Diabetes in Older Adults – Deepashree Gupta, MD | UCLAMDChat

August 30, 2019

So, my topic for the day is diabetes in older adults and some of the unique challenges we see in this patient population. So, please ask your questions on Twitter with #UCLAMDChat or post a comment on YouTube chat, and I’m happy to answer your questions. So, very quickly, we will talk about the demographics. So, some of the numbers we want to report are–9.4% of the United States population is currently living with diabetes. This is as of 2015. This is the tip of the iceberg. We have close to 70 million with pre-diabetes. So, that gives you some perspective about how big this problem is. What is even more challenging is that seniors have more diabetes than any other age group. 28.2% of patients over the age of 65 are living with diabetes. Now, this is an increase of 42% compared to 15 years earlier. Okay, so this is a very relevant topic. So, we’ll go over some of the diagnostic criteria for diabetes. So, diabetes is a disorder where, you know, there’s a mismatch between blood glucose and insulin levels. So when you eat your food, it’s broken down into a sugar called glucose, which gives you energy. To use glucose as energy, your body needs insulin. In diabetes, your body either does not make enough insulin–this is what we call as type 1 diabetes, right, so these are the kids–typically seen in young adults or children– where their body just doesn’t make insulin, and we have to give them insulin from the one of diagnosis. The other type of diabetes that is more common is the type 2 diabetes. Here, the body does make insulin, but it is not able to use it well, and we will discuss this in a little bit more detail. Most of this talk is relevant to type 2 diabetes. Some of the signs and symptoms of diabetes that our patients experience are unusual thirst, frequent urination, blurred vision, feeling tired for no apparent reason, extreme hunger, irritability, tingling/numbness in the hands or feet. Now, you might not have all these symptoms at the same time, but, you know, some of these clinical presentations to raise the concern about underlying uncontrolled blood sugars. Some women even present with recurrent urinary tract infections or yeast infections. So, the way we diagnose diabetes comes down to blood tests. The most commonly used blood test is glucose. So, we measure a blood glucose level– So, remember prediabetes precedes diabetes. The blood sugar–normal, fasting blood sugar is less than 100. So if you have a blood sugar in the morning between 100-126, that’s considered prediabetes. If your blood sugar is more than 126 early in the morning fasting, that’s actually considered as diabetes. We also have some criteria for after meal blood sugar. So if your blood sugar two hours after eating is between 180 to 200, that’s considered prediabetes, and more than 200 is considered diabetes. So, these are some glucose criteria that the American Diabetes Association has utilized to make a diagnosis of diabetes. Like we discussed, prediabetes is the bigger part of that iceberg that we were referring to earlier. So, prediabetes occurs when a person’s blood sugar is greater than normal, so, fasting more than 100, two hours after meal more than 180, but not high enough for a diagnosis of type two diabetes. Why do we emphasize this so much? Well, because we can either halt the progression of this or delay the progression of this to type two diabetes with weight loss, with diet changes, with exercise. So, it is relevant to intervene when we detect prediabetes. Type 2 diabetes, like we discussed, occurs when the body cannot properly use the insulin that it makes, so there is something called insulin resistance. So even though your body is making insulin, since the muscles and other tissues become resistant to the insulin, it’s not able to utilize glucose. Being overweight or obese is a leading risk factor for developing type 2 diabetes and makes treating diabetes difficult, so that’s why when we evaluate our patients. We don’t just talk about medications. We also talk a lot about lifestyle changes, including diet and exercise. Now, diabetes is a common disease, we discussed this. The point of my presentation today is that each patient needs unique care, okay, and that’s what I’m going to try and present to you. So, hemoglobin A1C is another blood test that we use along with blood glucose levels. This tells you your average blood glucose level for the past 2-3 months. Okay? So hemoglobin A1C is something most of our diabetic patients are familiar with. It’s a common blood test checked every three months. Usually we keep these numbers between 6.5-7. Less than 6.5 is considered prediabetes, and less than 5.7 is normal. So for most patients, when we are trying to control diabetes, we keep this number between 6.5-7. So, please remember that. Blood pressure control is very important. Now, we know that controlling your blood sugars is very important when it comes to controlling eye disease, neuropathy, or kidney disease, right, so when we are talking about heart attacks and strokes, the blood pressure control and cholesterol control becomes very relevant. Okay, so blood pressure control is very important for decreasing the strain on the heart, blood vessels, and kidneys, and cholesterol lowering can reduce your risk of having a heart attack or a stroke. So we try to do all three at the same time. Now, in addition to this, we always encourage our patients to get an eye exam once a year and a foot exam once a year. As you know, retinopathy, which is diabetes affecting the back of the eyes or causing bleeding and vision loss, is very common. Foot ulcers, lack of sensation– those are very common side effects or symptoms of neuropathy. So, we do want to keep monitoring for those as well. So, when it comes to specifically diabetes in older adults–and usually we describe this cohort as anyone above age 65–memory problems and depression become really relevant for this patient population. Okay, so older adults with diabetes that are at higher risk of memory loss and dementia– what we are learning is