coverage to adjust long acting insulins Should not be used as a substitute for long acting or short/regular insulin regimen. diabetesmanager.pbworks.com

15 The Sweet Spot: DM II treatment update

16 The Sweet Spot: DM II treatment update
Oral agents

17 Class Pharm Limitations Name Brand
Sulfonylureas Stimulates pancreas to release insulin Hypoglycemia CV risks Liver/renal Glimeprimide Glyburide Glipizide Gliclazide Amaryl Micronase Gluctorol Diamicron Biguanide Reduces glucose production Lactic acidosis Metformin Glucophage Alpha-glucosidase inhibitor Reduces glucose absorption GI side effects / take with meals Acarbase Miglitol Voglibose Precose, Glucobay Glyset Basen Thiazolidinedione Reduces insulin resistance Edema Heart failure Wt gain Liver fxn Rosiglitazone Pioglitazone Avandia Actos Prandial glucose regulators Incr. insulin secretion Repaglinide Nateglinide Prandin Starlix Incretin mimetics Incr. insulin sensitivity hypoglycemia, Fatigue, anorexia Pramlinitide Sitagliptin Exenatide Symlin Januvia Byetta

18 The Sweet Spot: DM II treatment update
Nutrition therapy Rec: “Consistent Carb” diet + Education & Accountability Exercise Therapy, activities, walking American Diabetes Association:

19 The Sweet Spot: DM II treatment update
Control Vascular Risk Factors Tobacco cessation Nutrition Weight Loss HTN management HLD management / statins Anti-inflammatory therapies Mental & physical activity

20 The Sweet Spot: DM II in elders
Treatment Considerations Micro-vascular Injury (in Years) Macro-vascular Injuries (in Years) Control of -- Glucose 8 -- Blood Pressure 2-3 3 Cholesterol 3-6 (CHF/AGS, presented at AGS Symposium, May 2003)

21 The Sweet Spot: DM II in elders

22 The Sweet Spot: DM II treatment update
DM in The Elderly: Unique Concerns Erratic eating (or dependency on being fed) Inability to report symptoms (dementia, vague symptoms) Polypharmacy: multiple meds – competition for clearance Slowed metabolism / impaired clearance Shift in water-fat body content Low reserve, can’t respond to hypoglycemia Med Care 2006 Apr;44(4): JAMA 2006 Oct 18;296(15): J Am Coll Cardiol 2009 Jan 20;53(3):

23 The Sweet Spot: DM II treatment updates
DM in Elders: Frailty Loss of functional reserve Slowed response to stress / pathologic illness Multisystem organ involvement Estimated prognosis (life expectancy)1-2 years Lancet 2013; 381(9868): JAGS 2006; 54(6): Clin Geriatr Med 2011; 27(1): 1-15.

24 The Sweet Spot: DM II treatment updates
DM in Elders: Frailty Philosophy, Ethics, and Humanities in Medicine 2009 4:3   doi: /

25 The Sweet Spot: DM II in elders
Treatment Considerations Hemoglobin A1C < 7 Mean plasma glucose 154 mg/dl (2-3 months) Healthy adults with > 10 year life expectancy Hemoglobin A1C between 7 – 8.5 Mean plasma glucose 180 mg/dl (2-3 months) Adults with limited life expectancy, history of severe hypoglycemia, or advanced micro-vascular or macro-vascular disease DIABETES CARE, 2013; 36(1): S11-S66

26 The Sweet Spot: DM II in elders
Treatment Considerations Blood Pressure & Lipid Goals Blood pressure < 140/80 LDL < 100 mg/dl or 70 with CVD HDL > 40 mg/dl Triglycerides < 150 mg/dl DIABETES CARE, 2013; 36(1): S11-S66

27 The Sweet Spot: DM II in elders
The “Sweet Spot” for Frail Elders J Am Geriatr Soc 60:1215–1221, 2012.

28 The Sweet Spot: DM II in elders
Other thoughts: Hypoglycemia 2 episodes = 80% increased risk for Dementia development 3 episodes = 94% increased risk for dementia development

29 The Sweet Spot: DM II in elders
Other thoughts Life Expectancy Changes w/ comorbidity Changes w/ frailty Goals of Care Pt Preferences

30 The Sweet Spot: DM II treatment update
Wrap up Blood glucose < 140 or Hg A1C < 7 Control vascular, other risk factors Consider QOL, pt preferences/GOC & life expectancy For most elders, especially frail elders, A1C = 8 is target 8 at 80 honey!

31 Belinda.Setters@va.gov Geriatrics & Extended Care
@BelindaSetters


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