Glycemic Control in Elderly Diabetes

With
Acute Coronary Syndrome

A. Makbul Aman M
Division Endocrine & Metabolism, Department
of Internal Medicine Faculty of Medicine
Hasanuddin University / RS. Dr. Wahidin
Sudirohusodo Makassar
 ELDERLY
It is generally agreed that there is no clear definition
of elderly and that it reflects an age continuum
starting somewhere in the 60s and is characterized
by a slow, progressive frailty that continues until
the end of life.

MAJOR AGE-ASSOCIATED CAUSES OF DEATH

CARDIOVASCULAR DISEASE
CANCER
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DIABETES
Who is Elderly ?

Young old 60-75 y

Old, old >75 y Very Old >80 y

Diabetes in aging
7.5% of population aged 25 years and over
17.9% 64-75 years
23.0% 75 years+
ELDERLY AND DIABETES
Co-Morbid Disease
50% of aged 65 and over > 3 conditions
Hypertension: 50%
Arthritis: 36%
Heart disease: 31%
Diabetes: 25% (half undiagnosed)
Depression: 15% per year
Other (COPD, Cancer, Osteoporosis, etc)
Problem Diabetes in Elderly
Poly Pharmacy
Perobahan perilaku
Depression
 Sleep disturbance

Kesulitan untuk memulai dan

mempertahankan tidur (43%)
Sering terbangun tengah
malam (30%)
Insomnia (29%)
Pola tidur yang tidak menentu (25%)
Terlalu cepat bangun (19%)
Tidak merasa segar setelah tidur (13%)
Aging and Diabetes
Poor diabetes control exacerbates the aging process.
Poor diabetes control causes age related disease to develop
earlier.
Poor diabetes control makes co-morbid conditions worse
and harder to manage.

9
 Hyperglycemia in the Elderly can cause :
Delirium
Mood swings and irrationality
Appetite changes
Sleep disturbances
Increases risk for:
Diabetic Ketoacidosis
Hyperglycemic Hyperosmolar State
(HHS)
Impairs cognitive ability
Reduces energy
Impairs memory
Decreased wound healing
Increased risk of HHS
Increases urine output
Impacts incontinence/dehydration
Increased risk of UTI
Impairs immune system
10
 Hypoglycemia in the Elderly
Aging increases risk of hypoglycemia:
Reduced hormonal counter regulation
Renal and hepatic changes
Hydration status
Inadequate or irregular nutrition
Decreased intestinal absorption
Autonomic neuropathy
Polypharmacy
Use of alcohol, other sedating meds
May cause:
Heart arrhythmias
Increased risk of falls
Signs and symptoms may be masked by co-
morbidities (i.e. Parkinsons)
Impairs concentration and cognition
Impairs reaction time 11
Case of Mistaken Identity
Signs of Aging
Needing glasses
More frequent urination
Cant do things like you did
when you were 20
Atherosclerosis
High Blood Pressure
Change in gait
Restlessness, confusion,
slower cognition.
Signs of Diabetes
Blurred Vision
Polyuria and nocturia
Fatigue
MI and CVAs 2 times more
common
High Blood Pressure
Neuropathy and foot
deformities
Restlessness/confusion with
high and low BG.
12
Diabetes Assessment
in the Older Adult
Physical Assessment
Mobility/ Physical Activity
Nutritional Assessment
Neurological Assessment
Psychosocial Assessment
Other Areas

13
 Physical Assessment
Cardiovascular System
Reduction in CVD risk factors may have greatest impact on
morbidity and mortality
Hypertension
Lipids
Increased risk of CVAs and MIs.
Heart rate in response to exercise reduced.
Thickening of basement cell membranes.
50% of newly diagnosed people with T2DM have CVD.
Ophthalmic
Higher rates of cataracts, glaucoma and macular
degeneration.
Auditory
Renal
Impair Immune system 14
 Nutritional Assessment
Nutritional status
Change in nutrient needs
Change in body composition
Hydration status
Alcohol use/abuse
Supplement/herbal use
Gastrointestinal tract
Absorption
Gastroparesis
Appetite

15
 Neurological Assessment
Autonomic and peripheral neuropathies:
Heart
Incontinence
Sexual function
Protective sensation
Hypoglycemia unawareness
Body Temperature regulation
Reduced ability to sense:
Thirst, Smell, Taste

16
Treatment Recommendations
Glycemic Control
Hypertension
Lipids
Tobacco cessation
Eye care
Foot care
Nephropathy
Diabetes Self-Management Training

17
Be Aktif
Tetap Ceria, jangan stres
Olah Raga
Tetap semangat dan Oprtimis
Jangan berlebihan
Hindari kebiasaan buruk
 The aim in elderly people with diabetes
is to
Relieve symptoms of high glucose levels
Avoid low glucose levels
Achieve agreed blood glucose levels
Monitor diabetes complications
Encourage health and fitness habits
Ensure older people are actively involved in
setting goals for their diabetes management

