This document discusses diabetes management challenges in elderly patients. It notes that the prevalence of diabetes increases with age and peaks between 60-74 years of age. Screening and diagnosing diabetes in elderly patients can be difficult due to non-specific symptoms. Management goals aim to avoid hypoglycemia and other adverse drug reactions while controlling hyperglycemia and risk factors. The risk of hypoglycemia, functional decline, depression and other geriatric issues increases with age, requiring special consideration in diabetes management for frail elderly patients.
A presentation on the care of diabetes in elderly people. This presentation is chiefly based on ADA guideline 2015 and focuses on the management of diabetes in persons aged >65 years.
A presentation on the care of diabetes in elderly people. This presentation is chiefly based on ADA guideline 2015 and focuses on the management of diabetes in persons aged >65 years.
lecture about diabetes mellitus for undergraduated student, master student
its include definition of diabetes, type 1 diabetes, type2, gestational, diagnosis criteria, complication, world day
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
Are you Struggling to Control of your Diabetes and Weight?
People who are overweight or obese are more prone to developing Type 2 diabetes. Those who have Type 1 and Type 2 diabetes with weight problems struggle to control their blood sugar levels. Research shows that people with diabetes find it more difficult to lose weight than those without diabetes.
Weight loss significantly improves blood sugar control and also reduces the risk of getting complications from diabetes. However, whilst attempting to lose weight, people with diabetes find it hard to restrict their intake of food since eating less may trigger hypoglycaemia (low blood sugar). All these facts explain the need for specialist input in management of weight in people with diabetes.
This Slideshow gives you insight to Diabesity
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The term ‘diabetes’ means excessive urination and the word ‘mellitus’ means honey.
Diabetes mellitus is a lifelong condition caused by a lack, or insufficiency of insulin. Insulin is a hormone – a substance of vital importance that is made by your pancreas. Insulin acts like a key to open the doors into your cells, letting sugar (glucose) in. In diabetes, the pancreas makes too little insulin to enable all the sugar in your blood to get into your muscle and other cells to produce energy. If sugar can’t get into the cells to be used, it builds up in the bloodstream. Therefore, diabetes is characterized by high blood sugar (glucose) levels.
SIGNIFICANCE
OVERVIEW
WHAT IS DIABETES?
DEFINITION
MECHANISM
PREVELANCE
EPIDEMIOLOGY
CLASSIFICATION
GESTATIONAL DIABETES
RISK FACTORS
DIAGNOSIS
COMPLICATIONS
MEDICAL TEST
MEDICAL NUTRITIONAL THERAPY
HERBS FOR DIABETES
MYTHS AND FACTS
REFERENCES
lecture about diabetes mellitus for undergraduated student, master student
its include definition of diabetes, type 1 diabetes, type2, gestational, diagnosis criteria, complication, world day
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
Are you Struggling to Control of your Diabetes and Weight?
People who are overweight or obese are more prone to developing Type 2 diabetes. Those who have Type 1 and Type 2 diabetes with weight problems struggle to control their blood sugar levels. Research shows that people with diabetes find it more difficult to lose weight than those without diabetes.
Weight loss significantly improves blood sugar control and also reduces the risk of getting complications from diabetes. However, whilst attempting to lose weight, people with diabetes find it hard to restrict their intake of food since eating less may trigger hypoglycaemia (low blood sugar). All these facts explain the need for specialist input in management of weight in people with diabetes.
This Slideshow gives you insight to Diabesity
For more information please visit
http://www.simplyweight.co.uk
Articles
http://www.simplyweight.co.uk/articles/
Videos
http://www.simplyweight.co.uk/video/
Blogs
http://simplyweight.co.uk/blogs/
Forum
http://www.simplyweight.co.uk/forum/forum.php
Contact Us
http://www.simplyweight.co.uk/how-to-contact-us/
The term ‘diabetes’ means excessive urination and the word ‘mellitus’ means honey.
