El anciano diabético

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  • 28-11-1995 vertigo paroxistico benigno trata con dogmatil 12-1995 dolores abdominales catalogados de colicos hepaticos ECO abdomina.- litiasis biliar 08-10-1996 sd toxico, sospecha de diabetes analitica peso 53, talla 150 HbA1c 5.9m glu 174 09-11-1996 sintomatologia de RGE- TEGD 12-1997 HbA1c 6.8, transaminitis Ac VHC+, VHB + Hepatitis ECO normal, no litiasis biliar 1997 HbA1c 6.3, glu 149- tratamiento con Minodiab 2001 glu 280, TA 160/080 tratamiento con glimepirida HbA1c 7.4, glu 203 09-2004 Glu 330- Pasa a la Dra Muñoz, pero vuelve Sintomatologia de polineuropatia en EEII Incontinencia urinaria- pañales HbA1c 14, glu 343 LANTUS 10 U AUMENTANDO CADA DOS DIAS 16 U infec urinaria- alterac sensirio- agitación risperdal 1 mg acudio a urgencias OD AIT ¿=? Lantus final 22 Ui 18-02-2012 se añade actrapid en basal-plus glu 490 15 años de DM TRAT LANTUS 14-0-0 FUROSEMIA 1/2 -0 -0 HALOPERIDOS GOTAS 4 GOTAS NOCHE HACE HIPOS, REDUCIR DOS UNIDADES Analítica: COLESTEROL 170.0 HBA1C (IFCC) 9.2 GLU 188, FILTRADO GLOMERULAR (MUJER) >60.0 TSH (TIROTROPINA) 1.482 FOLATO 8.1 MICROALBUMINURIA:13 CREATININA 92.56 INDICE/ALBUMINA/CREATININA 14.04 HABLO CON LA HIJA DIABETES 2 DIABETES 2, COFOSIS, SORDERA NEUROSENSORIAL TOTAL VULVOVAGINITIS CANDIDIAS EN OCASIONES BUEN CONTROL CON LA HIJAS- A VECES HIPOS ANIMADA Y NO AGITADA, HABLO CON LA HIJA DIABETES 2 DIABETES 2, COFOSIS, SORDERA NEUROSENSORIAL TOTAL VULVOVAGINITIS CANDIDIAS EN OCASIONES BUEN CONTROL CON LA HIJAS- A VECES HIPOS ANIMADA Y NO AGITADA,
  • According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged 65 years varies from 22 to 33%, depending on the diagnostic criteria Used Using the hemoglobin A1C (A1C) or fasting plasma glucose (FPG) diagnostic criteria, as is currently done for national surveillance, one-third of older adults with diabetes are undiagnosed.1 The epidemic of type 2 diabetes is clearly linked to increasing rates of overweight and obesity in the U.S. population but projections by the Centers for Disease Control and Prevention (CDC) suggest that even if diabetes incidence rates level off, the prevalence of diabetes will double in the next 20 years, in part due to the aging of the population. 6 Other projections suggest that the number of cases of diagnosed diabetes in those aged 65 years will increase by 4.5-fold (compared to 3-fold in the total population) between 2005 and 2050.7 The incidence of diabetes increases with age until about age 65 years, after which both incidence and prevalence seem to level off (estabilizarse)
  • Although management of diabetes in older people can be relatively straight forward especially when patients have no other co-morbidities and when vascular complications are absent. In many cases, however, special issues arise which increase the complexity of management and lead to difficult clinical decision-making . Issues which might pose specific problems include aims and strategies of care, patients ’ compliance, and risks of hypoglycaemia, choice of priorities, cost-effectiveness, and the presence of dementia or depression
  • consideration of quality of life, life expectancy, cognitive and physical skills and the presence or otherwise of frailty. treatment should be based on the likely benefit/risk ratio of the intervention for the individual concerned, but factors such as vulnerability to hypoglycemia, ability to self-manage, the presence or absence of other pathologies, the cognitive status, and life expectancy must be considered. ”
  • The lack of a sufficient clinical evidence base for establishing recommendations on best practice was recognised and highlighted by the absence of any large-scale intervention studies in older people with type 2 diabetes, no substantial evidence of benefi t for glucose or lipid lowering, no evidence of large studies in diabetic residents of care homes, and no evidence to recommend a particular care model. This extensive literature review has revealed numerous gaps in our knowledge of diabetes in older adults A limited number of randomized clinical trials in type 2 diabetes form the basis of our current understanding of the effects of glucose lowering on microvascular complications, cardiovascular complications, and mortality. While these trials have provided invaluable data and insights, they were not designed to evaluate the health effects of glucose control in patients aged 75 years or in older adults with poor health status.
  • The decision to offer treatment should be based on the likely benefi t/risk ratio of the intervention for the individual concerned, but factors such as vulnerability to hypoglycaemia, ability to self-manage, the presence or absence of other pathologies, the cognitive status, and life expectancy must be considered. Evidence level 2++, Grade of recommendation B
  • 3. The prevalence and incidence rates of diabetes mellitus in elderly subjects (> 65 years) may be underestimated when using only fasting plasma glucose. Evidence level 1+, Grade of recommendation A. 4. 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. Evidence level 1+, Grade of recommendation A. 5. 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. Evidence level 2++, Grade of recommendation B.
