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, AGSFMarch 6, 2014Kentucky Cardiopulmonary Rehab Symposium
2 The Sweet Spot: DM II treatment update DisclosuresActing Associate Chief of Staff , Geriatrics & Extended CareDirector, Acute Care for Elders & Transitional Care ProgramsRobley Rex VAMC, Louisville, KyAssociate Clinical ProfessorUniversity of LouisvilleDepts. of Internal and Family & Geriatric MedicineNo financial (or other) incentives, stock or compensation
3 The Sweet Spot: DM II treatment update Learning ObjectivesReview updated guidelines for DM II treatmentIdentify pitfalls of treatment in post acute (rehabilitation) careUnderstand unique features of elderly patients that complicate treatmentUnderstand 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 patientsDM II associated with 2 xhigher disability42% of persons > 65 yo have at least one disability= 14 million peopleAmerican Diabetes Association: CDC:NIH:
9 The Sweet Spot: DM II treatment update Treatment goals . . .Fasting blood glucose < 140 mgHemoglobin A1C < 7If can push to get better #s, without side effects (hypoglycemia), then ok to do so in adult patientsPost acute care (“rehabilitation”) guidelines follow those of non-critical care acute recommendationsJ Clin Endocrinol Metab 2012, 97(1):16-38
10 The Sweet Spot: DM II treatment update Treatment goals Short term concernsMinimize adverse effects of high glucoseWound healing & infectionConfusion/MS changeFatigue = decr. participation in therapyFallsMinimize HYPOglycemiaMinimize “pill burden”Transition patient to home
14 The Sweet Spot: DM II treatment update Insulin types “the slide”Sliding Scale InsulinGood for short term coverage to adjust long acting insulinsShould not be used as a substitute for long acting or short/regular insulin regimen.diabetesmanager.pbworks.com
16 The Sweet Spot: DM II treatment update Oral agents
17 Class Pharm Limitations Name Brand SulfonylureasStimulates pancreas to release insulinHypoglycemiaCV risksLiver/renalGlimeprimideGlyburideGlipizideGliclazideAmarylMicronaseGluctorolDiamicronBiguanideReduces glucose productionLactic acidosisMetforminGlucophageAlpha-glucosidase inhibitorReduces glucose absorptionGI side effects / take with mealsAcarbaseMiglitolVoglibosePrecose, GlucobayGlysetBasenThiazolidinedioneReduces insulin resistanceEdemaHeart failureWt gainLiver fxnRosiglitazonePioglitazoneAvandiaActosPrandial glucose regulatorsIncr. insulin secretionRepaglinideNateglinidePrandinStarlixIncretin mimeticsIncr. insulin sensitivityhypoglycemia,Fatigue, anorexiaPramlinitideSitagliptinExenatideSymlinJanuviaByetta
18 The Sweet Spot: DM II treatment update Nutrition therapyRec:“Consistent Carb” diet+Education & AccountabilityExerciseTherapy, activities, walkingAmerican Diabetes Association:
19 The Sweet Spot: DM II treatment update Control Vascular Risk FactorsTobacco cessationNutritionWeight LossHTN managementHLD management / statinsAnti-inflammatory therapiesMental & physical activity
20 The Sweet Spot: DM II in elders Treatment ConsiderationsMicro-vascular Injury (in Years)Macro-vascular Injuries (in Years)Control of --Glucose8--Blood Pressure2-33Cholesterol3-6(CHF/AGS, presented at AGS Symposium, May 2003)
22 The Sweet Spot: DM II treatment update DM in The Elderly: Unique ConcernsErratic eating (or dependency on being fed)Inability to report symptoms (dementia, vague symptoms)Polypharmacy: multiple meds – competition for clearanceSlowed metabolism / impaired clearanceShift in water-fat body contentLow reserve, can’t respond to hypoglycemiaMed 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: FrailtyLoss of functional reserveSlowed response to stress / pathologic illnessMultisystem organ involvementEstimated prognosis (life expectancy)1-2 yearsLancet 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: FrailtyPhilosophy, Ethics, and Humanities in Medicine 2009 4:3 doi: /
25 The Sweet Spot: DM II in elders Treatment ConsiderationsHemoglobin A1C < 7Mean plasma glucose 154 mg/dl (2-3 months)Healthy adults with > 10 year life expectancyHemoglobin A1C between 7 – 8.5Mean plasma glucose 180 mg/dl (2-3 months)Adults with limited life expectancy, history of severe hypoglycemia, or advanced micro-vascular or macro-vascular diseaseDIABETES CARE, 2013; 36(1): S11-S66
26 The Sweet Spot: DM II in elders Treatment ConsiderationsBlood Pressure & Lipid GoalsBlood pressure < 140/80LDL < 100 mg/dl or 70 with CVDHDL > 40 mg/dlTriglycerides < 150 mg/dlDIABETES CARE, 2013; 36(1): S11-S66
27 The Sweet Spot: DM II in elders The “Sweet Spot” for Frail EldersJ Am Geriatr Soc 60:1215–1221, 2012.
28 The Sweet Spot: DM II in elders Other thoughts:Hypoglycemia2 episodes = 80% increased risk for Dementia development3 episodes = 94% increased risk for dementia development
29 The Sweet Spot: DM II in elders Other thoughtsLife ExpectancyChanges w/ comorbidityChanges w/ frailtyGoals of CarePt Preferences
30 The Sweet Spot: DM II treatment update Wrap upBlood glucose < 140 or Hg A1C < 7Control vascular, other risk factorsConsider QOL, pt preferences/GOC & life expectancyFor most elders, especially frail elders, A1C = 8 is target8 at 80 honey!
31 Belinda.Setters@va.gov Geriatrics & Extended Care @BelindaSetters