Contemporary Approaches to Managing Diabetes in Older Adults
Dr. Sloane: Welcome to PracticeUpdate, I’m Jason Sloane and I’m here with Dr. Richard Pratley, and he’ll be speaking with us about a very interesting topic. So first, I was wondering if you could tell me some factors in glycemic control that contribute to cardiovascular risk and mortality in older diabetic individuals.
Dr. Pratley: So this is an important question and particularly it’s important because we know that there is an epidemic of diabetes but also an epidemic of diabetes among older individuals. It’s projected that now we have about 123 million people with diabetes but over the next 30 years that number will increase to 254 million. There’s nothing particularly unique about patients who are older with diabetes in terms of their cardiovascular risk except that they have more cardiovascular risk in general. That’s a major cause of death in older individuals, and that number keeps increasing as people get older.
But the things with diabetes that predispose to cardiovascular disease we believe to be essentially the same process in older individuals as well as other individuals, so there’s glycation of the vessels, there are abnormalities in lipid metabolism, there’s an increase risk of blood pressures that’s particularly prevalent in older individuals, and a myriad of other factors that increases risk in diabetes. So when you compound that with the risk of aging, you have people who are at very high risk for cardiovascular events.
Dr. Sloane: What’s the incidence of diabetes over treatment that you’ve seen in older individuals, over treatment being increased risk of hypoglycemia?
Dr. Pratley: Yeah. So this is a very interesting conversation because for years our conversation has focused on the appropriate treatments and getting people to target, but we have focused less on what appropriate targets are and the consequences of therapy, and maybe in that zealousness to get people to go, we have patients who are over treated, and here I think all of the societies are aligned around the principal that we need to personalize therapy. We need to personalize therapy based upon the expected life expectancy of the individuals, and that’s true for not just older individuals but for younger individuals as well. We need to personalize around their comorbidities and we need to personalize around also their treatment choices.
When we look at patients who are in the clinic, there are clearly many patients whose life expectancy comorbidities do not justify very rigid glycemic control. I have those people in my clinic as well. Having identified people that have relatively low A1cs who have perhaps a low life expectancy, then we have to look at are there consequences of their treatment? Are they on medications where there are problems, is it hypoglycemia with sulfonylurea? Is it other complications of medications? If they’re experiencing those complications, then I think those are the ideal patients where we might want to consider ramping back on the therapy a little bit, or selecting alternative therapies.
Now one problem that I see in my clinic is that I have many patients who had diabetes for decades and they’ve heard for decades that glycemic control is important, you should try to normalize your blood sugars and it’s very hard to ramp them off of that to convince them that the risk of over treatment is higher than the risk of having their A1cs a little higher, but it’s quite clear from the DCCT that those curves that link risk to A1c are not linear, they’re really hyperbolic and so that the net benefit you get from taking somebody from an A1c of seven and a half to six and a half is very small, particularly in older patient population.
I try to explain this to my patients with graphics but people who’ve been doing this for a long time have certain habits and behaviors that are built around their diabetes and it’s really difficult to change.
Dr. Sloane: The more and more evidence that diabetes increases risk of cognitive dysfunction, what are the main contributors in your opinion to cognitive decline and is there any way that we can change our approach to therapy for diabetes to maybe help stave off some of that complication risk?
Dr. Pratley: So this is a really interesting and evolving area of research. I’ve been working in this field for some years now when we first discovered that the amyloid precursor protein which is implicated in Alzheimer’s disease is actually expressed in adipocytes. It’s over expressed in patients who are obese and diabetes and that correlates nicely with the observation that midlife obesity and diabetes are risk factors for Alzheimer’s disease. It’s also true that things like hypertension and dyslipidemia are risk factors for Alzheimer’s disease.
So you can almost think of Alzheimer’s disease representing yet another aspect of almost a metabolic syndrome-like picture, one that evolves over decades instead of more acutely such as cardiovascular disease does. What I think is appropriate for us to think of that in the context of multiple metabolic abnormalities including things like insulin resistance. It’s a very interesting area in terms of therapeutics because there have been some studies that suggest insulin sensitizers help to decrease progression for people who have mild cognitive impairment. There have also been some treatments that are based upon diabetes drugs, including things interestingly like nasal insulin.
I would say that right now what we ought to do is treatment people’s risk factors for cardiovascular disease aggressively beginning in middle age and that over the long term this will decrease risk for Alzheimer’s disease. That’s our hope anyway, and there’s some good evidence to suggest that that might work from an epidemiologic basis, but as we get better and better at treating cardiovascular events, more people will be surviving and those people are still going to be at risk for developing Alzheimer’s disease.
So it’s an interesting area and one which I think represents the next epidemic in the area of diabetes and metabolism.
Dr. Sloane: Thank you for addressing that, and thank you for joining Practice Update.
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