  • The ADA recommends that overweight adults with risk factors—and all adults aged 45 years—be screened in the clinical setting every 1–3 years using either an FPG test, A1C, or oral glucose tolerance test The benefits of identification of prediabetes and asymptomatic type 2 diabetes in older adults depend on whether primary or secondary preventive interventions would likely be effective and on the anticipated timeframe of the benefit of interventions versus the patient ’ s life expectancy Most would also agree that finding prediabetes or early type 2 diabetes in a 95-year-old individual with advanced dementia would be unlikely to provide benefit.
  • For relatively healthy older adults with long life expectancy, following the screening recommendations for all adults with diabetes is reasonable. For very old patients and/or those with multiple comorbidities and short life expectancy, it is prudent to weigh the expected benefit time frame of identifying early signs of complications and intervening to prevent worsening to end-stage disease . For the latter group, particular attention should be paid to screening for risk factors of complications that might further impair functional status or quality of life over a relatively short period of time, such as foot ulcers/amputations and visual impairment. Considerations in clinical decision-making should also include prior test results. For example, there is evidence, including in the older adult population, that dilated eye examinations that are initially normal can safely be repeated every 2– 3 years instead of yearly 3.5. Functional evaluation [23-26] 1. Each older patient with type 2 diabetes should have an assessment of their functional status by a multidisciplinary team skilled in evaluation using well-validated assessment tools. Evidence level 1+, Grade of recommendation A. This should be at the time of diagnosis and annually thereafter. 2. Each functional assessment must include a measure of the three major domains of function: global/physical, cognitive and affective. Evidence level 1+, Grade of recommendation A. 3.6. Renal disease [27-30] 1. At the time of diagnosis and annually thereafter, all older people with type 2 diabetes have a measured serum creatinine, an estimated glomerular fi ltration rate, and an albumin-creatinine ratio undertaken. Evidence level 1+, Grade of recommendation B.
  • Con todo, dejan claro que existen evidencias claras de la relación entre el control glucémico (medido mediante la HbA1c) y el riesgo de complicaciones micro y macrovasculares –en menor grado-, tal como avanzó el UK Prospective Diabetes Study (UKPDS) con solo reducciones del 0.6% de la HbA1c en DM2 recién diagnosticados. Beneficios que se mantuvieron 10 años de acabado el estudio, como ya hemos visto en otros post. Los tres estudios del 2008, ya comentados, en DM2 evolucionados con alto riesgo cardiovascular, no mostraron beneficios evidentes CV, y el ACCORD incrementó en un 22% la mortalidad, achacándose este hecho a las tasas de hipoglucemia en el brazo intensivo, extremo este que aún hoy, no está del todo aclarado. De ello, el consenso extrae la conclusión, que el DM2 de corta duración sin eventos cardiovasculares se beneficiaría de una terapia intensiva (HbA1c más bajo). Inciden en el hecho que la incompetencia (no siempre irreversible) de la célula betapancreática es, en último término, el responsable de la progresión de la hiperglucemia con el tiempo. Como premisas para el tratamiento ponen de manifiesto la importancia de la fisiopatología de los fármacos utilizados, del sistema incretínico, de la insulinoresistencia en obesos, de la importancia de los ácidos grasos libres,… Los “Standards of Medical Care in Diabetes” del ADA recomiendan alcanzar y mantener una HbA1c inferior a 7.0%, algo que se puede alcanzar manteniendo la glucosa basal (GB) entre 150-160 mg/dl, aunque el objetivo es mantener la GB en 130 mg/dl y la postprandial en 180 mg/dl. Si bien es cierto que controles más estrictos de la HbA1c (6.0-6.5%) pueden ser útiles en determinados pacientes (DM2 de corta duración, larga esperanza de vida, no RCV), y controles más laxos (7.5-8.0%) en pacientes con riesgo de hipoglucemia, complicaciones avanzadas, comorbilidad o una esperanza de vida reducida…Por lo que mantener el porcentaje de pacientes que alcanzan el 7.0% de HbA1c como indicador de calidad no se sostiene en nuestros días.   Suggest the hypothesis that patients with shorter duration of type 2 diabetes and without established atherosclerosis might reap cardiovascular benefit from intensive glycemic control, [while] … potential risks of intensive glycemic control may outweigh its benefits in other patients, such as those with a very long duration of diabetes, known history of severe hypoglycemia, advanced atherosclerosis, and advanced age/frailty. ” 32 The ADA goals for glycemic control do not specifically mention age. The recommendation for many adults is an A1C <7% , but less stringent goals are recommended for those with limited life expectancy, advanced diabetes complications, or extensive comorbid conditions.17
  • Con todo, dejan claro que existen evidencias claras de la relación entre el control glucémico (medido mediante la HbA1c) y el riesgo de complicaciones micro y macrovasculares –en menor grado-, tal como avanzó el UK Prospective Diabetes Study (UKPDS) con solo reducciones del 0.6% de la HbA1c en DM2 recién diagnosticados. Beneficios que se mantuvieron 10 años de acabado el estudio, como ya hemos visto en otros post. 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.24,25 Los tres estudios del 2008, el Action to Control Cardiovascular Risk in Diabetes [ACCORD] trial, el Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation [ADVANCE] trial, y el Veterans Affairs Diabetes Trial [VADT]), ya comentados, en DM2 evolucionados con alto riesgo cardiovascular, no mostraron beneficios evidentes CV, y el ACCORD incrementó en un 22% la mortalidad, achacándose este hecho a las tasas de hipoglucemia en el brazo intensivo, extremo este que aún hoy, no está del todo aclarado. ACCORD trial was terminated after approximately 3 years because of excessive deaths in the intensive glucose control arm.27 The primary combined outcome of MI, stroke, and cardiovascular death was not significantly reduced De ello, el consenso extrae la conclusión, que el DM2 de corta duración sin eventos cardiovasculares se beneficiaría de una terapia intensiva (HbA1c más bajo). Inciden en el hecho que la incompetencia (no siempre irreversible) de la célula betapancreática es, en último término, el responsable de la progresión de la hiperglucemia con el tiempo. Como premisas para el tratamiento ponen de manifiesto la importancia de la fisiopatología de los fármacos utilizados, del sistema incretínico, de la insulinoresistencia en obesos, de la importancia de los ácidos grasos libres,… Los “Standards of Medical Care in Diabetes” del ADA recomiendan alcanzar y mantener una HbA1c inferior a 7.0%, algo que se puede alcanzar manteniendo la glucosa basal (GB) entre 150-160 mg/dl, aunque el objetivo es mantener la GB en 130 mg/dl y la postprandial en 180 mg/dl. Si bien es cierto que controles más estrictos de la HbA1c (6.0-6.5%) pueden ser útiles en determinados pacientes (DM2 de corta duración, larga esperanza de vida, no RCV), y controles más laxos (7.5-8.0%) en pacientes con riesgo de hipoglucemia, complicaciones avanzadas, comorbilidad o una esperanza de vida reducida…Por lo que mantener el porcentaje de pacientes que alcanzan el 7.0% de HbA1c como indicador de calidad no se sostiene en nuestros días.  