that poor glucose control from a long period of time–so longer duration of diabetes and poor control are associated with worsening memory function, and all our major societies, the American Diabetes Association, the Endocrine Society, are recommending screening for this. So some of the recommendations that come out for our practice, and it’s relevant to your care, are that we have the screening for early detection of mild memory loss or dementia, and depression is indicated for adults with diabetes 65 years of age or older at the initial visit and at least once a year. Needs do change sometimes, so even if this was not detected at the first appointment, it might happen in the subsequent years. And for patients who are screening positive for memory impairment, we try to co-manage our patients with specialists who deal with memory loss. So these are the geriatrics specialists or behavioral health providers. They do a formal evaluation for memory because we we only have time sometimes to do a screening test, but these specialists can do formal evaluation, sometimes offer treatments, and when managing patients with memory impairment, what becomes really relevant for us is simplifying drug regimens, right, we can’t put people who have a lot of memory problems on complicated regimens, and the other important aspect of this is involving families and caregivers in the care of our patients. The other important challenge we see with our older diabetic patients is loss of muscle mass and frailty, so loss of muscle mass is called sarcopenia, and sarcopenia is defined as an age-associated involuntary decline of skeletal or lean muscle mass, strength and/or physical performance. When sarcopenia persists, people can end up being frail, and frailty requires the following criteria: weight loss, exhaustion, weakness, slow walking speed, and decreased physical activity. The concern with this sarcopenia and frailty is the risk of falls, particularly, say blood sugars get too low, and if the muscle mass is not there, patients can fall, you know, have fractures. So this becomes very relevant, again, to this patient population. So if we do detect loss of muscle mass or frailty in our patients, we’ll talk about the need to individualizing hemoglobin A1C, blood pressure, and cholesterol goals, and then, again, we consider seeing the specialists and also doing physical therapy to improve muscle function and quality of life. The third major challenge–and this is something we see in our younger patients as well, but becomes really concerning in our diabetics above age 65–is the low blood sugars, and low blood sugars are technically defined as anything less than 70 milligrams per deciliter, but usually in our practice, if we see consistent blood sugars less than 100 on medications which can further lower them, we start getting worried and probably start backing off on those medications. So, repeated low blood sugars– so the numbers less than 70–can decrease the capability of detecting further low blood sugar, so this is dangerous. So, you could stop feeling a low blood sugar. Usually your diabetics will tell you if they have a low blood sugar, they get lightheaded, they get sweaty, they get dizzy. So there are some symptoms, and people can feel when their blood sugars are too low, but repeated episodes of low blood sugars actually takes away the body’s capability of feeling these low blood sugars, which is called unawareness. We are seeing some data that repeated low blood sugars can also predispose to these cardiac abnormal rhythms, maybe sudden cardiac death. Also, we know that there is this relationship between low blood sugars and memory loss, and there, the repeated low blood sugars really affect our patients above age 60 and affect memory in an adverse fashion. The other problem is if there is memory loss, then medication mistakes can happen and can further exacerbate low blood sugar. So there’s this bi-directional relationship between memory loss and low blood sugars, or hypoglycemia. So, lots of recommendations about this from American Diabetes Association. So, low blood sugar should be diligently monitored and avoided, okay, and again, the numbers to remember are less than 70 technically, but you know, we’d like to tell our patients to keep their blood sugars closer to 100 to low 100s. Blood sugar targets and medications need to be adjusted to accommodate for changing needs for older adults. So, if there is some patient who had no dementia at the time of presentation, but two years later had a stroke and now has memory loss, we can’t expect that patient to be able to do what they were able to do two years ago. We want to discuss findings of memory decline with patients and their caregivers. The family and caregivers need to be involved in decision making about medications, and in older adults at increased risk of low blood sugars, we want to use medications which are causing less low blood sugars. So, I will start to try to talk about some of the safer diabetes medications in the next few slides. So, some of the safer diabetes medications are– the first one is metformin. The American Diabetes Association is recommending this as first-line in the management of type 2 diabetes in older adults. Metformin decreases glucose released from the liver. It also makes muscles utilize glucose better, so that insulin resistance component is something that metformin works on. It rarely causes low blood sugars, which is why it makes sense in the context of this discussion. The other thing that has changed in the past two years is that FDA has approved the use of metformin even with patients who have compromised kidney function, so– albeit, we are using lower doses–only about 500 to 1,000. So, you know, the maximum dose of metformin can be up to 2,500, but we can still use lower doses if the kidneys are compromised. So, metformin is something we do offer to all our patients as the first-line of treatment. Now, there are some other oral medications that we don’t have long-term data on we do use, medications like genovia or the gliptins class of drugs, or once a week injections, but