1. Diabetes in Older People :
A common problem but (?) Different Strategies
Dr B. Manivannan FRCP
Consultant Physician and Geriatrician
Moseley Hall Hospital and BMI Priory Hospital

2. How Common?
3.2 million patients with diabetes in the UK
90% type 2, 10 % type 1
Approx 37 % over 70 ( 24% 70-79, 13% 80+)
Approx 63 % over 60
1 in 4 residents in Care homes

3. Why Different strategies ?
Most principles of treatment are the same
Some important differences in treatment aims and approaches
Why?
Balancing life expectancy vs Aim of tight glycaemic control
More co-morbid conditions and multiple medications

5. Aim of intense glycaemic control ?
Minimising the risk of microvascular and macrovacular complications
Mr Marriot is 85. He suffers from type 2 Diabetes; lives alone. Carers x 3 times.
Mr Smith is 65. He also suffers from type 2 Diabetes ; lives with his wife ; 3 X holidays per year. Works part time.

7. Mrs. A.S is a 86 year old lady, living independently on her own.
She even goes shopping on the bus.
Her only past medical history is that of a right Colles fracture when she slipped and fell on an icy morning in Feb 2012.
She is on no medication except co-codamol 8/500 prn.
What is the single most beneficial assessment and treatment you would want to consider ?

12. Older people : multiple co-morbidities
Multiple drugs
Less appetite
Difficulty getting food on time, cooking
Loss of muscle and adipose tissue
Declining renal function
Difficulty recognising symptoms of hypoglycaemia (blunted neuro glycopenic responses)

13. What is the optimum approach with Mr Marriot?
Achieve ‘reasonable’ glycaemic control
Prevent hypoglycaemic episodes at ALL costs
Prevent repeated and recurrent infections
Prevent HHS (HONK)

14. Number of factors
Duration of diabetes
Chronological age
Biological age and degree of frailty
Tendency to hypoglycaemia and degree of hypoglycaemia awareness
Social circumstances

15. What is reasonable glycaemic control?
What is ideal or intense glycaemic control?

16. HbA1c 6.5% - 7% (48-53 mmol/mol)
HbA1c % (53-58 )
HbA1C % (58-69)

17. Hypoglycamia
Dangerous
Medical emergency
Immediate harm –within minutes :’ here now’
(Hyperglycaemia –not ‘here now’; longer term complications)
Hypoglycaemia in the Elderly-even more dangerous
Blunted hypoglycaemia awareness

19. Conscious patient-
Unconscious /semi conscious patient
Glucagon IM but if no hepatic glycogen stores may not be helpful ( chronic liver disease, cachexia)
20% dextrose now recommended ( 20 % 100 ml stat Iv) and not 50 % destrose

20. Mr. Lambert is 78 years old; he has suffered from type 2 Diabetes since age 48. He is very health conscious and controlled his diabetes quite well. His wife passed away last year and now lives alone.
Currently he is on Metformin 1g bd and Gliclazide 80 mg bd.
He is being reviewed in surgery due to increasing falls and confusion. Latest HbA1c is 47.

21. Treatment of diabetes in Older people
Relatively shorter acting drugs
Minimal or low risk of hypoglycaemia
Awareness of drug metabolism and excretion and co-existing renal and liver dysfunction
Simple and gentler once or twice day insulin regimes rather than intensive basal bolus regimes
Start low Go slow
Treat your patient not the HbA1c !

22. Metformin Metformin: 60 years in clinical use (1957 to date )
Fit as a fiddle, and indispensable for its pivotal role in type 2 diabetes management: Diabetes Metab 2006 Dec: 32: 555–556
Inhibits hepatic gluconeogenesis
Increases insulin sensitivity in muscle and adipose tissue
Increases peripheral utilisation of insulin
No risk of hypoglycaemia
In overweight patients - a vascular protective effect
Renal route of excretion; avoid if eGFR less than 30 ( review dose if less than 45)
Diarrhoea and GI side effects –start slow ; long term use may cause vit B12 deficiency
If having a radiological examination with contrast –omit for atleast 48 hours

23. Sulfonylureas Most commonly used in UK is Gliclazide
Insulin secretagogues- need some pancreatic beta cell activity
More potent ( % reduction in HbA1c)
Can cause hypoglycaemia (sometimes profound hypoglycaemia)
In elderly use at lower doses mg od/bd
Hepatic route of excretion for Gliclazide but has renal metabolites
Weight gain a disadvantage

24. Gliptins or Dipeptidyl peptidase-4 (DPP-4) Inhibitors
Inhibits the action of DPP 4 ( DPP 4 breaks down incretin)
The levels of incretin (GLP1 and GIP ) thus rises
Incretin mimic
Incretins stimulate glucose dependant insulin release and inhibit glucagon release
Slow gastric emptying and promote satiety
Saxagliptin, Sitagliptin, Linagliptin, Vildagliptin, Alogliptin
Low risk of hypoglycaemia
No weight gain
Well tolerated even in older people
Gentle drugs , HbA1c reduction approx 0.5%-1%

25. GLP 1 Analogues or Agonists Also incretin mimics
stimulates glucose dependent insulin
Suppresses inappropriate glucagon secretion
Slows gastric emptying
Promotes satiety
Exanetide bd or once weekly
Liraglutide once daily –can be taken independent of meal time
Lixisenatide, Albiglutide, Dulaglutide

26. GLP 1 receptor agonists
More potent than the gliptins ;
Approx 1% HbA1c
Low risk of hypoglycaemia (unless combined with a sulphonyurea)
Weight loss or atleast maintenance
Injectable preparations
Can be used in the elderly
Clinical context : ‘young’ elderly, overweight

27. Sodium –Glucose Co Transport Inhibitors (SGLT2 inhibitors)
Action independent of insulin
Block re absorption of glucose in proximal renal tubule
Low risk of hypo (unless in combination)
Canagliflozin, Dapagliflozin, Empagaflozin
Dapagliflozin not recommended age over 75
EGFR atelast 45
Tendency to more UTIs, genital fungal infections, pollakiuria
Very new – medium and long term FU still to come

28. Insulin in Older people Start low-go slow
Get to know a few insulins across the duration of action ( short, intermediate and long/basal) well
Twice daily regimes quite common
In frail and carer/DN needed –once daily
Analogue Insulins vs Human Insulins
Biosimilar analogue insulins ( eg; Lantus Abasglar etc for Insulin Glargine

29. Treatment of diabetes in Older people- Summary
Relatively shorter acting drugs
Minimal or low risk of hypoglycaemia
Awareness of drug metabolism and excretion and co-existing renal and liver dysfunction
Simple and gentler once or twice day insulin regimes rather than intensive basal bolus regimes
Start low Go slow
Treat your patient not the HbA1c !

30. Thank you