  • El Accord las hipoglucemias y sus posthoc El ACCORD es un estudio que junto con otros dos publicados en el año pasado han supuesto un antes y un después en el control del diabético 2 de alto riesgo cardiovascular. Se estudió a una población de 10194 participantes con control metabólico alterado (HbA1c 7.5-11%) de alto riesgo cardiovascular. Población que se aleatorizó en dos ramas, una de tratamiento intensivo (HbA1c< 6 %) y otra de tratamiento convencional (HbA1c 7-7.9%). Como es conocido el estudio tuvo que pararse en febrero del 2008 por aumentar la mortalidad en la rama de tratamiento intensivo (1,4 muertes por 100 frente a 1,14 personas y año, HR 1,22, -1,1-1,46 CI 95%). Se achacó primariamente estas diferencias a la probable a las mayores hipoglucemias de la rama intensiva. Si bien se intentó relacionar este exceso de muertes con la hipoglucemias de la rama de tratamiento estricto no pudo demostrarse con fiabilidad absoluta, de ahí estas dos comunicaciones retrospectivas que intentan poner algo de luz en este asunto. Como se esperaba hubo más hipoglucemias graves en la rama de tratamiento estricto (3,4%) que en el tratamiento standard (1,3%). Sin embargo, la cantidad de muertes atribuidas a las hipoglucemias graves en el tratamiento intensivo era del 3.4% (0.9-12.3, 95% CI), frente al 5.4% (2.6-12.3, 95% CI) del tratamiento convencional, lo que iba en contra del hecho que esta fuera la causa principal de que hubiera mayor número de muertes por esta causa en la rama intensiva del estudio. De modo que se concluye que el mayor riesgo de muerte en el brazo intensivo no puede ser atribuido a la mayor tasa de hipoglucemias graves en estos pacientes. Como hechos curiosos, se observó que los pacientes que no responden su control metabólico -HbA1c- con precocidad tienen mayor riesgo de hipoglucemias, al contrario de lo que pudiera pensarse. Y que el peor control (mayor HbA1c) estaba relacionado con mayor riesgo de hipoglucemias, al tiempo que la velocidad de descenso de esta en los meses previos no estaba relacionado con el riesgo de hipoglucemias, o lo que es lo mismo que la falta de respuesta en el descenso de la HbA1c estaría relacionado con las hipos. Y sorprendentemente la mortalidad fue menor en aquellos que ya habían tenido un episodio de hipoglucemia previo en el brazo intensivo (tal vez por que se reajustaron los objetivos tras ellas). Y por último que las hipoglucemias graves están relacionadas con el mayor riesgo de muerte independientemente del brazo estudiado, *Denise E Bonds et al. The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ 2010;340:b4909 **Michael E Miller et al. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ 2010;340:b5444
  • Detrás de los estudios de intervención en pacientes con diabetes tipo 2 subyace la preocupación sobre la seguridad de los límites propuestos en las concentraciones de glucosa sanguínea. Se evaluó la supervivencia en función de la HbA1c en personas con diabetes tipo 2 Métodos: Dos cohortes de pacientes de 50 años o mas con diabetes tipo 2 obtenidos del registro UK General Practice Research Database entre noviembre de 1986 a noviembre del 2008. Se identificaron 27.965 pacientes cuyo tratamiento había pasado de monoterapia a terapia oral combinada con hipoglucemiantes orales, y a 20.005 que habían pasado a una pauta con insulina. Aquellos pacientes con diabetes secundaria a otras causas fueron excluidos. El objetivo primario fue la mortalidad por cualquier causa. La edad, el sexo, el tabaquismo, el colesterol, el riesgo cardiovascular y la morbilidad en general fueron identificados al ser considerados como importantes factores de confusión, de tal modo que se aplicaron ecuaciones de supervivencia tipo Cox que tuvieran en cuenta a este tipo de variables. Resultados: En las dos cohortes combinadas la comparación del decil de hemoglobina glucosilada (HbA1c) con el menor riesgo obtuvo una media de HbA1c del 7,5 ( IQR 7,5–7,6%), el cociente o tasa de riesgo (HR) para cualquier causa de mortalidad en el decil de HbA1c más bajo (6,4%, 6,1 –6,6) fue del 1,52 (Intervalo de confianza –IC- 95% 1,32 –1,76), y en el decil de HbA1c más alto (media 10,5%, IQR 10,1 –11,2%) fue del 1,79 (CI 95% 1,56 –2,06). Los resultados mostraron gráficamente una asociación en forma de U, con el HR mas bajo alrededor del valor del 7.5%. El HR por cualquier causa de mortalidad en la población con tratamiento insulínico (2834 defunciones) frente a aquellos en tratamiento con tratamiento combinado con agentes orales (2.035) fue del 1,49 ( IC 95%, 1,39–1,59). Se interpreta que los valores altos o bajos de la HbA1c estarían asociados con un aumento de la mortalidad por todas las causas, así como de causa cardiaca. Todo ello confirma que las Guías de Diabetes precisan una revisión que incluya el valor mínimo de HbA1c.
