ueda2016 workshop - diabetes in the elderly - mesbah kamel

Diabetes in the Elderly

A REAL PRACTICAL

CHALELENGE

MESBAH SAYED KAMEL

MD

Optimizing the Management of T2D Patients....

AGENDA Impact of diabetes in the elderly patient

Factors specific to the management of diabetes in the elderly:

Screening and diagnosis .

Specific complications of type 2 diabetes in the elderly:

Risk of hypoglycaemic episodes

Functional disability

Depression, cognitive impairment and other geriatric syndromes, such as fractures and falls.

How to adapt management and treatment goals in the elderly patient with type 2 diabetes.

Adapted from http://www.indexmundi.com/egypt/demographics_profile.html , https://www.cia.gov/library/publications/the-world-factbook/geos/eg.html , http://en.worldstat.info/World accessed 22-2-2014

http://www.indexmundi.com/egypt/demographics_profile.html

https://www.cia.gov/library/publications/the-world-factbook/geos/eg.html

http://en.worldstat.info/World

2013

≥60 Years

≤60 Years

International Diabetes Federation. Managing Older People with Type 2 Diabetes Global Guidelines.

http://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Older%20People.pdf accessed 15-12-2013

2050

≥60 Years

≤60 Years

These changes present significant challenges to welfare, pension, and healthcare systems in

both developing and developed nations

Diabetes-related complications are the major causes of morbidity,

disability and mortality in older patients with type 2 diabetes:

There is now overwhelming evidence that the level and duration of

glycemia influences the development of diabetes-related

complications

Sinclair 2004. Clinical guidelines for type 2 diabetes mellitus. EDWOP 2004

Microvascular: Neuropathy,Retinopathy,Nephropathy

Macrovascular: Cardiovascular disease, Stroke

• Advanced age

• Recent hospitalization

• Intercurrent illness

• Chronic liver, renal or cardiovascular disease

• Endocrine deficiency (thyroid, adrenal, pituitary)

• Loss of normal counter-regulation

• Hypoglycaemicunawareness

SU=sulfonylurea.

Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.

I. Patient risk factors

• Poor nutrition or fasting

• Prolonged physical exercise

• Alcohol (ethanol)

• Use of SU and / or insulin

• Drug interactions with SUs

III. Drug risk factors

II. Lifestyle risk factors

T2DM=type 2 diabetes mellitus.

Greco D, et al. Exp Clin Endocrinol Diabetes. 2010; 118: 215–219.

Decompensated

diabetes39%

Intercurrent

illness14%

Acute

cardiovascular events

13%

Chronic

complications of diabetes

17%

Severe

hypoglycaemia17%

Prevalence of diabetes is strongly influenced by increasing age

Around 18% of people >65 years have diabetes

Diagnosed diabetes (%)

Combined age-group (years)

≥20 7.8 (7.0−8.6)

≥65 17.7 (15.6−19.7)

Age-specific groups (years)

20−39 1.9 (1.4−2.4)

40−59 8.1 (6.9−9.4)

60−74 17.6 (15.7−19.5)

≥75 15.2 (12.9−17.6)Adapted from Cowie C, et al. Diabetes Care. 2010;33:562-68.

Prevalence increases with age and peaks at age 60–74 years, falling slightly in olderages (≥75)

Crude prevalence of diagnosed diabetes by age: NHANES (National Health and Nutrition

Examination Survey) 2003-2006 (n=13094), US

Age at diagnosis The peak age at diagnosis is between 40 and 55, with a

sharp decline after age 65. Among elderly patients with diagnosed diabetes, the majority of diabetes is diagnosed in middle-age (aged 40-64 years) and a minority diagnosed at age ≥65 years.

1. Selvin E, et al. Diabetes Care. 2006;29:2415-19.2. Adapted from IDF Diabetes Atlas. 2011; Fifth Edition

Age (years)

Prevalence (%) of people with diabetes by age and sex 2011

Female

Male

0

15

10

5

605550454035302520 65 70 75

20

Screening and diagnosisin the elderly

Recommendations for screening and diagnosis in the

elderly

Clinical presentation of diabetes in old age is often asymptomatic and non-specific and clinical diagnosis may be delayed

In general, screening for and diagnosis of diabetes in older subjects should be in accordance with published international/national criteria and guidelines, and no age modified criteria are currently recognised

The prevalence and incidence rates of diabetes mellitus in elderly subjects (>65 years) may be underestimated when using only fasting plasma glucose.