Diabetes mellitus is a lifelong condition caused by a lack, or insufficiency of insulin. Insulin is a hormone – a substance of vital importance that is made by your pancreas. Insulin acts like a key to open the doors into your cells, letting sugar (glucose) in. In diabetes, the pancreas makes too little insulin to enable all the sugar in your blood to get into your muscle and other cells to produce energy. If sugar can’t get into the cells to be used, it builds up in the bloodstream. Therefore, diabetes is characterized by high blood sugar (glucose) levels.
SIGNIFICANCE
OVERVIEW
WHAT IS DIABETES?
DEFINITION
MECHANISM
PREVELANCE
EPIDEMIOLOGY
CLASSIFICATION
GESTATIONAL DIABETES
RISK FACTORS
DIAGNOSIS
COMPLICATIONS
MEDICAL TEST
MEDICAL NUTRITIONAL THERAPY
HERBS FOR DIABETES
MYTHS AND FACTS
REFERENCES
Is Europe ready for elimination of hepatitis B and C? The World Health Organization (WHO) will launch a global strategy on viral hepatitis in 2016 with the aim to eliminate hepatitis B and C as public health threats by 2030. The joint poster from ECDC, EMCDDA and WHO/Euro looks at the current availability of data for each of the core indicators and how existing gaps in data availability could be addressed.
June 6, 2010. The Effects of Obstructive Sleep Apnea and Visceral Fat on Insulin Resistance: The Icelandic Sleep Apnea Cohort, Associated Professional Sleep Societies, LLC (APSS).
Mr. AH is a 70-year-old man who was diagnosed with T2DM 10 years ago. He was initially treated with lifestyle management and metformin.
3 years later, his doctors advised him to add long acting basal insulin analogue to metformin, reached to 40U/day .
Other current medical conditions include: hypertension, hypothyroidism, and mild osteoporosis without fracture history.
Current medications; Metformin 1000 mg bid, long acting basal insulin analogue 40U/day , Candesartan 16 mg qd, Alendronate 70 mg once weekly, Levothyroxine 100 mg qd.
Physical exam: BMI 26 kg/m2, BP 140/80 mmHg, otherwise unremarkable.
His current FPG 140 mg/dL and HbA1c 8.5%. Kidney and liver functions are normal.
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
The growing epidemic of type 2 diabetes is one of the leading causes of premature morbidity and mortality worldwide, mainly due to the micro- and macrovascular complications associated with the disease. A growing body of evidence suggests that although the risk of developing complications is greater with glucose levels beyond the established
Know the signs and symptoms of diabetes and possible solutionssupreme100
Diabetes mellitus is a serious metabolic disease, affecting people of all geographic, ethnic or racial origin and its prevalence is increasing globally,Burden from this costly disease is high on the low and middle-income countries (LMIC) where the impacts of modernization and urbanization have caused marked adverse changes in lifestyle parameters. How To Know the signs and symptoms of diabetes and possible solutions
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
3. 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.
5. 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
6. 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
7. • Advanced age
• Recent hospitalization
• Intercurrent illness
• Chronic liver, renal or
cardiovascular disease
• Endocrine deficiency
(thyroid, adrenal,
pituitary)
• Loss of normal counter-
regulation
• Hypoglycaemic
unawareness
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
9. 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 older
ages (≥75)
Crude prevalence of diagnosed diabetes by age:
NHANES (National Health and Nutrition
Examination Survey) 2003-2006 (n=13094), US
10. 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
12. 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.
13. 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
14. 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.
15. 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.
16. 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-
being
and good quality of life
Acquisition of skills and
knowledge to adapt to lifestyle
changes
Encouragement of diabetes
self-care
17. 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.
18. 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.
20. Complications of type 2 diabetes in the elderly
Hypoglycaemia
Cardiovascular
Microvascular (retinopathy/nephropathy)
Cognitive (dementia)
Depression
Falls and fractures
Peripheral neuropathy
21. The frail, elderly patient with diabetes
Older persons with diabetes are at higher risk
than 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 and
Diabetes
Cognitive
dysfunction
CV disease,
cancer and
all cause
morbidity/
mortality
Falls and
fractures
Functional
disability 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.