  • A central concept in geriatric diabetes care guidelines is that providers should base decisions regarding treatment targets or interventions on life expectancy .2,17,57 Patients whose life expectancy is limited (e.g., <5 years, <10 years) are considered unlikely to benefit from intensive glucose control, for example, whereas those with longer life expectancy may be appropriate candidates for this intervention. An observation supporting this concept is that cumulative event curves for the intensive and conventional glycemic control arms of the UKPDS separated after the 9-year mark. A combination of multiple comorbid illnesses and functional impairments was a better predictor of limited life expectancy and diminished benefits of intensive glucose control than age alone.
  • A limited number of randomized clinical trials in type 2 diabetes form the basis of our current understanding of the effects of glucose lowering on microvascular complications, cardiovascular complications, and mortality. While these trials have provided invaluable data and insights, they were not designed to evaluate the health effects of glucose control in patients aged 75 years or in older adults with poor health status. 1. For older patients with type 2 diabetes, with single system involvement (free of other major co-morbidities), a target HbA1c range of 7-7.5% should be aimed for (DCC T aligned). Evidence level 1+, Grade of recommendation A . The precise target agreed will depend on existing cardiovascular risk, presence of microvascular complications, and ability of individual to self-manage. 2. For frail (dependent; multisystem disease; care home residency including those with dementia) patients where the hypoglycaemia risk is high and symptom control and avoidance of metabolic decompensation is paramount, the target HbA1c range should be 7.6-8.5%. Evidence level 1+, Grade of recommendation A. 3. For older patients with type 2 diabetes, with single system involvement (free of other major co-morbidities), a fasting glucose range of 6.5-7.5 mmol/l can be regarded as indicating good control. Evidence level 2++, Grade of recommendation B. 4. For frail patients including those residing in care homes, a fasting glucose range 7.6-9.0 mmol/l should minimise the risk of hypoglycaemia and metabolic decompensation. Evidence level 2+, Grade of recommendation C.
  • Blood glucose levels consistently over the renal threshold for glycosuria (~180–200 mg/dL, but can vary) increase the risks for dehydration, electrolyte abnormalities, urinary incontinence, dizziness, and falls. Hyperglycemic hyperosmolar syndrome is a particularly severe complication of unrecognized or undertreated hyperglycemia in older adults
  • Hypoglycemia is linked to cognitive dysfunction in a bidirectional fashion: cognitive impairment increases the subsequent risk of hypoglycemia,60 and a history of severe hypoglycemia is linked to the incidence of dementia.63 The risk factors for hypoglycemia in diabetes in general (use of insulin or insulin secretagogues, duration of diabetes, antecedent hypoglycemia, erratic meals, exercise, renal insufficiency)104 presumably apply to older patients as well. In the Medicaid study cited above, independent risk factors included hospital discharge within the prior 30 days, advanced age, black race, and use of five or more concomitant medications.10 4.3. Hypoglycaemia 1. All physicians involved in the care of older patients with type 2 diabetes should assess the risk of hypoglycaemia and adjust therapy to minimise this risk. Evidence level 1+, Grade of recommendation A. 2. Where the risk of hypoglycaemia is considered moderate (renal impairment, recent hospital admission) to high (previous history, frail patient with multiple comorbiditities, resident of a care home) use an agent with a lower hypoglycaemic potential, e.g. DPP4 inhibitor, lower risk sulphonylurea. Evidence level 1+, Grade of recommendation A. In fi gure 1, we have presented an algorithm for glucoselowering for frail older people with diabetes which has attempted to incorporate some of the above evidence-based recommendations but has also simplifi ed the treatment path to avoid unnecessary over-treatment and polypharmacy, and to align more closely with likely treatment targets in a patient with frailty.
  • 1. In non-obese older people with diabetes in whom target levels of glucose or HbA1c have failed to be maintained on dietary/lifestyle changes, first line therapy with an insulin secretagogue (normally a sulphonylurea) or metformin should be offered. Evidence level 1++, Grade of recommendation A. 2. Metformin should normally be fi rst line therapy for overweight older adults with type 2 diabetes (BMI>25.0 kg/ m2). Evidence level 1++, Grade of recommendation A. 3. An insulin secretagogue may be used in combination with metformin in normal or overweight patients where glycaemic targets have not been achieved or maintained. Evidence level 1+, Grade of recommendation B 4. In those cases where metformin is contraindicated or not tolerated, an insulin secretagogue may be prescribed. Evidence level 1+, Grade of recommendation B. 5. Age per se is not a contraindication to the use of metformin but its use is contraindicated in those with renal impairment (serum creatinine>130 μ /litre), severe coronary, cerebrovascular or peripheral vascular disease. Evidence level 2++, Grade of recommendation B. 6. Glibenclamide should be avoided for newly diagnosed cases of type 2 diabetes in older adults (>70 years) because of the marked risk of hypoglycaemia. Evidence level 1+, Grade of recommendation A. 7. Consider a DPP-4 inhibitor as an add-on to metformin when use of a sulphonylurea may pose an unacceptable hypoglycaemia risk in an older patient with diabetes. Evidence level 1+, Grade of recommendation A. 8. In the very obese older patient (age less than 75 years) with type 2 diabetes (BMI>35) a GLP-1 mimetic (e.g. exenatide, liraglutide) may be considered as 3rd line therapy to metformin and a sulphonylurea. Evidence level 2++, Grade of recommendation B. Glyburide has the highest hypoglycemia risk and should not be prescribed for older adults.98 Glinides are dosed prior to meals, and their short half-life may be useful for postprandial hyperglycemia.
