ADA/AGS Consensus report 2013 Updtaes and Discussion

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Presentation Description

DM Treatment goals for the elderly need to be individualized due to this group of patients particular population criteria and needs


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PowerPoint Presentation:

Diabetes in Older Adults : A Consensus Report Mohamed Shehata,MD,FACP Clinical Assistant Professor of Medicine, Baylor College of Medicine


Goals What is DM? Understand Scope of DM in the elderly. Understand Goals of DM Management in the elderly can be different. Understand the Value of Patient centered Care concept. Understand how fast is medicine and our information are changing.

PowerPoint Presentation:


What is DM:

What is DM A group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both

A crisis in the making:

A crisis in the making

Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958–2010 :

Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958–2010

US Diabetes Prevalence by Age Group :

US Diabetes Prevalence by Age Group

Obesity and Diabetes Prevalence by Age:

Obesity and Diabetes Prevalence by Age

Type 2 DM:

Type 2 DM

DM means: :

DM means: DM IS NOT “ HIGH SUGAR PROBLEM ” 2 x the risk of high blood pressure 2 to 4 x the risk of heart disease 2 to 4 x the risk of stroke #1 cause of adult blindness #1 cause of kidney failure Causes more than 60% of non-traumatic lower-limb amputations each year NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2010.

DM Complications:

DM Complications A) Microvascular : 1-Retiopathy 2-Nephropathy 3-Neuropathy

B)Macro vascular Complications:

B)Macro vascular Complications The central pathological mechanism in macrovascular disease is the process of atherosclerosis, which leads to narrowing of arterial walls throughout the body 1-Coronary artery disease 2-CVA 3-PVD the association between DM and CVD is profound. CVD is the primary cause of death in people with either type 1 or type 2 diabetes .

PowerPoint Presentation:

Atherosclerosis is thought to result from chronic inflammation and injury to the arterial wall in the peripheral or coronary vascular system. In response to endothelial injury and inflammation, oxidized lipids from LDL particles accumulate in the endothelial wall of arteries. Angiotensin II may promote the oxidation of such particles. Monocytes then infiltrate the arterial wall and differentiate into macrophages, which accumulate oxidized lipids to form foam cells. Once formed, foam cells stimulate macrophage proliferation and attraction of T-lymphocytes. T-lymphocytes, in turn, induce smooth muscle proliferation in the arterial walls and collagen accumulation. The net result of the process is the formation of a lipid-rich atherosclerotic lesion with a fibrous cap. Rupture of this lesion leads to acute vascular infarction

Control the ABCS:

Control the ABCS

A Typical Patient Encounter:

A Typical Patient Encounter “So, Mrs. Smith, it looks like you do have diabetes. Your repeat fasting blood sugar was 178, and as you recall the first one was 187. Over 126 is diabetes. Also, your hemoglobin A1c was way too high at 8.6%. Normal is less than 6%. We need to get it below 7%.”

A Typical Patient Encounter:

A Typical Patient Encounter “What’s a hemoglobin A…whatever you said? I remember my hemoglobin was low when I was pregnant. What were those other numbers? What do you mean, 7%...of what?”

A Typical Patient Encounter:

A Typical Patient Encounter “So, Mrs. Smith, it looks like you do have diabetes. Your average blood sugar is around 200. When people don’t have diabetes, this number is below 125. We need to work with you to try to get this number, the average glucose, down below 150 over the next few months with some weight loss, exercise, and a medication. Let’s talk some more about what you can do…”

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“Wow, I’m not happy to hear that…I know that diabetes can do some bad things. Tell me what I can do to get my average glucose down.” A Typical Patient Encounter

ADAG Study: “Translation” of HbA1c into eAG:

ADAG Study: “Translation” of HbA1c into eAG HbA1c (%) (mg/dl) ( mmol /l)_ 5 97 5.4 6 126 7.0 7 154 8.6 8 183 10.2 9 212 11.8 10 240 13.4

ADA 2007—Treatment Goals:

ADA 2007—Treatment Goals FPG 90—130 mg/dl A 1 c <7% Peak PPG <180 mg/dl Blood pressure <130/80 mmHg LDL-C <100 mg/dl Triglycerides <150 mg/dl HDL-C >40 mg/dl* *for women HDL-C goal may be increased by 10 mg/dl American Diabetes Association Standards of medical care in diabetes. Diabetes Care 30:S4-S36, 2007

