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205 Cards in this Set
- Front
- Back
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The Geriatric Population
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In 2030 20% of the US population will be over age 65
In 2050 at least 50% of Americans will live to age 85 If a person survives to age 65, likely to survive 13-20 more years If a person survives to age 85; likely to survive 6-7 more years |
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Health Care Costs
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Elderly comprise 13% of the population but account for:
34% of Rx expenditures 36% of hospital stays 33% of US health care expenditures 40% of drug-related hospitalizations 50% of drug-related deaths At least $30 Billion/year spent on drug-related morbidity |
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Demographics
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Lots of variability between patients
Community vs institutionalized Independence vs dependence Young-old vs old-old “Functional age” Only 4% of patients > 65 reside in LTCF, but 20% will be in a LTCF at some point LTC facilities cost approximately $25,000-50,000/year Goal is to keep patients independent |
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Hallmarks of Geriatrics
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Diseases present differently, earlier
Iatrogenesis is more common There are often multiple etiologies for patient presentation Drug effect on function may be more important than effect on mortality Treatment and prevention may be more effective because of consequence of disease Pharmacokinetic and pharmacodynamic changes in elderly patients |
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The I’s of Geriatrics
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Iatrogenesis
Insomnia Impaired senses Infection Isolation (drugs with shorter T 1/2 lives are betterin a medical setting because the patient will not leave as medicated Impaction Inanition Immobility Incontinence Instability Impotence Intellectual impairment Immunodeficiency |
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atypical presentations in the elderly
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AMI- confusion, syncope, abdominal pain
CHF- lethargy, confusion (not profusing the brain) CAP- may not have fever, productive cough UTI-incontinence, confusion Delirium, falls, nonspecific functional decline may be presenting symptoms of disease Labs are more likely to be done because present so differently |
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Chronic Conditions
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Types of conditions in the elderly often more disabling
May be more severe Several conditions present Most common: Arthritis HTN Hearing Loss Heart Disease |
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Age related physiologic changes
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↓ functional reserve capacity and homeostatic control mechanisms (less ability of the body to respond to changes)
Cardiovascular, Musculoskeletal, CNS Presents as: Postural instability Orthostatic hypotension Decreased cognitive reserve Diminished bowel and bladder function (more likely to have incontinence from a med) |
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Age related physiologic changes (cardiac, GI/liver)
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Cardiac
↓ myocardial sensitivity to β adrenergic stimulation ↓ baroreceptor activity ↓ cardiac output GI/Liver ↑ gastric pH ↓ absorption of weakly acidic meds e.g. warfarin, PCN ↑ absorption of weakly basic meds e.g. TCAs slowed intestinal transit ↓ liver blood flow |
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Age related physiologic changes (renal, skeletal, pulmonary)
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Renal
↓ GFR (SCr can be normal so always check) ↓ renal blood flow Skeletal Loss of skeletal bone mass Pulmonary ↓ vital capacity ↓ chest wall compliance |
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Sensory changes- Eyes can be due to
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Presbyopia
Cataracts Macular degeneration Glaucoma Dry eyes |
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Sensory Changes - Eye low vision aids
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increased wattage light bulbs
tinted glasses may decrease glare magnification devices night lights larger print on labels/education materials |
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Sensory Changes - Hearing
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Approximately 50% of persons >65
presbycusis - high frequency hearing loss conductive hearing loss - middle ear; can uderstand speech with amplification sensorineural hearing loss - inner ear; distortion of loudness and pitch |
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Sensory Changes - Hearing (interviewing hearing impaired adults)
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quiet well lit place
sit at eye level lower the tone of your voice speak slowly and clearly avoid shouting mime and use non-verbal gestures amplification |
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pk changes in the elderly (absorption)
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Absorption: usually no changes in bioavailability, but for some drugs ↓ first pass means ↑ bioavailability (e.g. morphine, propranolol, nifedipine)
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pk changes in the elderly (protein binding)
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May have ↓ albumin, ↓ protein binding increasing the amount of free drug if highly protein bound
Decreased serum albumin (disease/nutrition) free (active) concentrations of highly protein bound drugs (phenytoin, phenobarbital, warfarin, diazepam) drugs may be displaced from protein binding sites (adding salsalate to stable warfarin regimen) |
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Pk changes in the elderly (distribution)