  • Use of insulin 9. When oral agents fail to lower glucose levels adequately, insulin may be given either as monotherapy or in combination with a sulphonylurea or metformin. Evidence level 1+, Grade of recommendation A. 10. In older adults with diabetes, the use of pre-mixed insulin and pre-filled insulin pens may lead to a reduction in dosage errors and an improvement in glycaemic control. Evidence level 2++, Grade of recommendation B. 11. Use of a long-acting insulin analogue (e.g. glargine, determir) rather than NPH-insulin should be considered in older patients who require the assistance of a carer, those residing within a care home, or where there is a defi ned higher risk of hypoglycaemia. Evidence level 1+, Grade of recommendation A. The addition of long-acting insulin was similarly effective in achieving A1C goals for older patients with type 2 diabetes (mean age 69 years) in a series of trials with no greater rates of hypoglycemia than in younger patients (mean age 53 years) .100 However, there are few data on such regimens in people aged >75 years or in older adults with multiple comorbidities and/or limited functional status who were excluded from these trials. Problems with vision or manual dexterity may be barriers to insulin therapy for some older adults. Pen devices improve ease of use but are more costly than the use of vials and syringes. Hypoglycemia risk (especially nocturnal) is somewhat lower with analog compared with human insulins, but the former are more expensive
  • Use of insulin 9. When oral agents fail to lower glucose levels adequately, insulin may be given either as monotherapy or in combination with a sulphonylurea or metformin. Evidence level 1+, Grade of recommendation A. 10. In older adults with diabetes, the use of pre-mixed insulin and pre-filled insulin pens may lead to a reduction in dosage errors and an improvement in glycaemic control. Evidence level 2++, Grade of recommendation B. 11. Use of a long-acting insulin analogue (e.g. glargine, determir) rather than NPH-insulin should be considered in older patients who require the assistance of a carer, those residing within a care home, or where there is a defi ned higher risk of hypoglycaemia. Evidence level 1+, Grade of recommendation A.
  • 3.6. Renal disease [27-30] 1. At the time of diagnosis and annually thereafter, all older people with type 2 diabetes have a measured serum creatinine, an estimated glomerular fi ltration rate, and an albumin-creatinine ratio undertaken. Evidence level 1+, Grade of recommendation B. 2. In older people with type 2 diabetes who have a raised albumin/creatinine ratio (>2.5 mg/mmol, women; > 3.5 mg/ mmol, men), treatment with an ACE inhibitor is recommended – extrapolated data. Evidence level 1+, Grade of recommendation B. 3. In older patients with diabetes and microalbuminuria, maintaining a blood pressure target of 140/80 or less, and a HbA1c range of 6.5-7.5%, may help to reduce the development of chronic kidney disease (CKD). Evidence level 2++, Grade of recommendation B. 4. Specialist review by a nephrologist at an earlier stage of CKD may prevent late referrals of older patients with diabetes for renal replacement therapy and improve outcomes. Evidence level 2++, Grade of recommendation B.
  • However, the benefits of aspirin for primary prevention of CVD events have not been thoroughly elucidated in older adults with diabetes and must be balanced against risk of adverse events such as bleeding 1. At initial assessment, all older patients aged less than 85 years with diabetes should have a cardiovascular risk assessment undertaken. Evidence level 1+, Grade of recommendation A. 2. All older patients with type 2 diabetes aged less than 85 years should have a review and discussion of modifi able cardiovascular risk factors and be offered advice on smoking cessation. Evidence level 2++, Grade of recommendation B. 3. The ten-year risk of developing symptomatic cardiovascular disease should be calculated for all patients who have 2 or more risk factors to assess the need for primary prevention. Evidence level 1+, Grade of recommendation B. 4. There is insuffi cientevidence at present to routinely recommend low-dose aspirin for older patients with type 2 diabetes for the primary prevention of stroke or cardiovascular mortality. Evidence level 1+, Grade of recommendation A. 5. All older patients with type 2 diabetes, irrespective of baseline cardiovascular risk, should be offered aspirin treatment at a dose of 75-325 mg/d for secondary prevention. Evidence level 2++, Grade of recommendation B.
