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Prof. Leocadio Rodríguez Mañas
Geriatrics Service
Getafe University Hospital
Universidad Europea de Madrid
España
Clinical...
Prevalence of diabetes
Di@bet.es study
0
5
10
15
20
25
30
35
40
45
18-30 31-45 46-60 61-75 >75
Known DM Unknown DM
0
5
10
...
TOPICS
 Do they need a different approach?
 Different pathophysiology
 Different risks
 Different targets
 Different ...
 Older people
 Oxidative phosporilation <40%
 Decrease in ATP synthesis
 Acumulation of intramyocelular lipids
 Like ...
Loss of muscle mass
Vandervoort
Muscle and Nerve 25,
31 yrs (M)
66 yrs (M)
73 yrs (F)
85 yrs (M)
Buford et al,
Exp. Geront...
El Assar M, Angulo J, Rodriguez-Mañas l. J Physiol 2015
MECHANISMS OF VASCULAR DAMAGE
DM and Mortality
Bertoni AG. Diabetes Care 2002;25:471-475
0
0,5
1
1,5
2
2,5
65-69 70-74 75-79 80-84 >85
Age
Mortalityrate...
Cognitive dysfunction should be added to the list of the complications of diabetes,
along with retinopathy, neuropathy, ne...
DIABETES AND FUNCTIONAL IMPAIRMENT
Wong et al.,
Lancet Diabetes and Endocrinol., 2013
Diabetes? What about my flight?
No
diabetes
Non-insulin-treated
diabetes
Insulin-treated
diabetes
n 8.620 530 99
Incidence of falls (per
person-year)
70–7...
DM2 and risk of hip fracture
RRl: 1,7 (IC: 1,3-2,2)
Janghorbani M, et al. Am J Epidemiol. 2007; 166: 495–505.
DM (n) No DM (n) Risk and 95% CI
Hassing et al 38 220 2.1 (0.99−4.4)
Leibson et al 1455 NA 1.7 (1.3−2.0)
Macknight et al 5...
 Focused on preservation of function
 Tailored to the characteristics of the
patient
 Avoiding undesired effects of
tre...
What is going to happen after death….
….SIMPLY, IT DOES NOT HAPPEN
When you have the appointment for surgery?
In one month...
15
10
0
20
5
25
65 70 75 80 85 90 95
Hombres Mujeres 2004
HTA
c-LDL
HbA1c - micro
HbA1c - macro
INE. Anuario Estadístico, ...
15
10
0
20
5
25
65 70 75 80 85 90 95
Male Female 2004
INE. Anuario Estadístico, 1997.
Life-expectancy in Spain for people
...
TOPICS
 Do they need a different approach?
 Different pathophysiology
 Different risks
 Different targets
 Different ...
OCTOBER, 2015
LONGEVITY
(AMOUNT OF LIFE)
QUALITY OF LIFE
(FUNCTION)
CHRONIC
DISEASE
HEALTH
SYSTEMS
+
SOCIAL
SYSTEMS
Prevention
Risk mana...
COMPREHENSIVE BIOPSYCHOSOCIAL ASSESSMENT
Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33. Haas L. Diabetes Spectrum. 200...
Defining functional
categories
Defining functional categories
Initial clinician
assessment
Vascular complications
profile
...
Clinical assessment of older people with Type 2 DM
Patient willings and
preferences
Frailty and shorten life
expectancy
Po...
Robust Frail Functional
Limitation
Disability Dependency
Definition
Interventions to
improve quality
and outcomes -
and pr...
DM ALONG THE TIME
1922
PRE-
TREATMEN
T
¡¡FIRST TREATMENT WITH INSULIN!!
POST-
TREATMEN
T
Focused on
• Type 1 DM
• Children...
1969
Abdominable
Focused on
• Type 2 DM
• Middle-age people
• To Save lives
• CVD
DM ALONG THE TIME
2015
Focused on
• Type 2 DM
• Older adults
• To avoid disability
• To avoid dependency
DM ALONG THE TIME
TO PROVIDE THE BEST FITTED
CARE TO OUR PATIENTS WE
SHOULD MOVE TOWARDS THIS NEW
AGE IN DIABETES
CONCLUSIONS
 NOWADAYS, OL...