22. Hypoglycaemia is a risk marker of frailty
The relationship between
hypoglycaemia and geriatric
comorbidities
Hypoglycaemia
is accompanied by many adverse
consequences for which elderly
patients are already at an
increased risk
Hypoglycaemia
Falls and
fractures
Functional
disability and
depression
Cognitive
dysfunction
CV disease,
cancer and
all cause
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.
23. 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.
24. 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.
25. 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.
26. 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
Autonomic
symptoms
Baseline Hypo Recovery
**
12
10
8
6
4
2
0
Neuroglycopenic
symptoms
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?????
27. 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.
28. Older
patients with diabetes
have higher rates
of 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
The frail, elderly patient with diabetes
Ageing and
Diabetes
Cognitive
dysfunction
CV disease,
cancer and
all cause
morbidity/
mortality
Falls and
fractures
Functional
disability and
depression
Sinclair A. Diabetes Spectrum. 2006;19:229-33.
Emerging Risk Factors Collaboration, et al. N Engl J Med. 2011;364(9):829-41.
29. 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 deaths
HR
(95% CI)
Interaction
p-value
Vascular 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)
30. The frail, elderly patient with diabetes
Older persons with diabetes
are at higher risk than those
without diabetes of:
Cancer mortality and vascular
deaths
Functional disability
Older adults with diabetes
have greater difficulty
walking, climbing stairs,
doing housework ...,
compared with their
counterparts without
diabetes
Ageing and
Diabetes
Cognitive
dysfunction
CV disease,
cancer and
all cause
morbidity/
mortality
Falls and
fractures
Functional
disability and
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.
31. The frail, elderly 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, such
as depression
Ageing and
Diabetes
Cognitive
dysfunction
Falls and
fractures
Functional
disability and
depression
The presence of diabetes doubles the odds of
comorbid depression
Anderson RJ, et al. Diabetes Care. 2001;24(6):1069-78.
CV disease,
cancer and
all cause
morbidity/
mortality
32. Cognitive dysfunction should be added to the list of the complications of diabetes,
along with retinopathy, neuropathy, nephropathy and cardiovascular disease.
The frail, elderly 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
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
33. 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
34. 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 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):2
460-9.
35. 10,025 participants in the population-based NHANES sample followed
over 8 years (83,624 person-years of follow-up)
%Alive
60 12
0
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
37. 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
38. 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
ACCOR
D
(n=1025
1)
ADVAN
CE
(n=1114
0)
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
39. Intensified blood glucose lowering treatment:
what are the benefits in the older patient?
Standard Intensive
Estimatedeffectsofintensified
glycaemiccontroloneventrates
(per1000in5years)
20
100
60
80
40
0
CHD
Stroke
Blindness
oneeye
Renal
replacement
therapy/
renaldeath
Allcauses
mortality
Cardiovascular
mortality
Severe
hypoglycaemia
-7*
-1
-4
-2
+3
+4
+47*
CHD= cronary heart disease
Numbers 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.
40. 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.
41. 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
42. 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.
43. 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 in
renal/hepatic dysfunction,
respiratory/heart failure,
anorexia, gastrointestinal
disease
Alternative treatments:
DPP-IV inhibitors, or lower risk
sulphonylureas (SU)
Glinides
Further weight loss with a
GLP-1 agonist may have
adverse consequences in a
frail patient
Alternative treatments:
Metformin + lower-risk SU
Metformin + GLP-1 agonist
Frailty associated with
increased hypoglycaemia
risk: caution when using
insulin or sulphonylurea
therapy
Alternative treatments:
Low risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria:
Care home residency
Significant cognitive decline
Major lower limb mobility disorder
History of disabling stroke
Recommended glucose targets:
Fasting glucose range =
7.6−9.0 mmol/l
HbA1c range = 7.6−8.5%
45. 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 impairment
SELECT antihyperglycemic therapy carefully
Caution 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
46. 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,
47. 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