  • Benefit for older adults with diabetes has been inferred from the trials of older adults including but not limited to those with diabetes and from the trials of middle- and older-aged adults with diabetes.42 There is consistent evidence that lowering blood pressure from very high levels (e.g., systolic blood pressure [SBP] 170 mmHg) to moderate targets (e.g., SBP 150 mmHg) reduces cardiovascular risk in older adults with diabetes. Selected trials have shown benefit with targets progressively lower, down to SBP < 140 mmHg and diastolic blood pressure (DBP) <80 mmHg.45 The ACCORDBP trial showed no benefit on the primary outcome (major adverse cardiovascular events) of SBP targets <120 mmHg compared with <140 mmHg, but found a significant reduction in stroke, a secondary outcome.46 A post hoc analysis of the cohort of participants with diabetes in the International Verapamil SRTrandolapril Study (INVEST), whose mean age was ~65 years, showed that achieved SBP under 130 mmHg was not associated with improved cardiovascular outcomes compared with SBP under 140 mmHg.47 4.4. Blood pressure regulation [45-48] The following decisions are based on the likelihood of reducing cardiovascular risk in older subjects balanced with issues relating to tolerability, clinical factors and disease severity, and targets likely to be achievable with monotherapy and/or combination therapy, and with agreement with primary care colleagues. A lower value of blood pressure should be aimed for in those who are aged less than 80 years and are able to tolerate the therapy and self-manage, and/or those with concomitant renal disease: 1. The threshold for treatment of high blood pressure in older subjects with type 2 diabetes should be 140/80 mmHg or higher present for more than 3 months and measured on at least three separate occasions during a period of lifestyle management advice (behavioural: exercise, weight reduction, smoking advice, nutrition/dietary advice). Evidence level 2++, Grade of recommendation B. 2. In non-frail subjects with diabetes older than 80 years, an acceptable blood pressure on treatment is a systolic of 140-145 mmHg, and a diastolic less than 90 mmHg. Evidence level 1+, Grade of recommendation B. 3. For frail (dependent; multisystem disease; care home residency including those with dementia) patients, where avoidance of heart failure and stroke may be of greater relative importance than microvascular disease, an acceptable blood pressure is <150/90 mmHg. Evidence level 2+, Grade of recommendation C (extrapolated data). 4. In older patients with a sustained blood pressure (≥140/80 mmHg) and in whom diabetic renal disease is absent, fi rst-line therapies can include: use of ACE inhibitors, angiotensin II receptor antagonists, long-acting calcium channel blockers, beta blockers or thiazide diuretics. Evidence level 1+, Grade of recommendation A. 5. In older patients with a sustained blood pressure (≥140/80 mmHg) with microalbuminuria or proteinuria, treatment with an ACE inhibitor or angiotensin II receptor antagonist is recommended. Evidence level 1+, Grade of recommendation B. 6. Use of a perindopril-based regimen in older patients with type 2 diabetes (with or without hypertension) improves both microvascular and macrovascular outcomes. Evidence level 1+, Grade of recommendation A.
  • There are no large trials of lipid-lowering interventions specifically in older adults with diabetes. Benefits have been extrapolated from trials of older adults that include but are not limited to those with diabetes and trials of people with diabetes including but not limited to older adults. A statin study in older adults (participants aged 70–82 years) found a 15% reduction in coronary artery disease events with pravastatin.39,40 A meta-analysis of 18,686 people with diabetes in 14 trials of statin therapy for primary prevention showed similar 20% relative reductions Cardiovascular prevention with statins, especially secondary benefit, emerges fairly quickly (within 1–2 years), suggesting that statins may be indicated in nearly all older adults with diabetes except those with very limited life expectancy. 4.5. Plasma lipid regulation [49-52] 1. In subjects with no history of cardiovascular disease, a statin should be offered to patients with an abnormal lipid profi le if their 10-year cardiovascular risk is >15%. Evidence level 1-, Grade of recommendation A. 2. A statin should be offered to patients with an abnormal lipid profile who have proven cardiovascular disease. Evidence level 1+, Grade of recommendation A. 3. Consider statin therapy in older subjects with diabetes to reduce the risk of stroke as part of secondary prevention of cardiovascular disease. Evidence level 2++, Grade of recommendation B. 4. A fibrate should be considered in patients with an abnormal lipid profi le who have been treated with a statin for at least 6 months but in whom the triglyceride level remains elevated (≥2.3 mmol/l). Evidence level 2+, Grade of recommendation C.
  • El anciano diabético

    1. 1. El anciano diabéticoM Seguí DíazUBS Es Castell Menorca
    2. 2. Carmen  Antecedentes: No sale de casa,tiene 92 años cofosis y alteración de la visión1997 (77 años). SdToxico  Tres hijas: anciana golondrinaHepatitis VHC+, VHB+  IMC desconocidoHbA1c 6.3, Glu 149 TratMinodiab  TA 150/092  COLESTEROL 170.0,2001 HbA1c 7.4, Glu 203Glimepirida  HBA1C (IFCC) 9.2  GLU 188,2004 Incontinenciaurinaria + agitación HbA1c  FIL GLOMERULAR >60.014, Glu 343: Infec urinaria  TSH (TIROTROPINA) 1.482 ,I Glargina 22 u, Risperdal INDICE/ALBUM/CREA 14.04Actualmente Glargina 14u, Furosemida, haloperidol
    3. 3. El anciano diabético- El problema  Entre el 22-33% de los adultos mayores de 65 años en EEUU  Si HbA1c en vez de la Gb 1/3 de los DM2 se quedan sin diagnosticar  Por mayor sobrepeso y obesidad  Mayor longevidadSue Kirkman M, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS.Diabetes in Older Adults: A Consensus Report. J Am Geriatr Soc. 2012 Oct 25. doi: 10.1111/jgs.12035. [Epub ahead of print]
    4. 4. El anciano diabético-Importancia  El anciano diabético sin comorbilidades y sin complicaciones vasculares es infrecuente  Los problemas principales que presentan tienen que ver con el cumplimiento terapéutico, la hipoglucemia, los trastornos cognitivos y la depresiónAlan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    5. 5. El anciano diabético- Importancia • Calidad de vida • La esperanza de vida • Afectación cognitiva • FragilidadAlan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012Sue Kirkman M, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS.