Sinclair A, et al. Diabetes & Metabolism. 2011;37:S27-S38.

The presence of isolated post-challenge hyperglycaemia (IPH) is common in older subjects and should alert the clinician to screen for cardiovascular disease and institute risk intervention strategies to minimise premature death.

In high-risk older subjects with a normal fasting glucose, and where an OGTT is not feasible, determination of HbA1c may be helpful in the diagnosis of diabetes. A value of HbA1c >6.5% may indicate the likely presence of diabetes

Managing type 2 diabetes in the elderly

Special considerations

Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care

Their approach is influenced by a multitude of factors, such as the higher frequency of medical comorbidities, frailty and socioeconomic issues

Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs.

Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.

Management goals in the elderly The overall goals of diabetes management in older adults

are similar to those in younger adults and include management of both hyperglycaemia and risk factors1

However, in frail, elderly patients with diabetes, avoidance of hypoglycaemia, hypotension, and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes1,2.

In addition, management of coexisting medical conditions is important because it influences their ability to perform self-management2

1.Brown AF, 2003; 51(5):S265-286. 2.Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.

Major aims in managing older adults with diabetes

1. Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33; 2. Inzucchi SE, et al. Diabetes Care. 2012;55(56):1577-96.

Medical1 Patient oriented1

Freedom from hyperglycaemic symptoms

Prevention of undesirable weight loss

Avoidance of hypoglycaemia and other adverse drug reactions

Estimation of cardiovascular risk as part of screening for and preventing vascular complications

Detection of cognitive impairment and depression and functional disabilities at an early stage

Achievement of a normal life expectancy for patients where possible

Protect against heart failure, renal dysfunctions , bone fractures and drug-drug interactions2

Maintenance of general well-beingand good quality of life

Acquisition of skills and knowledge to adapt to lifestyle changes

Encouragement of diabetes self-care

Rationale for high-quality diabetes care in the

elderly

Recommendations:

Screening and early diagnosis may prevent progression of undetected vascular complications

Overall improved metabolic control will reduce cardiovascular risk

Improved screening for maculopathy and cataracts will reduce visual impairment and blind registrations

An integrated approach to management of peripheral vascular disease and foot disorders will reduce amputation rate

Sinclair A, et al. Diabetes & Metabolism. 2011;37:S27-S38.

Associated problems affecting management in the

elderly… Poor Hepatic Glycogen Reserve:

Decreased stores related to poor nutrition and decreased appetite.

Cataract: Both age and DM contribute to its causation

Neuropathy: Autonomic neuropathy (postural hypotension, constipation, etc.)

Neuropathy, atherosclerosis of peripheral vessels and poor vision makes elderly more prone to foot problems and contribute to sexual impotence in a large number of elderly diabetics.

Managing the frail, elderly patientwith type 2 diabetes

Complications of type 2 diabetes in the elderly

Hypoglycaemia

Cardiovascular

Microvascular (retinopathy/nephropathy)

Cognitive (dementia)

Depression

Falls and fractures

Peripheral neuropathy

The frail, elderly patient with diabetes

Older persons with diabetes are at higher riskthan those without diabetes of:

Vascular death and cancer mortality1

Functional disability2

Geriatric syndromes: Depression2

Cognitive impairment2

Other geriatric syndromes2

Severe hypoglycaemia2

(when treated with sulphonylureas or insulin)

Elderly patients with diabetes are at higher risk for hypoglycaemia and also lack of awareness about hypoglycaemia compared to younger patients2

Ageing andDiabetes

Cognitivedysfunction

CV disease,cancer andall cause

morbidity/mortality

Falls andfractures

Functionaldisability and

depression

1. Emerging Risk Factors Collaboration, et al. N Engl J Med. 2011;364(9):829-41.2. Sinclair A. Diabetes Spectrum. 2006;19:229-33.