Clinical management of elderly people with diabetes
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Clinical management of elderly people with diabetes

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Clinical management of elderly people with diabetes

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Clinical management of elderly people with diabetes

  1. 1. Prof. Leocadio Rodríguez Mañas Geriatrics Service Getafe University Hospital Universidad Europea de Madrid España Clinical management of elderly people with diabetes 24 October 2015 PCDE Session
  2. 2. Prevalence of diabetes Di@bet.es study 0 5 10 15 20 25 30 35 40 45 18-30 31-45 46-60 61-75 >75 Known DM Unknown DM 0 5 10 15 20 25 30 35 40 45 18-30 31-45 46-60 61-75 >75 Known DM Unknown DM Male Female Soriguer F. Diabetologia 2011
  3. 3. TOPICS  Do they need a different approach?  Different pathophysiology  Different risks  Different targets  Different management  Conclusions
  4. 4.  Older people  Oxidative phosporilation <40%  Decrease in ATP synthesis  Acumulation of intramyocelular lipids  Like Relatives of patients with Type 2 DM  But without obesity Science 2003; 300: 1140-2 Science 2005; 307: 384-7 Am J Med. 2006; 119 (Suppl 1): S10–S16. Insulin resistance
  5. 5. Loss of muscle mass Vandervoort Muscle and Nerve 25, 31 yrs (M) 66 yrs (M) 73 yrs (F) 85 yrs (M) Buford et al, Exp. Gerontol, 2012 Plus changes in adipose tissue? Plus changes in muscle bioenergetics?
  6. 6. El Assar M, Angulo J, Rodriguez-Mañas l. J Physiol 2015 MECHANISMS OF VASCULAR DAMAGE
  7. 7. DM and Mortality Bertoni AG. Diabetes Care 2002;25:471-475 0 0,5 1 1,5 2 2,5 65-69 70-74 75-79 80-84 >85 Age Mortalityrate Females Males
  8. 8. Cognitive dysfunction should be added to the list of the complications of diabetes, along with retinopathy, neuropathy, nephropathy and cardiovascular disease. The older patient with diabetes  Older persons with diabetes are at higher risk than those without diabetes of:  Cancer mortality and vascular deaths  Functional disability  Geriatric syndromes: depression  Falls and fractures  Geriatric syndromes: cognitive impairment Ageing and Diabetes Cognitive dysfunction Falls and fractures Functional disability and depression Cukierman T, et al. Diabetologia. 2005;48(12):2460-9. CV disease, cancer and all cause morbidity/ mortality
  9. 9. DIABETES AND FUNCTIONAL IMPAIRMENT Wong et al., Lancet Diabetes and Endocrinol., 2013 Diabetes? What about my flight?
  10. 10. No diabetes Non-insulin-treated diabetes Insulin-treated diabetes n 8.620 530 99 Incidence of falls (per person-year) 70–74 years old 0.43 0.56* 1.26* 75–79 years old 0.52 0.74* 0.82* 80–84 years old 0.66 0.89* 1.31* 85 years old 0.98 1.32* 1.37* All ages 0.62 0.85* 1.12* Fall more than once a year (%) 17.0 25.7* 35.4* Fall more than twice a year (%) 6.8 10.6* 15.2* Follow-up (years) 7.2 ± 1.9 6.6 ± 2.2* 6.2 ± 2.4* Diabetes and Risk of Falls Schwartz A, JAGS 2002
  11. 11. DM2 and risk of hip fracture RRl: 1,7 (IC: 1,3-2,2) Janghorbani M, et al. Am J Epidemiol. 2007; 166: 495–505.