Construct a rational management plan for an

older patient with DM, taking into account
goals and preferences, life expectancy,
abilities, and resources
Glycemic Control in Elderly
A1c-
<7% in healthy adults with good functional status
<8% appropriate in:
Frail older adults
Life expectancy less than 5 years
Those whom risk of intensive glycemic control outweighs benefits
Blood pressure: < 130/85 mm Hg
LDL-cholesterol: < 100 mg/dl
Smoking cessation
Body mass index: < 25 kg/m2
Regular exercise
The same glycemic, blood pressure and lipid targets apply
to the otherwise healthy elderly. In people with multiple
comorbidities, a high level of functional dependency and/or
limited life expectancy, the goals should be more
conservative. In these latter groups, symptoms of
hyperglycemia and hypoglycemia should be avoided.
Gllycemic Control in Elderly Diabetes patients with
acute coronary syndromes
Diabetes and acute coronary syndrome
ACS describes a spectrum ranging from
unstable angina to acute myocardial
infarction (AMI)

Hyperglycemia in cardiac emergencies is

associated with more frequent adverse major
cardiovascular events and worse prognosis
 Acute MI Data
Elevated glucose levels predict mortality in acute MI
patients with and without diabetes
Elevated glucose levels in STEMI is associated with
larger infarct size in patients without history of
diabetes
Meta-analysis of 15 studies of patients with acute MI
reports higher mortality and more frequent CHF when
glucose >110 mg/dL
Hyperglycaemia and hypoglycaemia associated with
adverse outcomes including mortality

Sala J, et al. J Epidemiol Community Health. 2002;56:707-712.

Kosiborod M, et al. Circulation. 2005;111:3078-3086.
Timmer J, et al. Am Heart J. 2004;148:399-404.
Capes S, et al. Lancet. 2000;355:773-778.
 Hyperglycemia in ACS : Patophysiology

Angeli F et al Hyperglycemia During Acute Coronary Syndrome: Prognostic Implications. J Diabetes Metab 2013, 4:7
Hyperglycemia in ACS

Approximately 85% of patients who present

with ACS have some degree of
dysglycaemia1

20% of are known to have 31% have undiagnosed 35% have impaired glucose
diabetes diabetes tolerance

Hyperglycaemia at the time of admission with ACS is a powerful predictor of

poorer survival and increased risk of in-hospital complications

Norhammar et al Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective
study The Lancet 2002 359(9324):2140-4
Admission glucose in AMI associated with mortality, independent of T2DM
diagnosis

N = 141,680 hospitalized with AMI

30 days 1 year
60 60

50 50

40 40
Mortality
(%) 30 30

20 20

10 10

0 0
110 >110- >140- >170- >240 110 >110- >140- >170- >240
140 170 240 140 170 240

Admission glucose (mg/dL)

Diabetes No diabetes

AMI = acute myocardial infarction Kosiborod M et al. Circulation. 2005;111:3078-86.

 Hyperglycemia in ACS
NICE guidelines (UK) 2011

Patient admitted for ACS

Management of hyperglycemia
within 48 hrs of ACS

Ongoing management Test for patients without

of known diabetes known diabetes

Advice and ongoing monitoring for

patients without known diabetes
Adapted from NICE guidelines 2011 Hyperglycaemia in acute coronary syndromes http://guidance.nice.org.uk/CG130/Guidance/pdf/
 Treatment Hyperglycemia in The Hospital

Antihyperglycemic therapy

Insulin Non-insulin agents

Stable patients
Recommended No contraindication to
non-insulin agents

IV Insulin SC Insulin

Critically ill patients Non-critically

in the ICU ill patients

Moghisis 2009
 Management for patients presenting with ACS
General consensus (although not good-quality evidence) to
treat if over 200 mg/dl

Aim for blood glucose levels <180 mg/dL while avoiding

hypoglycaemia

Insulin therapy usual treatment for hospitalised patients

Consider a continuous variable rate intravenous insulin

infusion with hourly monitoring of blood glucose levels if
intensive control is indicated

NICE guidelines 2011 Hyperglycaemia in acute coronary syndromes http://guidance.nice.org.uk/CG130/Guidance/pdf/English

Kushner et al ACC/AHA Guidelines for the management of patients with ST-elevation myocardial infarction Circulation. 2009
120:2271-2306
 Treating Hyperglycemia In Patients Presenting
With Acute MI

Inpatient Glycemic Goals in ACS

Professional
Patient/Clinical Setting Specific Goal
organization

ADA/AACE1 ICU Non-critical care units

140-180 Pre-meal BG: <140 mg/dL in conjunction
mg/dL* with
random BG <180 mg/dL

AHA2 ICU with ACS Non-ICU patients with ACS

90-140 mg/dL <180 mg/dL

1. AACE/ADA Consensus Statement. Moghissi ES et al. Diabetes Care. 2009; 32:1119-1131;

2. Deedwania P et al. Circulation. 2008;117;1610-1619.
 AACE-ADA Consensus Statement on
Inpatient Glycemic Control: ICU
Tighter targets ( <110 mg/dl ) not
safe; >180 mg/dl not acceptable.

Lower target ( 110-140 mg/dl )

acceptable in selected patients if
hospital achieving this successfully.
Start IV insulin at threshold
no higher than 180 mg/dl.

Glucose target = 140-180 mg/dl

Not recommended Acceptable Recommended Not recommended

< 110 110-140 140-180 >180
Consider A1C 7.1-8.5% if
Limited life expectancy
High level of functional dependency
Extensive coronary artery disease at high risk of
ischemic events
Multiple co-morbidities
History of recurrent severe hypoglycemia
Hypoglycemia unawareness
Longstanding diabetes for whom is it difficult to
achieve an A1C 7%, despite effective doses of
multiple antihyperglycemic agents, including
intensified basal-bolus insulin therapy