Hypoglycaemia is a risk marker of frailty The relationship between

hypoglycaemia and geriatriccomorbidities

Hypoglycaemiais accompanied by many adverse consequences for which elderly patients are already at an increased risk

HypoglycaemiaFalls andfractures


depression



morbidity/mortality

1. Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.2. Emerging Risk Factors Collaboration, et al. N Med. 2011;364(9):829-41.

Ageing increases the risk of (sulphonylurea-

or insulin-induced) hypoglycaemia

Incremental increase in baseline age was associated with increased risk for severe hypoglycaemia, both for patients following intensive or standard treatment strategies

Annual incidence of hypoglycaemia requiring medical assistance (%)

Subgroup Intensive glycaemia control Standard glycaemia control

Overall 2.80 0.90

Age (years)

<65 2.38 0.80

65−69 3.04 1.00

70−74 4.25 1.39

≥75 5.27 1.39

Miller ME, et al. BMJ. 2010;340:b5444. doi: 10.1136/bmj.b5444.

Ageing increases the risk of (sulphonyl urea

or insulin-induced) hypoglycaemia

Hazard ratios from model predicting hypoglycaemia requiring medical assistance

Hazard ratio (95% CI) P value

Effects for both intensive arm participants and standard arm participants

Age (per 1 year increase) 1.03 (1.02 to 1.05) <0.0001

Each one year increment in baseline age was associated with a 3% increase in the risk for severe hypoglycaemia

Miller ME, et al. BMJ. 2010;340:b5444. doi: 10.1136/bmj.b5444.

Why is the elderly diabetic patient

at high risk of hypoglycaemia?

Defective Counter-regulation or perception of symptoms

1.The effects of ageing on the responses to hypoglycaemia1

2.The effects of type 2 diabetes on the responses to hypoglycaemia2

3.The effects of type 2 diabetes and ageing on the counter-regulatory responses to hypoglycaemia3

1. Meneilly GS, et al. J Clin Endocrinol Metab. 1994;78(6):1341-8; 2. Bolli GB. et al. J Clin Invest. 1984;73(6):1532-41; 3. Bremer JP, et al. Diabetes Care. 2009;32(8):1513-7.

Older Patients have Less Perception of Hypoglycemia

Bremer JP et al. Diabetes Care. 2009; 32 (8):1513-17

12

14

10

8

6

4

2

0

Auto

no

mic

sym

pto

ms

Baseline Hypo Recovery

**

12

10

8

6

4

2

0

Neu

rogl

yco

pen

ic

sym

pto

ms

Baseline Hypo Recovery

*

Middle-aged (39-

64 years)

Older

(≥65 years)

• 1-Attention to hypoglycemic symptoms may be reduced by depression, cognitive dysfunction or other chronic conditions.

2-Many elderly patients have limited knowledge about the symptoms of hypoglycemia: knowledge of diabetes is essential for symptom recognition.

WHY?????

1. The effects of ageing on the responses to hypoglycaemia:

There is defective perception of symptoms in the elderly 1

2. The effects of type 2 diabetes on the responses to hypoglycaemia:

Glucose counter-regulatory mechanisms may be abnormal in patients with Typ2 DM: impaired glucagon, growth hormone, cortisol, and perhaps epinephrine responses during hypoglycaemia could all contribute to a lack of compensatory increase in glucose production2

3. The effects of type 2 diabetes and ageing on the counter-regulatory responses to hypoglycaemia:

Impaired perception of hypoglycemia in older type 2 diabetes patients3

The elderly patient with diabetes is at high risk of hypoglycemia

1. Meneilly GS, et al. J Clin Endocrinol Metab. 1994;78(6):1341-8; 2. Bolli GB. J Clin Invest. 1984;73(6):1532-41; 3. Bremer JP, et al. Diabetes Care. 2009;32(8):1513-7.

Olderpatients with diabetes

have higher ratesof various comorbidities

such as hypertension, coronary heart disease, and stroke than

those without diabetes

Older adults with diabetes are at greater risk than other older adults for premature death, functional disability, and several common geriatric syndromes, such as polypharmacy, depression, cognitive impairment, or falls


Ageing andDiabetes



morbidity/mortality

Falls andfractures


depression

Sinclair A. Diabetes Spectrum. 2006;19:229-33.Emerging Risk Factors Collaboration, et al. N Engl J Med. 2011;364(9):829-41.

