Diabetes in Older Adults: 제14차 분당서울대학교병원 내과 연수강좌 3 March, 2017 Diabetes in Older Adults: 노인당뇨병관리: 무엇이 중요한가? 서울의대 분당서울대학교병원 내과 장학철

Contents 노인 당뇨병의 병태생리 노인에서 당뇨병이란? 노인 당뇨병 관리의 원칙 노인 당뇨병의 약물요법

노인 당뇨병의 역학 Korean Diabetes Fact Sheet 2015

노화에 따른 근육량, 근력, 운동능력의 변화 Short KR, Vittone J, Bigelow ML,Proctor DN,Nair KS. Age and aerobic exercise training effects on whole body and muscle protein metabolism. Am J Physiol 2004;286:E92–101.

노화와 인슐린 저항성 Aging Sarcopenic Visceral obesity Obesity Muscle mass/ strength Endurance capacity Muscle weakness Fatigability Physical activity Sarcopenic Obesity Energy expenditure Visceral obesity Insulin Resistance HTN T2DM Dyslipidemia

노인당뇨병의 병태생리 Intrinsic Extrinsic B-cell Dysfunction Coexisting Illness Low Insulin Stress: Counter- regulatory Hormones Adiposity Sarcopenia Insulin Resistance Decreased Glucose Disposal Decreased Mobility Hyperglycemia Impaired Insulin Action /Secretion Ethnicity Genetics Medications: B-blocker, Diuretics

노인에서 당뇨병 진단 시 고려사항 Clinical Features Diagnosis Cautions Most often asymptomatic and diagnosed based on routine laboratory evaluation Classic symptoms (polyuria, polydipsia) may be absent May present with dehydration, confusion, incontinence, and diabetes complications, such as neuropathy or nephropathy Diagnosis Standard diagnostic criteria apply More likely to have abnormal 2-hour plasma glucose during an OGTT Cautions The HbA1c level may not accurately reflect hyperglycemia in conditions common among older adults, including anemia, recent blood transfusions, treatment with erythropoietin, or chronic kidney disease JAMA. 2016;315(10):1034-1045.

노인에서 당뇨병이란? 노인 당뇨병 환자: 하지 절단, 심근경색, 시력장애, 만성신부 전의 발생률이 제일 높다. 특히 75세 이상의 노인 환자는 65-74세 노인환자에 비하여 합병증의 발생률이 더 높다. 비록 최근 20년간 고혈당 위기로 인한 사망률이 감소하였지 만, 노인 당뇨병 환자에서 고혈당 위기로 인한 사망률이 제 일 높다. 75세 이상의 노인 당뇨병 환자는 저혈당으로 인한 응급실 방문 빈도가 2배 높다. Diabetes Care, ePub October 25, 2012

노인 당뇨병 환자에서 신체 기능장애의 발생위험이 높다 노인 당뇨병에서 신체 기능장애 발생 위험 1.5-2.0배 증가 (NHANES, 1999-2006; Kalyani et al., 2010) 위험인자: CVD, Complications, Obesity, A1C, Depression 신체기능 장애  건강수명 ↓, 의료비용 ↑ 당뇨병 관리의 어려움 신체기능 장애 질병의 악화

심한 고혈당은 근육의 질을 저하시키고, 일상 생활 수행 능력을 감소시킨다 SPPB, short physical performance battery Diabetes Metab J. 2016 Apr;40(2):140-6

노인에서 당뇨병이 있으면? 합병증 및 사망률 증가 기능 감소 또는 신체장애 증가 요양시설에 입원할 위험 증가

Contents 노인 당뇨병의 역학/병태생리 노인에서 당뇨병이란? 노인 당뇨병 관리의 원칙 노인 당뇨병의 약물요법

Primary Goal of Diabetes in Older Adults Prevent or delay the onset and progression of acute and chronic complications associated with diabetes Prevent treatment related complications, especially hypoglycemia Maintaining an acceptable quality of life and function is an overarching goal

Characteristics of Older Adults with Diabetes in Different Settings Living status Patient characteristics Issues pertaining to diabetes management Community-dwelling High functioning Perform self-care independently with/without caregiver support Consider comorbidities that interfere with ability to perform self-care Avoid complex regimen and medications that increase risk of hypoglycemia Assisted care facilities Needs some support with IADL High caregiver needs Frail, more comorbidities Need some assistance with medication management Can’t get help with insulin injection- may become an issue if acutely ill Nursing homes Low functioning Total dependence for self-care Limited life expectancy Little control over timing or content of diet Higher risk of acute illness, anorexia, dementia/delirium interfering glucose control Self-care performed by NH staff

“Unique” Management Strategies in Elderly Diabetes Unique issues Management Strategies Goal setting Avoiding hypoglycemia is as important as achieving target A1C goal Elderly with multiple chronic conditions may have difficulty achieving individual disease goals Goals may change if overall health changes Weigh risk of hypoglycemia before setting A1C goal Balance glycemic goal and other chronic disease goals with overall life goals and patients preferences Assess and adjust goals periodically Hypoglycemia Even mild episode combined with other medical conditions may result in catastrophic fall, fracture, and poor QoL High risk of hypoglycemia unawareness and missed reporting Avoid medications with high risk of hypoglycemia Adjust glycemic goals Carefully look for hidden/subtle symptoms Consider continuous glucose monitoring