Back Ground:

Back Ground Till recently the elderly Has been excluded from controlled trials for Diabetes treatment and its complications despite the elderly carry the burden of having high prevalence of the disease of any age group


Case1 79 years old female patient with complaint of progressive weight loss and increased fatigue, she is on ADA diet 1800 K.Cal Past medical History: DM,HTN, Medications: Glipzide, Lisinopril,aspirin,statin HGbA1C 7.6 Blood glucose random occasionally at or above 300

What is Treatment::

What is Treatment: 1-add metformin 2-add insulin 3-Liberal diet. 4-Add Acarbose 5-increase Glipizide

The UK Prospective Diabetes Study (UKPDS):

The UK Prospective Diabetes Study ( UKPDS) provided valuable evidence of the benefits of glycemic control on microvascular complications, enrolled middle-aged patients with newly diagnosed type 2 diabetes, excluding those aged 65 years at the time of enrollment


UKPDS 80 This post-trial study (UKPDS 80) included more than 66,000 person-years of follow-up Benefits of intensive blood glucose control in patients with T2DM were sustained for up to 10 years after cessation of randomized interventions Benefits were maintained despite the early loss of differences in A1C levels between groups—a “legacy effect” These long-term results also demonstrated the importance of glucose control in reducing mortality and cardiovascular risk Thus, this study strengthened the rationale for achieving optimal glycemic control and indicate emergent long-term benefits on cardiovascular risk

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The UK Prospective Diabetes Study (UKPDS), which provided valuable evidence of the benefits of glycemic control on microvascular complications , enrolled middle-aged patients with newly diagnosed type 2 diabetes, excluding those aged 65 years at the time of enrollment

Patient centered care :

Patient centered care Treat patients not numbers. We care for the quality of life for our elderly patients Till 2007 ADA recommendations based on studies not designed for elderly ages >75 or older adults with poor health status -when such studies results available later after 2008 it clearly showed increased mortality in the elderly with tight glycemic control

Back Ground:

Back Ground People with type 2 diabetes mellitus (T2DM) are at increased risk of cardiovascular events 1 In prospective epidemiologic studies the incidence of these events is associated with the degree of hyperglycemia Previous studies have not established the effects of intensive glucose lowering on cardiovascular events or mortality in patients with T2DM


ACCORD STUDY The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group Conducted in 77 clinical centers across the United States and Canada Objective: The objective of this study was to determine whether a therapeutic strategy targeting an A1C of <6.0 % compared with a strategy targeting an A1C of 7.0 %- 7.9% in patients with T2DM would reduce the rate of cardiovascular events

ACCORD Study: :

ACCORD Study: Summary: C ompared with standard therapy, use of intensive therapy to target normal A1C levels for 3.5 years increased mortality and did not significantly reduce major cardiovascular events A higher mortality rate in the intensive - therapy group led to discontinuation of intensive therapy after a mean of 3.5 years of follow-up I f there is any benefit associated with intensive glucose lowering, it may take several years to emerge, during which time there is an increased risk of death The ACCORD Study Group. N Engl J Med. 2008;358(24):2545-2559

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No difference in prevalence of cardiovascular disease (CVD) or peripheral neuropathy

Diabetes Prevention program (DPP):

Diabetes Prevention program (DPP) 1ry Goal : To prevent or delay the development of type 2 diabetes in persons with impaired glucose tolerance (IGT ) Seconday Goals: Reduce cardiovascular disease (CVD) events Reduce CVD risk factors Reduce atherosclerosis

Lifestyle Intervention:

Lifestyle Intervention > 7% loss of body weight and maintenance of weight loss Dietary fat goal -- <25% of calories from fat Calorie intake goal -- 1200-1800 kcal/day > 150 minutes per week of physical activity

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Modifiable risk factors : Body fat distribution,obesity , elevated fasting in 2 hours glucose test, physical inactivity Results: Decreased mortality/morbidity in the elderly