Older individuals with diabetes are at higher risk of cancer,

mortality and vascular death than those without diabetes

Cancer deaths (+23%,) and vascular deaths (+67%) (the most common causes of deaths in the elderly)

Emerging Risk Factors Collaboration, et al. N Engl J Med. 2011;364(9):829-41 (supplemental material).

Age at survey Cancer deathsHR

(95% CI)Interaction

p-valueVascular deaths

HR(95% CI)

p-value

40−59

60−69

70+

1.51(1.32, 1.72)

1.27(1.11, 1.45)

1.23(1.07, 1.41)

0.6208

3.03(2.59, 3.55)

2.18(1.88, 2.53)

1.67(1.41, 1.97)

0.0002

.5 1 2 4.5 1 2 4

Hazard ratios(diabetes vs. non-diabetes)

Hazard ratios(diabetes vs. non-diabetes)

The frail, elderly patient with diabetes Older persons with diabetes

are at higher risk than thosewithout diabetes of:

Cancer mortality and vascular deaths


Older adults with diabetes have greater difficulty walking, climbing stairs, doing housework ..., compared with their counterparts without diabetes

Ageing andDiabetes



morbidity/mortality

Falls andfractures


depression

This excess disability in patients with diabetes was largely due to comorbidities, whereas poor glycaemic control (A1C ≥ 8%) alone only accounted for <10%

Kalyani RR, et al. Diabetes Care. 2010;33(5):1055-60.


Older persons with diabetes are at higher risk than those without diabetes of:



Geriatric syndromes, suchas depression

Ageing andDiabetes


Falls andfractures


depression

The presence of diabetes doubles the odds of comorbid depression

Anderson RJ, et al. Diabetes Care. 2001;24(6):1069-78.


morbidity/mortality

Cognitive dysfunction should be added to the list of the complications of diabetes,along with retinopathy, neuropathy, nephropathy and cardiovascular disease.


Older persons with diabetes are at higher risk than those without diabetes of:



Geriatric syndromes:depression

Geriatric syndromes: cognitive impairment

Ageing andDiabetes


Falls andfractures


depression

Cukierman T, et al. Diabetologia. 2005;48(12):2460-9.


morbidity/mortality

Cognitive decline in the elderly diabetes patient

When assessed by the Mini-Mental State Exam (MMSE) and the Digit Symbol Span tests (DSS), diabetes increased the odds of cognitive decline 1.2-fold and 1.7-fold respectively

Cognitive decline as assessed by the MMSE

DM (n) No DM (n) OR and 95% CI

Gregg et al 402 584 1.0 (0.8, 1.4)

Fontbonne et al 55 768 1.0 (0.5, 2.2)

Nguyen et al 347 1412 1.1 (0.9, 1.4)

Stewart et al 62 154 1.2 (0.9, 1.6)

Wu et al 585 1204 1.7 (1.2, 2.3)

Kanaya et al 118 632 0.7 (0.3, 1.7)

Total (95% CI) 1569 10014 1.2 (1.05, 1.4)

Cognitive decline as assessed by the DSS

DM (n) No DM (n) OR and 95% CI

Fontbonne et al 55 768 2.3 (1.2, 4.3)

Gregg et al 339 5098 1.6 (1.2, 2.2)

Total (95% CI) 394 5866 1.7 (1.3, 2.3)

0.01 0.1 10 1001

0.01 0.1 10 1001

Cukierman T, et al. Diabetologia. 2005;48(12):2460-9. DM= diabetes mellitus

DM (n)

No DM (n)

Risk and 95% CI

Hassing et al 38 2202.1

(0.99−4.4)

Leibson et al 1455 NA1.7

(1.3−2.0)

Macknight et al

503 50711.2 (0.9,

1.7)

Ott et al 689 45321.9

(0.9−1.7)

Peila et al 900 16741.5

(1.0−2.2)

Allparticipants

2723 100441.6

(1.4−1.8)

0.01 0.1 1 10 100

Development of dementia in patients with type 2

diabetes

Development of future dementia

The odds of future dementia is increased 1.6-fold

Cukierman T, et al. Diabetologia. 2005;48(12):2460-9.

