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Insulin therapy: Diabetes and the elderly

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Insulin therapy: Diabetes and the elderly
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This ADVANCE insulin programme is guided by two expert South African endocrinologists; each presents a view of the topic: Treating elderly patients with Diabetes.

Both endocrinologists have extensive teaching and clinical expertise.

Included in this module is a review of the topic and two case studies to test your learnings and clinical approach.

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This case study represents a typical clinical situation of a type 2 diabetic patient that is ageing and developing co-morbidities.

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With his co-morbidities, his diabetes has become poorly controlled.

The patient is seriously ill with both cancer and chronic obstructive lung disease.

In terms of treating his diabetes, a definition of functional category is helpful to guide therapy.

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Click on answer below:

  1. Functional category 1
  2. Functional category 2
  3. Functional category 3
  4. Subcategory 2b
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Click on answer below:

  1. 6%
  2. 7%
  3. 8.5%
  4. 7.5%
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Click on answer below:

  1. Basal insulin
  2. Premix insulin
  3. Fourth oral agent or replace third oral agent
  4. Bolus insulin
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While this presentation is primarily directed at type 2 diabetes mellitus (T2DM), the principles of categorisation and treatment approaches also applies to type 1 diabetes (T1DM) patients.

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As treatment options have improved over the last 10 years, clinicians need to be alert to the changing pathophysiology of type 2 and type 1 diabetes.

Also, the ageing process alters the pathophysiology of type 2 and type 1 diabetes.

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The challenges of treating elderly T2DM patients can be daunting. However, the use of functional categorisation and an understanding of the pathogenesis of elderly T2DM  is key to therapeutic choices.

The duration of diabetes is very important; in a patient who reaches 65 with diabetes diagnosed at age 50, it is much easier to introduce and intensify insulin than in a patient who only develops T2DM at the age of 65 years and older.

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The diversity of elderly patients coming to a clinic or general practitioner is evident from the moment he/she enters the surgery – on his own, walking or in a wheelchair with carer.

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Pathogenesis in the elderly is affected by external factors, as well as genetics, medication and co-existing illness.

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The pathogenesis of diabetes is accompanied by ageing changes at a cellular level; importantly, loss of beta cell mass and function, reduced insulin secretion, increasing insulin resistance and differences between the lean and obese elderly patient.

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A very important factor is cognitive functioning, as this needs to be considered when selecting an insulin regimen. A recent study in elderly diabetics is instructive: when enrolled, 11% were initially evaluated as being affected by cognitive disorders and 3% assessed as being dementia sufferers.

However, on completion of the Mini-Mental State Examination (MMSE) more than one in four patients showed evidence of cognitive dysfunction. This ‘underestimation’ of cognitive functioning ability must be kept in mind when initiating insulin regimens.

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The clinical presentation of T2DM in the elderly may not display any of the classic symptoms we recognise in younger diabetes. This is also an explanation of why we see these older patients with a myocardial infarction (MI) without their diabetes having been diagnosed.

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Diabetes is missed in older patients because of altered early signs – they can have insulin resistance and a delayed first phase insulin release. Also, they can present with a raised PPG, but a normal FPG. For this reason, if you only check FPG, you will miss the presence of diabetes. Rather do a FPG and an HbA1c, or if cost is not an issue, do a PPG also.

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Symptoms are often gradual in onset and can commonly be confused with the signs of ageing. Clinicians need to have a higher index of suspicion and action with regard to possible diabetes in the older patient.

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Once a diagnosis has been made, there must be a goal for treatment which can be different to the target for a younger patient. Clinicians should still seek a target that will avoid micro-and macrovascular complications. This is vital, particularly in the elderly functional class 1 patient, who may still be active for a decade or more. As clinicians, for our patients, it is key to choose targets that will avoid complications.

Targets will differ in different functional categories, but the therapy should still aim to keep the patient asymptomatic, even in category 3 where life-expectancy is shortened.

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The functionally independent Category 1 patient can be treated with targets as for a younger patient. There should always be targets for functionally dependent patients, except at the end of life where there is no target HbA1c, other than to still aim therapy at preventing symptoms.

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Individualisation of patient care is the principle of therapy even in the aged.

Indications for insulin therapy for elderly patients diagnosed before the age of 60 is the same as those diagnosed afterthe age of 65 years – a very important guiding principle.

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One other factor that must be kept in mind, particularly in patients whom the clinician has treated for a number of years, is that basal insulin needs vary and diminish with age.

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Disadvantages are well-known and newer agents in T2DM management seek to address these complications of insulin therapy. Hypoglycaemia is particularly important in the elderly patient. Insulin therapy must be tailored to the patient’s dietary habits.

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The clinical objective is to mimic the physiological profile determined by timing of breakfast, lunch and dinner.

In the elderly, meal times are often in an individual pattern, e.g. breakfast at 10h00, supper at 17h00.