    6. 6. El anciano diabético-Importancia La falta de evidencias para establecer recomendaciones Control metabólico Lípidos Tensión arterial Cuidados domésticos Sistemas de atenciónAlan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    7. 7. El anciano diabético-Importancia  La decisión de tratar debe basarse en el probable cociente riesgo/beneficio de la intervención en el paciente tomado de forma individual  Se debe valorar la vulnerabilidad a la hipoglucemia , la capacidad de los autocuidados, la presencia o ausencia de otras patologías, el estado cognitivo y la esperanza de vida ( B)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    8. 8. ¿podemos pensar que Carmen es una anciana frágil?M Seguí DíazUBS Es Castell Menorca
    9. 9.  A FAVOR: Alteración de los sentidos: vista, y oído ¿podemos pensar Edad: 92 años Dependiente de las tres hijas: que Carmen es una anciana golondrina anciana frágil?  A EN CONTRA No alto RCV ???M Seguí Díaz No comorbilidadUBS Es Castell Menorca No polimedicada
    10. 10. El anciano diabético-Diagnóstico • La incidencia de la DM2 en el anciano se infraestima si solo se utiliza la glucosa basal en el diagnóstico (A)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    11. 11. El anciano diabético- Cribado El ADA recomienda que en todos los adultos con sobrepeso o adultos > 45 años deben hacerse pruebas diagnósticas cada 1-3 años (Gb, HbA1c, SOG)  Beneficios de diagnosticar la prediabetes o la DM2 asintomática. Prevención de complicacionesSue Kirkman M, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS.Diabetes in Older Adults: A Consensus Report. J Am Geriatr Soc. 2012 Oct 25. doi: 10.1111/jgs.12035. [Epub ahead of printAmerican Diabetes Association. Standards of Medical Care in Diabetes 2012. DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012]
    12. 12. El anciano diabético-Evaluación  El anciano diabético debe ser evaluado de manera multidisciplinar (A)  Al diagnóstico y anualmente  A nivel cognitivo y afectivo (A)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    13. 13. ¿Tiene buen control metabólico con una HBA1C (IFCC) 9.2%, GLU 188?M Seguí DíazUBS Es Castell Menorca
    14. 14. El anciano diabético-Control  Los “Standards of Medical Care in Diabetes” del ADA 2012 recomiendan alcanzar y mantener una HbA1c inferior a 7.0%  Menos extrictos según esperanza de vida, complicaciones, comorbilidadManagement of Hyperglycemia in Type2 Diabetes:A Patient-Centered Approach Position Statement of the American DiabetesAssociation (ADA) andthe European Association for the Study of Diabetes (EASD. DiabetesCare Publish Ahead of Print, published online April 19, 2012American Diabetes Association. Standards of Medical Care in Diabetes 2012. DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012
    15. 15. El anciano diabético- Control glucémico • UK Prospective Diabetes Study (UKPDS) con solo reducciones del 0.6% de la HbA1c en DM2 recién diagnosticados • DM2 evolucionados con alto riesgo cardiovascular, en el ACCORD se incrementó en un 22% la mortalidadManagement of Hyperglycemia in Type2 Diabetes:A Patient-Centered Approach Position Statement of the American DiabetesAssociation (ADA) andthe European Association for the Study of Diabetes (EASD. DiabetesCare Publish Ahead of Print, published online April 19, 2012American Diabetes Association. Standards of Medical Care in Diabetes 2012. DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012
    16. 16. ACCORD Study *Denise E Bonds et al. The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ 2010;340:b4909 **Michael E Miller et al. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ 2010;340:b5444 • Objetivos/hipótesis.-. Investigar las causas de las hipoglucemias graves y su asociación con la HbA1c en el estudio Action to Control Cardiovascular Risk in Diabetes (ACCORD) • 10.194 participantes con 10.194 participantes con control metabólico alterado control metabólico alterado (HbA1c 7.5-11%) de alto (HbA1c 7.5-11%) de alto riesgo CV riesgo CV Se aleatorizó en dos ramas, Se aleatorizó en dos ramas, una de tratamiento intensivo una de tratamiento intensivo (HbA1c< 6 %) y otra de (HbA1c< 6 %) y otra de tratamiento convencional tratamiento convencional (HbA1c 7-7.9%). (HbA1c 7-7.9%). Se paró en febrero del 2008 Se paró en febrero del 2008  por aumentar la mortalidad Más hipoglucemias graves en la rama de por aumentar la mortalidad tratamiento estricto (3,4%) que en el en la rama de tratamiento en la rama de tratamiento intensivo (1,4 frente a 1,14 tratamiento standard (1,3%). intensivo (1,4 frente a 1,14 muertes por 100 personas y  Las muertes atribuidas a las hipoglucemias muertes por 100 personas y año, HR 1,22) graves en el tratamiento intensivo era del 3.4%, año, HR 1,22) frente al 5.4% del tratamiento convencional.