10,025 participants in the population-based NHANES sample followed

over 8 years (83,624 person-years of follow-up)

% A

live

60 120

100

60

40

Follow-up (years)

82

20

No diabetes, no depression Diabetes present, no depression

104

80

No diabetes, depression present Diabetes and depression present

Eqede LE, et al. Diabetes Care. 2005;28(6):1339-45.NHANES = National Health and Nutrition Examination Survey

Depression among people with diabetes reduces

quality of life and is associated with morbidity and mortality

It is imperative that clinicians review patients’ depressive symptoms and that goal setting and future management may need to involve psychogeriatric input1

Management and treatment

considerations in the elderly patient

with type 2 diabetes

1. Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33;2. Inzucchi SE, et al. Diabetes Care. 2012;55(56):1577-96.

Treatment priority of the elderly: prevention of hypoglycaemia

The risks of tight glycaemic control may exceed the benefits in many elderly patients1

In elderly patients, who are frail and may have comorbidities limiting ability to self-management, tight glycaemic control is unlikely to benefit...

… and hypoglycaemia is associated with a wide variety of disabling consequences, including amputation, peripheral neuropathy, immobility, falls, stroke, and cognitive

change. The frequency of hypoglycaemia is high and is exacerbated by older people having

little knowledge about the signs and symptoms of hypoglycaemia.

The goal of minimising symptomatic hypoglycaemia, short-term geriatric syndromes and maximising quality of life should be the primary factors in individualising glycaemic targets

Glycemic targets for elderly with long-standing or more complicated disease should be less ambitious than for the younger, healthier individuals2

Apart from the UKPDS, these large studies (intensive vs standard treatment) were conducted in patients >60 years old and with a long history of diabetes (9 years)

Intensified blood glucose lowering treatment:

what are the benefits in the older patient?

Participant characteristics at baseline

ACCORD

(n=10251)

ADVANCE

(n=11140)

UKPDS(n=3867

)

VADT(n=1791

)

Demographic characteristics

Mean age (years) 62.2 65.8 53.3 60.4

Median duration of known diabetes (years)

10 7 0 10

Turnbull FM, et al. Diabetologia. 2009;52(11):2288-98.

Meta-analysis using the data from the 4 main studies explored by the Collaborators on Trials of Lowering Glucose (CONTROL) group

Intensified blood glucose lowering treatment:

what are the benefits in the older patient?

Standard Intensive

Esti

mate

d e

ffects

of

inte

nsif

ied

gly

caem

ic c

on

tro

l o

n e

ven

t rate

s(p

er

1000 in 5

years

)

20

100

60

80

40

0

CH

D

Str

oke

Blindness

one e

ye

Renal

repla

cem

ent

thera

py/

renal death

All c

auses

mort

ality

Card

iovascula

rm

ort

ality

Severe

hypogly

caem

ia

-7*

-1

-4

-2

+3

+4

+47*

CHD= cronary heart diseaseNumbers on top of the bars indicate the absolute risk reductions/increases per 1000 participants treated for 5 years.• Statistically significant treatment effects (CHD p=0.03; severe hypoglycaemia p<0.00001)

• Mean age of patients : 62 years old

Yudkin JS, et al. Diabetologia. 2010;53(10):2079-85.

The benefits of intensified glucose control require long-term adherence

Older patients or those with reduced life expectancy will therefore experience little benefit

Recent studies, which have used modelling techniques to estimate the impact of glycaemic control on life expectancy are enlightening in this respect. The UKPDS outcomes model estimated that intensified glucose control would increase quality-adjusted life years (QALY) by 0.27, or about 99 days.