Summary Both interventions were effective in men and women and all ethnic groups Intensive lifestyle intervention was effective in all age goups , including those > 60 years of age Intensive lifestyle intervention reduced the development of diabetes by 58% Metformin reduced the development of diabetes by 31% Lifestyle was more effective than metformin

Comparison of A1C Goals :

Comparison of A1C Goals AGS Guidelines 7-7.5% may be appropriate if safe to achieve 7.5-8% for healthy older adults 8 – 9% for patients in whom risks of tight control outweighs benefits ADA/AGS Consensus 7.5% for healthy patients < 8.0% for complex/intermediate , < 8.5% for very complex/poor health

HbA1C conversion:

HbA1C conversion HbA1c (%) (mg/dl) ( mmol /l)_ 5 97 5.4 6 126 7.0 7 154 8.6 8 183 10.2 9 212 11.8 10 240 13.4

Evidence that Groups Exist - Clinical Complexity Groups (HRS) :

Evidence that Groups Exist - Clinical Complexity Groups (HRS ) RELATIVELY HEALTHY < 3 chronic diseases • No cognitive or significant visual impairment • 0 or 1 instrumental activities of daily living (IADL) dependencies DIFFICULT TO IMPLEMENT ≥ 3 chronic diseases • Mild cognitive impairment • Severe vision impairment • ≥ 2 IADL dependencies


Continue LIMITED BENEFIT Moderate to severe cognitive impairment • ≥ 2 ADL dependencies • Residence in a long-term nursing facility

Comparison of Blood Pressure Goals :

Comparison of Blood Pressure Goals AGS Guidelines Target blood pressure of < 140/90 if tolerated Potential harm in lowering systolic blood pressure < 120 ADA/AGS Consensus Target of blood pressure of <140/80 if healthy or complex/intermediate Target blood pressure < 150/90 if very complex/poor health

Evidence from Blood Pressure Trials :

Evidence from Blood Pressure Trials Blood pressure lowering trials Old people with diabetes subgroup (SHEP) Diabetes patients with older subgroup (UKPDS) Older people with diabetes (rare) •Cardiovascular and microvascular benefit •Legacy effect not observed (UKPDS) •Optimal target remains unclear ACCORD BP 133.5 vs. 119.3 No cardiovascular benefit JAMA. 1996;276(23):1886. BMJ. 1998;317(7160):703. N Engl J Med. 2008;359(15):1565. N Engl J Med. 2010; 362:1575.

Case Discussion:

Case Discussion 75 male patient with history of Stroke with residual Right sided weakness, comes in to office for follow up visit, has recent fall at home and complain of leg pain. She is allergic to ACEI, she is taking Aspirin and Glipzide Past medical history: DM, Hypertension, depression, GERD, Urine incontinence, VS: BP 144/85 HR 75 RR 16 Temp 37.1 her Hgba1c 7.5 LDL 150,HDL 40, TG 140 , Hgb 12.0, eGFR 80

Start patient on:

Start patient on 1-Niacin 2-ARBs 3- Metformin 4-Glyburide 5-Statin

PowerPoint Presentation:

“The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission.” Sir Osler William

DM & Geriatrics syndromes:

DM & Geriatrics syndromes Depression Falls Sarcopneia Pain Urinary incontinence Depression Malnutrition Cognitive impairment Chronic pain syndromes Polypharmacy

Case Discussion:

Case Discussion 64 years old patient with c/o knee pain has been evaluated by several orthopedic surgeons, and had extensive imaging over last 2 years including CT and MRI of knee and spine has been negative for cause to explain her pain. Today BP155/95 HR 65 she is on BB Past medical history + ve for HTN and GERD. Medications including NSAIDs for pain and PPI On Evaluation HGB is 13.0, eGFR = 55, BG random=320 On Exam has glove and stocking on RT LE whre she has pain with increased tingling and further history taking reveals sharp shooting like pain .

PowerPoint Presentation:

Role of Primary care provider CKD Health care system Overhaul.

Take home message:

Take home message Patient individual care plan Patient centered care Patient preferences Treat your patient as a whole.

Important links:

Important links

Words of wisdom:

Words of wisdom Can’t transform everything at once Use the web sites to print out forms and “recipes” Don’t re-invent the wheel Learn from others

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