    17. 17. Currie et al. El valor de la HbA1c en la mortalidad Currie CJ, Peters JR, Tynan A, Evans M, Heine RJ, Bracco OL, Zagar T, Poole CD. Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. Lancet 2010: 375 (9713):481 - 489 • Objetivos/hipótesis.-. Detrás de los estudios de intervención en pacientes con diabetes tipo 2 subyace la preocupación sobre la seguridad de los límites propuestos en las concentraciones de glucosa sanguínea. Se evaluó la supervivencia en función de la HbA1c en personas con diabetes tipo 2  Conclusión: Los valores altos o bajos de la HbA1c estarían asociados con un aumento de la mortalidad por todas las causas, así como de causa cardiaca.  Dos cohortes de pacientes de 50 años oomas con diabetes tipo 22obtenidos del  Dos cohortes de pacientes de 50 años mas con diabetes tipo obtenidos del registro UK General Practice Research Database entre noviembre de 1986 aa registro UK General Practice Research Database entre noviembre de 1986 noviembre del 2008. noviembre del 2008.  Se identificaron 27.965 pacientes cuyo tratamiento había pasado de monoterapia  Se identificaron 27.965 pacientes cuyo tratamiento había pasado de monoterapia aaterapia oral combinada con hipoglucemiantes orales, yyaa20.005 que habían terapia oral combinada con hipoglucemiantes orales, 20.005 que habían pasado a una pauta con insulina
    18. 18. El anciano diabético- Esperanza de vida  Los objetivos deben individulizarse a la esperanza de vida (EV)  Menos intensivos si es < a 5 años  La comorbilidad y las limitaciones funcionales son predictores de la EVAlan Sinclair, et al. Diabetes Mellitus in Older People: Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG),the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA 13, Issue 6 , Pages 497-502, July 2012Sue Kirkman M et al. Diabetes in Older Adults: A Consensus Report. J Am Geriatr Soc. 2012 Oct 25. doi: 10.1111/jgs.12035. [Epub ahead of print]
    19. 19. El anciano diabético- Objetivo glucemico • FALTAN EVIDENCIAS • El anciano DM2 sin comorbilidad 7-7.5% HbA1c • Anciano frágil + riesgo hipoglucemia 7.6-8.5% HbA1c • Anciano frágil + casas de acogida 7.6-9%Alan Sinclair, et al. Diabetes Mellitus in Older People: Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG),the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA 13, Issue 6 , Pages 497-502, July 2012Sue Kirkman M et al. Diabetes in Older Adults: A Consensus Report. J Am Geriatr Soc. 2012 Oct 25. doi: 10.1111/jgs.12035. [Epub ahead of print]
    20. 20. El anciano diabético-Hiperglucemia • Deshidratación • Alteraciones electrolíticas • Incontinencia urinaria • Mareos • Caídas • Sd hiperosmolarAlan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012Sue Kirkman M et al. Diabetes in Older Adults: A Consensus Report. J Am Geriatr Soc. 2012 Oct 25. doi: 10.1111/jgs.12035. [Epub ahead of print]
    21. 21. El anciano diabético-Hipoglucemia  Ajustar el riesgo de Hipo (A)  En moderado riesgo de hipos (IRC, ingresos) o alto (historia, frágil, comorbilidad o dependiente) DPP-4, o SU de bajo riesgo (A)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    22. 22. El anciano diabético-ADO  En los DM2 no obesos si dieta/ejerc falla, iniciar MET o SU (A)  En sobrepeso (IMC >25), MET (A)  2º Nivel MET+ secretagogo (SU, METG) (B)  DDP-4 +MET, cuando las SU riesgo Hipo (A)  En IMC >35 y ≤ 75 años, GLP-1 en 3º nivel (B)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    23. 23. El anciano diabético-Insulina  Si fallan los ADO, ISN + SU o MET o bien sola (A)  ISN análogos lentos (glargina, detemir) en vez de NPH en ancianos que requieran asistencia externa, hospicios… o riesgo de hipo (A)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    24. 24. El anciano diabético-InsulinaAlan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    25. 25. El anciano diabético-Renal  Anualmente evaluación de creatinina, FG, alb/crea (B)  Si la alb/crea >2.5 mg/mmol, mujeres; > 3.5 mg/ mmol, varones , tratamiento con IECAS (B)  Si DM2 + microalbuminuria la TA ≤ 140/80 y una HbA1c entre 6.5- 7.5% (B)  Remitir al nefrólogo cualquier nivel de enfermedad renal crónica (B)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    26. 26. El anciano diabético-RCV  El anciano menor de 85 años evaluar el RCV a 10 años (A)  No hay evidencias AAS en prevención primaria AVC o MCV  AAS en prevención secundariaAlan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    27. 27. ¿Es correcta una TA 150/092 para Carmen?M Seguí DíazUBS Es Castell Menorca
    28. 28. El anciano diabético-Hipertensión arterial  Ajustar TA 140/080 mmHg en ≤ 80 años (B)  TA 145/090 mmHg en ≥ 80 años no frágiles (B)  En frágiles TA 150/090 mmHg (C)  Si ERC + proteinuria IECAS o ARA2 (B)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    29. 29. El anciano diabético-Lípidos  Si RCV > 15% sin ECV estatinas (A)  Si ECV y alt lipidica estatinas (A)  Las estatinas reducen el AVC en DM2 (B)Alan Sinclair, John E. Morley, Leo Rodriguez-Mañas,Giuseppe Paolisso,Tony Bayer, Andrej Zeyfang, et al. Diabetes Mellitus in Older People:Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People(EDWPOP), and the International Task Force of Experts in Diabetes. JAMDA. Volume 13, Issue 6 , Pages 497-502, July 2012
    30. 30. El anciano diabético-CorolarioM. Seguí Díaz. Aspectos prácticos en la insulinización del paciente anciano con diabetes. Av Diabetol. 2010;26:320-5
    31. 31. Gracias

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