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Body composition
decrease in total body water and lean muscle mass and increase adipose tissue ↓ volume of distribution of water soluble drugs (digoxin, aminoglycosides, lithium) volume of distribution of lipid soluble drugs (chlordiazepoxide, diazepam) |
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pk changes in the elderly (metabolism)
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Metabolism: ↓ in phase I (oxidative) reactions
May affect diazepam, piroxicam, theophylline Phase II (conjugative) reactions less changed with aging |
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pk changes in the elderly (elimination)
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Elimination: GFR often ↓ with aging
May affect allopurinol, amantadine, captopril, aminoglycosides, digoxin, lithium, diuretics, vancomycin, quinolones Also affects active metabolites: normeperidine, morphine-6-glucuronide |
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Pharmacodynamic Changes Increased sensitivity may be due to:
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Increased sensitivity may be due to:
Change in receptor numbers Change in receptor affinity Postreceptor alteration Impairment of homeostatic mechanisms More sensitive to opioids, benzodiazepines, anticoagulants |
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Aging in the brain
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Significant loss of active cells
Reduction in cerebral blood flow Decrease in cholinergic neurons Decrease in norepinephrine and dopamine levels |
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Anticholinergics
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Antiparkinson Medications
Antihistamines TCAs Neuroleptics Antispasmodics Antiarrhythmics |
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The Risk for Drug Related Problems
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Polypharmacy (1 or more unnecessary medications) may occur in up to 60% of community-dwelling older persons
3-4 meds/day in elderly outpatients (doesnt take into accout OTCs) Almost 7 meds/day in institutionalized elderly 14-27% of elderly take a medication on the Beers’ list |
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Drug Related Problems
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Excessive/Subtherapeutic Dosing
Improper drug Underuse/Untreated Indications ACE inhibitors in CHF, anticoagulation in A fib, drug therapy post MI, untreated depression Drug Interactions ADRs Lack of indication Lack of Monitoring Not receiving/taking |
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Medication Adherence
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Intentional or unintentional nonadherence
Intentional due to “don’t need”, side effects Unintentional related to “forgot”, misunderstood Cost also significant contributor |
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Improving Adherence
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Minimize # of meds when possible
Simplify drug regimen Increase user’s knowledge Compliance aids |
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Function in the Elderly
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Good function may be more important than duration of life
Important to measure function in the elderly Important to consider role of drugs on function in the elderly |
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Activities of Daily Living (ADLs)
functional |
feeding
dressing ambulation toileting bathing transfer |
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Instrumental Activities of Daily Living (IADLs)
cognative |
writing
reading cooking cleaning shopping telephone managing medications/money |
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Drugs and Function: improving function
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Diuretics decrease dyspnea in CHF patients
Analgesics decrease pain Bronchodilators reduce dyspnea in COPD pts Antidepressants decrease anhedonia |
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drugs and function: adverse reactions can contribute to diability
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Mental status changes
Impaired balance Weakness Dyskinesias Hypotension Urinary incontinence |
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Potential Causes of Delirium
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Anticholinergics
TCAs Antipsychotics Antihistamines H2 blockers Opioids Digoxin Antihypertensives Alcohol Benzodiazepines Antiparkinsonian drugs Antiinfectives Corticosteroids |
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Impaired Balance caused by drugs
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Anticholinergics
Visual problems Anticonvulsants ataxia Alcohol, aminoglycosides, loop diuretics, high dose ASA Vestibular dysfunction Benzodiazepines, antihistamines Cerebral impairment |
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Hypotension caused by drugs
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Antihypertensives
Diuretics Nitrates Low potency Antipsychotics |
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urinary incontinence caused by drugs
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Urge: diuretics, caffeine, alcohol, donepezil
Stress: alpha blockers, reserpine Overflow: anticholinergics, calcium channel blockers Functional: diuretics, opioids, sedative-hypnotics |
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Role of Pharmacists and elderly
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History taking
Assessing nonpresciption and alternative medications Utilizing Medication Appropriateness Index Obtaining allergy history Assessing patient’s ability to self-medicate Evaluating undertreatment Monitoring for drug-food or drug-lab interactions Recommending alternative formulations Suggesting compliance aids |
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Medication Appropriateness Index
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Is there an indication?