  12. 12. DM (n) No DM (n) Risk and 95% CI Hassing et al 38 220 2.1 (0.99−4.4) Leibson et al 1455 NA 1.7 (1.3−2.0) Macknight et al 503 5071 1.2 (0.9, 1.7) Ott et al 689 4532 1.9 (0.9−1.7) Peila et al 900 1674 1.5 (1.0−2.2) All participants 2723 10044 1.6 (1.4−1.8) 0.01 0.1 1 10 100  Development of future dementia  The odds of future dementia is increased 1.6-fold Cukierman T, et al. Diabetologia. 2005;48(12):2460-9. Development of dementia in patients with type 2 diabetes DM= diabetes mellitus
  13. 13.  Focused on preservation of function  Tailored to the characteristics of the patient  Avoiding undesired effects of treatment (hypos) But also  Timely NEW OBJECTIVES for new challenges, MEAN a different management
  14. 14. What is going to happen after death…. ….SIMPLY, IT DOES NOT HAPPEN When you have the appointment for surgery? In one month, but I do not know if I will come, because it does not disturb me currently
  15. 15. 15 10 0 20 5 25 65 70 75 80 85 90 95 Hombres Mujeres 2004 HTA c-LDL HbA1c - micro HbA1c - macro INE. Anuario Estadístico, 1997. Tiempo necesario para obtener beneficios del control de los FRCV en sujetos >65 años
  16. 16. 15 10 0 20 5 25 65 70 75 80 85 90 95 Male Female 2004 INE. Anuario Estadístico, 1997. Life-expectancy in Spain for people older than 65 yrs Time for functional decline Mobility disability Frailty BADL Dementia posthypos
  17. 17. TOPICS  Do they need a different approach?  Different pathophysiology  Different risks  Different targets  Different management  Conclusions
  18. 18. OCTOBER, 2015
  19. 19. LONGEVITY (AMOUNT OF LIFE) QUALITY OF LIFE (FUNCTION) CHRONIC DISEASE HEALTH SYSTEMS + SOCIAL SYSTEMS Prevention Risk manag. Empowerment Integrated Coordinated. Continued  Management of chronic disease oriented to avoid frailty and preserve function  Management of frailty, as the phenotypic expression of disease in older adults  Management of frailty, as the main predictive factor of adverse outcomes  Promoting integrated, coordinated and continued care OUR CHALLENGE OUR APPROACH TO MAINTAIN
  20. 20. COMPREHENSIVE BIOPSYCHOSOCIAL ASSESSMENT Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33. Haas L. Diabetes Spectrum. 2006;19(4):240-4. HOW TO ACHIEVE AN OPTIMAL MANAGEMENT OF OLDER ADULTS WITH DM Avoid symptoms of hyperglycemia Prevent undesired weight loss due to inapropritae diets Prevent vascular complications Avoid hypoglycemia Avoid Adverse Drugs Reactions Prevent cardiovascular risk Improve quality of life FUNCTION INDIVIDUALIZED AIMS OF TREATMENT
  21. 21. Defining functional categories Defining functional categories Initial clinician assessment Vascular complications profile Physical function/frailty/cognition Comorbidities/Drugs Consideration of Findings Total/active life expectancy Risk of complications Competing risks Need for carer/social support Hypoglycaemia and ADR* risk Individualised management of the patient Nutrition, physical activity/exercise, drugs, level of care, coordination of care Independent Frail Physical/ End of life robust cognitive impairment Focus on disease Focus on function ADR: adverse drug reaction Sinclair AJ, Dunning T, Rodriguez-Mañas L Lancet, Diabetes Endocrinol, 2015
  22. 22. Clinical assessment of older people with Type 2 DM Patient willings and preferences Frailty and shorten life expectancy Polipharmacy Comorbidities and risk factors Cognitive impairment Social isolation/loneliness Unvoluntary weight loss Depression Factors to take into account in the proper management of older people with DM Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33.
  23. 23. Robust Frail Functional Limitation Disability Dependency Definition Interventions to improve quality and outcomes - and prevent or delay further functional decline What How Where ? What How Where ? What How Where ? What How Where ? What How Where ? Potential reversibility of functional decline Frailty and function as a dynamic state CARE FOCUSED ON Preventing frailty Preventing Disability Treating Frailty Preventing Disabilty Treating Functional Decline Preventing Dependency Treating Disability Managing Dependency
  24. 24. DM ALONG THE TIME 1922 PRE- TREATMEN T ¡¡FIRST TREATMENT WITH INSULIN!! POST- TREATMEN T Focused on • Type 1 DM • Children/Young people • To Save lives • Starvation
  25. 25. 1969 Abdominable Focused on • Type 2 DM • Middle-age people • To Save lives • CVD DM ALONG THE TIME
  26. 26. 2015 Focused on • Type 2 DM • Older adults • To avoid disability • To avoid dependency DM ALONG THE TIME
  27. 27. TO PROVIDE THE BEST FITTED CARE TO OUR PATIENTS WE SHOULD MOVE TOWARDS THIS NEW AGE IN DIABETES CONCLUSIONS  NOWADAYS, OLDER ADULTS REPRESENT 50% OF PERSONS WITH DM  THEY SHOW DIFFERENT CHARACTERISTICS  THEY NEED DIFFERENT APPROACHES  THEY NEED DIFFERENT MANAGEMENT  FRAILTY IS BOTH AN OUTCOME AND A CONDITIONING FACTOR  FRAILTY MUST BE ASSESSED IN ANY OLDER ADULT WITH DM AS A FUNDAMENTAL PART OF THE DECISSION-MAKING PROCESS leocadio.rodriguez@salud.madrid.org FACING THE RISKS FOR DISABILITY IN DIABETES

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