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Human insulins are tricky in the elderly; and in all instances the role of the care-giver is very, very important. Human insulins in resource-poor settings may be the only option, so patient/care-giver education is vital and the motto “start low, go slow” should be applied in initiation of insulin therapy.

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A reminder: prior to selection of the type of insulin, note diabetes duration (was the patient diagnosed by age of 50 years) and the functional category of the patient as this will influence your choice of insulin.

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Where a care-giver is involved, this may well require ‘double-education’ but this investment in education may be very valuable and essential for good outcomes. The investment is very rewarding, as experienced recently in the case of an elderly teacher who was very incapacitated by her diabetes; when put on insulin, she regained her earlier energy levels.

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Please note the conservative introduction and up-titration of insulin – this is to reduce the risk of hypoglycaemia.

Rather go ‘slow’ with elderly patients, even in this highly independent group of elderly patients in functional category 1.

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While you may consider adding bolus insulin to the basal insulin, this may cause hypoglycaemia. A preferable approach for these patients may well be the use of an ultra-long acting insulin once or twice a day.

Be careful with metformin in the frail, lean elderly patient.

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In Category 3patients, the clinical aim is to control symptoms of hyperglycaemia with any insulin regimen, so long as you avoid the risk of hypoglycaemia.

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The message is to start low and go slow: you may start with basal insulin less than 10u if you are scared of hypoglycaemia. Monitor at every step of intensification.

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What to do if the patient has no care giver or support system?

You may in this situation choose a premix biphasic insulin, but you have to ensure that the patient has regular meals. If a one-meal-a-day delivery system can be introduced, this can be very helpful to avoid hypoglycaemia.

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This is relevant to all diabetes patients on insulin.

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While benefits of this technology are clear, are they really relevant and useful in the elderly patient?

The next case is illustrative of the value of these devices.

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A patient with high glucose levels early in the morning over a few days.

Should one up-titrate?

A likely thought, but examination of the CGM showed nocturnal hypoglycaemia prior to the morning spike, which would indicate a need to rather reduce insulin therapy.

So use these devices periodically in the elderly patient, when you are uncertain where to go with insulin intensification or reduction.

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These treatment challenges in T1DMare also important.

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  • T2DM is a common disease in the elderly.
  • There is a correlation between ageing and the prevalence of T2DM
  • Progressive decline in beta function means that most elderly patients will require insulin
  • Elderly patients should not be denied insulin if indicated
  • Before initiating insulin in the elderly, assess co-morbidities, life expectancy, functional status, duration of diabetes and diabetes complications.
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NOTE: This article was made possible by an unrestricted educational grant from Sanofi, which had no control over content.

References

  1. Doucet J, Le Floch JP, Bauduceau B, et al. GERODIAB: Glycaemic control and 5-year morbidity/mortality of type 2 diabetic patients aged 70 years and older: 1. Description of the population at inclusion. Diabetes Metab2012; 38(6): 523-30.
  2. Scheiner G, Boyer BA. Characteristics of basal insulin requirements by age and gender in Type-1 diabetes patients using insulin pump therapy. Diabetes Res Clin Pract2005; 69(1):14-21.
  3. Nathan DM, Buse JB, Davidson MB, et al.Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes.  Diabetes Care2006; 29(8): 1963-72.
  4. Henderson JN, Allen KV, Deary IJ, et al. Hypoglycaemia in insulin-treated Type 2 diabetes: frequency, symptoms and impaired awareness. Diabet Med 2003; 20(12): 1016-1021.
  5. Donnelly LA, Morris AD, Frier BM, et al. Frequency and predictors of hypoglycaemia in Type 1 and insulin-treated Type 2 diabetes: a population-based study. Diabet Med 2005; 22(6): 749-755.
  6. Akram K, Pedersen-Bjergaard U, Carstensen B, et al. Frequency and risk factors of severe hypoglycaemia in insulin-treated Type 2 diabetes: a cross-sectional survey Diabet Med 2006; 23: 750 -756.
  7. MacLeod KM, Hepburn DA, Frier BM. Frequency and morbidity of severe hypoglycaemia in insulin-treated diabetic patients. Diabet Med1993;10: 238–245.
  8. Chico A, Vidal-Rios P, Subira M, et al.The Continuous Glucose Monitoring System Is Useful for Detecting Unrecognized Hypoglycemias in Patients With Type 1 and Type 2 Diabetes but Is Not Better Than Frequent Capillary Glucose Measurements for Improving Metabolic Control. Diabetes Care2003; 26(4): 1153–1157.
  9. Weber KK, Lohmann T, Busch K, et al. High frequency of unrecognized hypoglycaemias in patients with type 2 diabetes is discovered by continuous glucose monitoring. Exp Clin Endocrinol Diabetes2007; 115: 491–494.
  10. Cefalu WT, et al, eds. CADRE Handbook of Diabetes Management. New York, NY: Medical Information Press; 2004.

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