Treatment priority of the elderly: prevention of hypoglycaemia

The elderly patient with diabetes is often a frail patient1

Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness1,2

Hypoglycaemia is associated with many adverse consequences1

The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1

1. Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.2. ADA Diabetes Care;2012:35(1):S11-S63

EASD/ADA recommendations for managing

hyperglycaemia in the elderly (2012)

Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger, healthier individuals

If lower targets cannot be achieved with simple interventions, an HbA1c of <7.5–8.0% may be acceptable, transitioning upward as age increases and capacity for self-care, cognitive, psychological and economic status, and support systems decline

In the aged, the choice of anti-hyperglycaemic agent should focus on drug safety, especially protecting against hypoglycaemia, heart failure, renal dysfunction, bone fractures, and drug–drug interactions. Strategies specifically minimising the risk of low blood glucose may be preferred

Inzucchi SE, et al. Diabetes Care. 2012;55(56):1577-96.

Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus

Sinclair AJ, et al. Diabetes Metab. 2011;37 Suppl 3:S27-38.

3−6 months dietary

and lifestyle advice

Not achieving agreed

glucose targets

Metformin

Metformin + DPP-IV

inhibitor

Metformin + insulin

Metformin contraindicated inrenal/hepatic dysfunction,respiratory/heart failure,anorexia, gastrointestinal disease

Alternative treatments:DPP-IV inhibitors, or lower risksulphonylureas (SU)Glinides

Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient

Alternative treatments:Metformin + lower-risk SUMetformin + GLP-1 agonist

Frailty associated with increased hypoglycaemia risk: caution when using insulin or sulphonylureatherapy

Alternative treatments:Low risk SU + insulin

Failure to achieve glucose targets

Failure to achieve glucose targets

Frailty criteria:

Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke

Recommended glucose targets:Fasting glucose range = 7.6−9.0 mmol/lHbA1c range = 7.6−8.5%

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright © 2013 Canadian Diabetes Association

• CAUTION in the elderly

• Initial doses = HALF of usual dose

• Avoid glyburide

• Use gliclazide, gliclazide MR, glimepiride,

nateglinide or repaglinide instead

• CAUTION in the elderly

• Increased risk of fractures

• Increased risk of heart failure

• May use detemir or glargine instead of NPH or

human 30/70 for less hypos

• Premixed insulins and prefilled insulin pens

instead of mixing insulin to reduce dosing errors

• CAUTION with renal dysfunction

2015

Diabetes in the Elderly Checklist

ASSESS for level of functional dependency (frailty)INDIVIDUALIZE glycemic targets based on the above (A1C

≤8.5% for frail elderly) but if otherwise healthy, use the same targets as younger people

AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefullyCaution with sulfonylureas or thiazolidinediones

Basal analogues instead of NPH or human 30/70 insulin

Premixed insulins instead of mixing insulins separately

GIVE regular diets instead of “diabetic diets” or nutritional formulas in nursing homes.

Canadian D A Guidelines 2015

2015

In the frail elderly, while avoiding symptomatic

hyperglycemia, glycemic targets should be an A1C of

≤8.5% and FPG or pre-prandial PG of

5.0-12.0 mmol/L, depending on the level of frailty.

In elderly people with cognitive impairment, strategies

should be employed to strictly avoid hypoglycemia,

which include the choice of antihyperglycemic

therapy and less stringent A1C target [Grade D, Consensus].

Elderly people with type 2 diabetes should perform

aerobic exercise and/or resistance training, if not

contraindicated, to improve glycemic control [Grade B,

Summary and conclusions Advancing age is a risk factor for the development of diabetes1

Elderly onset diabetes should be diagnosed as early as possible in accordance with national guidelines to avoid the progression of vascular complications, retinopathy and renal impairment2

Hypoglycaemia is a danger in elderly diabetes patients due to a higher level of hypoglycaemic unawareness and medication combinations in this population3

The presence of comorbidities presents unique challenges for the management of elderly type 2 diabetes patients3

Cognitive dysfunction, depression, risk of falls, frailty and other morbidities need to be addressed as part of comprehensive care3

1. Cowie C et al. Diabetes Care. 2010;33:562-68; 2. Sinclair et al. Diabetes & Metabolism. 2011;37:S27-S38; 3. Sinclair A. Diabetes Spectrum. 2006;19(4):229-33

Thank you

ueda2016 workshop - diabetes in the elderly - mesbah kamel

Health & Medicine