I’m not presenting them to you because we don’t have long-term data of the safety in the patient population. So, some of the medications that are actually causing more low blood sugars are what I’m going to present to you next. These do increase risk of low sugars. The first classes are these pills called sulfonylureas. They are taken once or two times a day. They promote insulin secretion from the pancreas. The common names you’ve probably heard of are glipizide, glyburide, glimepiride. The American Geriatrics Society actually recommends that longer durations of fonylureas like glyburide and glimepiride be avoided in our patients above age 65 because they can increase the risk of severe prolonged low blood glucose episodes. So if we do use these drugs, and remember, we do use them because they are cheaper, they are easily available, so if used, we’d prefer to use shorter durations of fonylureas like glipizide. The other point to remember is when these drugs are combined with insulin, again, the risk of low blood sugars goes up. So, we have to be cautious about checking blood sugars frequently If we see this class of medication, particularly in combination with insulin. So the insulin therapy is something that we are forced to use in certain patients who can’t get control just with oral medications. So, American Diabetes Association guidelines recommend the use of once daily insulin–it’s called basal insulin– injection as a reasonable option in many older patients with diabetes who are uncontrolled on oral medications. Insulin therapy–now, we know whether insulin is delivered as in a pen or in a vial and syringe, so, therapy requires good visual and motor skills as well as cognition, which is the memory aspect of things that we talked about earlier, so this can be challenging in some individuals. Multiple daily injections in particular–4 insulin injections a day sometimes– might be too complex, especially in patients with multiple medical conditions as well as memory loss and frailty. So we also have to pay attention to interactions with other medications and/or incorrect dosing because these can predispose older individuals to low blood sugars. So, insulin can be challenging, and that’s something, again, we have to reevaluate at every appointment and always make note of low blood sugars. So, I want to put all these things together for you in this slide. This is coming directly from the American Diabetes Association guidelines that were published in January of this year. So, to summarize: what ADA is telling us is that if a patient is relatively healthy, which means less than 3 chronic illnesses, their mental status or cognition is completely intact, they are very physically active, they have a longer remaining life expectancy, or that’s what we expect– hemoglobin A1C–remember what we were talking about before–6.5-7, so that is very reasonable, so we can keep the hemoglobin A1C less than 7.5 in these patients, blood pressure control is very important, cholesterol control with a statin is very important. In patients who have 3 or more serious medical conditions enough to require medications, patients who have mild to moderate cognitive impairment requiring support with day to day activities because they are frail, and they have intermediate remaining life expectancy. This is very important to us. High treatment burden– they feel very burdened with the treatments that we give them, they have recurrent low blood sugars, they are at fall risk. The A1C targets can be liberalized to less than 8%. Blood pressure and cholesterol control is still very, very important because we don’t want them to have heart attacks and strokes. So, A1C can be a little bit higher possibly in this patient population, and patients at end-of-life, in long term care, with end-stage chronic illnesses–so there are patients who are on dialysis who have end-stage heart failure or liver failure, and they have severe memory issue, memory problems. They are completely dependent on caregivers for day-to-day activities, so very frail. They have limited life expectancy. In these patients, A1C can even be higher than the other two categories, which is 8.5. So, for most patients, 8.5 means an average blood sugar closer to 200, so to give you relevance regarding this number, blood pressure can be higher in this patient population as well, and cholesterol loading is typically recommended only if there has been a previous event, like a heart attack or a stroke. So, these are guidelines that are coming out of American Diabetes Association. Now, remember guidelines are a broad– it’s a broad roadmap for everyone. We individualize our treatments based on what we encounter in our day-to-day practice. But, you know, I do think that we have to do a memory assessment and a physical assessment to make sure people are not frail and avoid hypoglycemia at all costs, and to summarize the guidelines, I am going to present the next two slides. So, individualization of blood-glucose targets are of paramount importance. Tighter glucose control in this patient population with other medical conditions can lead to overtreatment and increased risk of low blood glucose. Complex insulin regimens, frequent low-cost testing, and timing insulin with glucose checks with meals that they were able to previously follow might be difficult to maintain, particularly in individuals dealing with memory loss. Caregivers should be involved in decision making about insulin. Instruction should be written down at every appointment, and deintensification of medication regimens should be considered to match patient’s self-management abilities to reduce the risk of low blood sugars without worsening high blood sugars and related distress. So with this, I will move on to some frequently asked questions that are– so some of the questions that have come online, I see that there are some questions people have, so I’m happy to answer them. So the first question is “How often throughout the day should type 2 diabetes patients check their glycemic levels?” So, I’m happy to answer this question. It depends on what medications you’re