“Unique” Management Strategies in Elderly Diabetes Unique issues Management Strategies Geriatric syndrome Suspect unrecognized self-care barriers if recent unexpected deterioration in control frequent errors in medications/ judgment fails to achieve glycemic goal after reasonable attempts Screen for cognitive dysfunction, depression, physical disabilities, poly-pharmacy, chronic pain Improve barriers such as depression, poly-pharmacy Simplify regimen to fit barriers that are not reversible Treatment strategies Patients’ ability to learn new information might be limited, causing stress and errors Changes in dietary habits are more difficult Many older adults feel discouraged with other health issues and avoid exercise due to pain Assess patients’ ability to perform self-care before developing strategy Simple dietary plans to avid large carbohydrate load Provide detailed prescription for individualized physical activity

노인증후군 노인에서 분리된 질병으로 구별되지 않는 임상 증후군을 노인증후군으로 정의 인지장애, 다약제, 우울증, 뇨실금, 낙상, 통증 노인, 특히 노쇠한 노인에서 흔히 발생함 삶의 질이나 신체장애에 미치는 영향이 큼 여러 장기에, 또 다양한 기저원인에 의하여 발생 원인을 규명하기 위한 진단적 검사가 비효율적이거나 부담스러울 때가 있음. 확진이나, 원인 규명 없이 임상상에 따라 치료하는 것이 도움이 됨. 섬망(delirium), 낙상, 노쇠(frailty), 어지럼증, 실신(syncope), 뇨실금 J Am Geriatr Soc. 2007, 55(5): 780–791 J Am Geriatr Soc. 2003;51:265-280

Geriatric syndromes: dementia Hyperglycemia – vascular dementia Hypoglycemia * Alzheimer’s-type and multi-infarct dementia are approximately twice. * Cross-sectional studies have shown an association between hyperglycemia and cognitive dysfunction. Hypoglycemia is linked to cognitive dysfunction in a bidirectional fashion: cognitive impairment increases the subsequent risk of hypoglycemia, and a history of severe hypoglycemia is linked to the incidence of dementia. In the ACCORD trial, for which referred participants were felt to be capable of adhering to a very complex protocol, 20% of those in the ancillary trial of cognition were found to have undiagnosed cognitive dysfunction at baseline ( J. Williamson, personal communication) (60). In this trial, neither intensive glycemic control nor blood pressure control to a target SBP <120 mmHg was shown to prevent a decline in brain function (61) Korean Diabetes Fact Sheet 2015

노인 당뇨병과 노인증후군 Falls and fractures Higher risk of hip and proximal humeral fractures in women with DM It is important to assess fall risks and perform functional assessment periodically Polypharmacy (use of six or more prescription medications) Increased risk of drug side effects and drug-to-drug interaction Increased risk of falling in older people Substantial costs Depression Leading to difficulty with self-care, medication adherence, and preventive care Higher risk of mortality and dementia in patients Vision and hearing impairment Functional impairment Peripheral neuropathy  postural instability, balance problems, muscle atrophy Vision and hearing difficulties Gait and balance problems Women with diabetes have a higher risk of hip and proximal humeral fractures after adjustment for age, BMI, and bone density. It is important to assess fall risks and perform functional assessment periodically in older adults. Diabetes is associated with a high prevalence of depression. Clinical tools such as the Geriatric Depression Scale (80) can be used to periodically screen older patients with diabetes. Nearly one in five older U.S. adults with diabetes report visual impairment (81). Hearing impairment involving both high- and low/mid-frequency sound is about twice as prevalent in people with diabetes.

영양평가 At risk for under-nutrition due to anorexia, altered taste and smell, swallowing difficulties, and oral/dental issues Medical nutrition therapy (MNT) Intentional weight loss in overweight and obese older adults  worsen sarcopenia, bone mineral density, and nutrition deficit ? Though energy needs decline with age, macronutrient needs are similar throughout adulthood. Older adults may be at risk for undernutrition due to anorexia, altered taste and smell, swallowing difficulties, oral/dental issues, and functional impairments leading to difficulties in preparing or consuming food. The Mini-Nutritional Assessment, specifically designed for older adults. Obesity exacerbates decline in physical function due to aging and increases the risk of frailty. Physical activity + nutrition therapy Nutrition therapy Physical activity

Exercise Training and Nutritional Supplementation for Frailty in very Elderly People Randomized, placebo controlled trial comparing resistance exercise training, and/or nutrient supplementation in 100 frail nursing home residents (87.1 yrs) over a 10 weeks period. N Engl J Med 1994;330:1769

Anti-hyperglycemic medication use in older adults Changes in pharmacokinetics (in particular reduced renal elimination) Changes in pharmacodynamics (increased sensitivity to certain medications) Increased risk for hypoglycemia Potential need for reduced doses of certain medications Attention to renal function to minimize side effects Comparative effectiveness studies of medications to treat diabetes in older adult populations are lacking.

Anti-hyperglycemic medication use in older adults Changes in pharmacokinetics (in particular reduced renal elimination) Changes in pharmacodynamics (increased sensitivity to certain medications) Increased risk for hypoglycemia Potential need for reduced doses of certain medications Attention to renal function to minimize side effects Comparative effectiveness studies of medications to treat diabetes in older adult populations are lacking.

Anti-hyperglycemic medication use in older adults Changes in pharmacokinetics (in particular reduced renal elimination) Changes in pharmacodynamics (increased sensitivity to certain medications) Increased risk for hypoglycemia Potential need for reduced doses of certain medications Attention to renal function to minimize side effects Comparative effectiveness studies of medications to treat diabetes in older adult populations are lacking.

Minimizing Polypharmacy in Older Adults Education of both patient and care-giver on the prevention, detection, and treatment of hypoglycemia is paramount.

Summary

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