on. So, if you’re on 4 insulin injections a day, you need to check 4 times a day. If you’re on 1 insulin injection a day with orals, it’s reasonable to check once in the morning fasting and once either before lunch or dinner. If you are only on orals and checking blood sugars is difficult–so orals like metformin, which don’t cause low blood sugars– it’s probably reasonable to check 3-4 times a week. If you are on medications like glipizide, which do cause low blood sugars, I would still recommend checking at least once a day so that you don’t have low blood sugars. The second question is “How do you handle the somogyi effect in patients with diabetes? Is this more common in older population?” So, somogyi effect, for explanation, means that you could have a low blood sugar in the middle of the night, which leads to a rebound high blood sugar early in the morning. So this can be seen in the older population, certainly, because our patients are sensitive to insulin, and these medications that we just discussed, the sulfonylureas, we typically recommend checking blood sugars at bedtime and then first thing in the morning. Typically, if they drop significantly overnight, I start backing off on medications to avoid nighttime low blood sugars. You can also get up and check in the middle of the night. So, that’s one way of doing it. There is a device called continuous glucose monitor that sometimes we place on patients diagnostically for two weeks and see what happens to blood sugar trends overnight. If they’re dropping again, I would recommend backing off on medications. “Should you be sweating when your blood sugar level is 165?” Very good question. So if your diabetes has been uncontrolled– so, say your blood sugar has been running 400-500, and then suddenly we give medications to bring your blood sugars down, 165 is low for what your body was used to. So at 165, you could have those episodes of low symptoms in that context. However, 165 in a pretty well controlled diabetic is still considered a reasonable number, particularly in someone above age 65, so it depends on the preceding control, to answer that question. “Should a patient be tested for slow digestion before being diagnosed with diabetes?” So, I’m going to try and answer this question with respect to gastroparesis. Gastroparesis does–literally, the word means slowing down of your gut motility. Usually, we see this about 5-10 years after being diagnosed with uncontrolled blood sugars. Gastroparesis is one of those complications we talked about like retinopathy, kidney disease, neuropathy– so, gastroparesis is one of those complications but usually happens, you know, with long-standing uncontrolled blood sugars, so to answer the question about diagnosing that before diagnosis of diabetes, I’m not sure if that’s something we recommend at this point. So, I’m going to also go over some questions that are frequently asked in my practice. I think we talked about this. “Who should check blood sugars, and how often?” So I’ll just add on to what we just discussed. Patients who benefit from checking blood sugars include those who are taking insulin, okay, we just talked about this, and also the number of injections matter– so if you’re doing 1 injection versus 4 injections really determines the frequency how often you’re checking. Patients who are having a hard time controlling blood sugar levels. This is why, if Medicare approves, we do recommend these continuous glucose monitors, and this will help increase frequency of checking blood sugars, give more control to our patients. Usually, Medicare approves these devices if you’re on 4 injections of insulin per day. If patients are having low blood sugar levels, then we definitely recommend checking fingers more often, and if patients are having lows without the usual warning signs–we call this unawareness–this is a very worrisome phenomena, so if we see this in our patients, we always ask if our patients feel low blood sugars. If they don’t, I make them check blood sugars more frequently. So, “what should the blood sugar target be?” So this is asked a lot. “What should be my fasting? What should be my meals? What should be my blood sugar after meals?” So before a meal, typically we recommend 80-130. With my older patients, I bring that 80 closer to 100 because sometimes if blood sugars are less than 100, frequently it predisposes you to low blood sugars, particularly on sulfonylureas or insulin, but two hours after a meal, blood sugar should be less than 180 milligrams per deciliter. To emphasize that, please don’t check blood sugars within two hours of eating. They will be high. So, to get better number check, at least two hours after eating. These are, by the way, guidelines from American Diabetes Association. Some of the other questions that we get are “Should my hemoglobin A1C always be less than 7%?” and I hope that what I presented earlier can answer this question. So, the answer is it depends. It depends because if there is a lot of memory decline or lack in, you know, muscle mass, frailty, you know, I think this number can be liberalized to 8 or 8.5%. In our very functional patients it’s reasonable to control this less than 7% or up to 7.5%. So, it depends. The answer to this question is it depends on the memory, functional, and other comorbid conditions, the coexisting medical conditions. A1C number is an average, okay, so you could have a 40 and a 200, and your average might look perfect. So, keeping most of your blood sugars in a good target range makes more sense, and I think that’s where diabetes management is going versus just focusing on hemoglobin A1C. So, it’s not a perfect measure, and then the key in older adults with diabetes is to avoid low blood sugar episodes, and like, we said that was less than 70, but less than 100 if you have symptoms, you know, that is really a top priority for our practice. And with that, I thank you for joining us and having this interesting discussion. So if you have any further questions, please go online and forward them to me. I’m happy to answer them.

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