Is the medication effective for condition? Dosage correct? Directions correct? Directions practical? Clinically significant drug-drug interactions? Clinically significant drug-disease interactions? Unnecessary duplication? Duration acceptable? Is it the least expensive, most appropriate alternative? |
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Potentially Inappropriate Medications
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Beer’s List
HEDIS Drugs to Avoid in the Elderly Drug-Disease Interactions in the Elderly Usual suspects: Propoxyphene and combos Amitriptyline (use nortrityline because less anticholinergic) Skeletal Muscle Relaxants Diazepam Indomethacin (has an active metabolite and a long T1/2, so use clonazepam because no metabolites) (xanax good on, bad off, easily addicted, because very short acting) Anticholinergics |
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Meds in the Elderly Pearls
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Assess Risk/Benefit
Start low/go slow Review maintenance meds periodically Consider nondrug alternatives When in doubt, blame the drug |
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Care of the Older Diabetic
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Per CDC: The prevalence increases with increasing age with roughly 27% of seniors are estimated to have diabetes
Diagnostic criteria for diabetes are the same in older adults as in younger people Can be challenging by clinical and functional heterogeneity It is important to focus on: Time required to benefit from the therapeutic intervention Glycemic Goals Life expectancy and comorbidities base goals on comorbidities and life expectancy |
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Time to benefit: Microvascular Complications
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Retinopathy, Neuropathy, Nephropathy
Striking lack of clinical trials focused on the elderly, but estimates from other trials: ~Approximately 8 years to prevent microvascular complications in new-onset DM (UKPDS) VADT: 5.6 years of mean follow-up; HgbA1c from 8.4% to 6.9% appeared to have minimal effects (decreased albuminuria, no changes for retinopathy, neuropathy) |
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Improved glycemic control
in a 45 year old |
End-Stage Renal Disease: Risk Reduction from 3.5 to 2.0%
Blindness due to Retinopathy: Risk Reduction from 2.6 to 0.3% |
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improved glycemic control in 65 year old
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End-Stage Renal Disease: Risk Reduction from 0.6 to 0.3%
Blindness due to Retinopathy: Risk Reduction from 0.5 to <0.1% |
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improved glycemic control in 75 year old
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Benefit very small – because risk was already so low
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improved glycemic time to benefit and microvascular complications control and age
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Improved glycemic control
45-year-old: End-Stage Renal Disease: Risk Reduction from 3.5 to 2.0% Blindness due to Retinopathy: Risk Reduction from 2.6 to 0.3% 65-year-old: End-Stage Renal Disease: Risk Reduction from 0.6 to 0.3% Blindness due to Retinopathy: Risk Reduction from 0.5 to <0.1% 75-year-old: Benefit very small – because risk was already so low |
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greatest risk of mortality and morbidity in patients is ____________
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macrovascular
heart disease stroke |
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lower A1C has not been consistently shown to reduce _____________
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macrovascular complications (CAD, PVD, CVA)
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Focus on control of hypertension and hyperlipidemia
i the elderly and time to benefit |
Estimated time to benefit: ~2 to 3 years
Hypertension in the Very Elderly Trial (HVET) Systolic Hypertension in the Elderly Program (SHEP) trial Scandinavian Simvastatin Survival Study and PROSPER |
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The issue of glycemic control in general has been brought to the forefront by three recently reported randomized controlled trials:
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The issue of glycemic control in general has been brought to the forefront by three recently reported randomized controlled trials: Action to Control Cardiovascular Risk in Diabetes (ACCORD),[7] Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE),[8] and the Veteran Affairs Diabetes Trial (VADT).[9] The results from these trials are reshaping our thinking of how we should treat older adults with diabetes, especially the oldest adults. However, the fundamentals of clinical decision making remain the same: balance the risks and benefits for the individual patient. the aggregate, the average age of people at the time of enrolment in these studies was 60-66 years. Thus, a majority of the patients could not be considered "elderly" and extrapolation of the findings to an older population must be done with caution.
Three randomized controlled trials ACCORD – the Action to Control Cardiovascular Risk in Diabetes trial ADVANCE – Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation trial VADT – Veterans Affairs Diabetes Trial Intensive lowering of A1C levels over 3-5 years does not reduce the risk of CVD outcomes. In fact, the ACCORD trial demonstrated a slightly higher risk of macrovascular complications – and the study was stopped early because of a significant increase in mortality in the intensive arm (relative increase of 22%) compared with standard therapy. The cause of excess deaths in the ACCORD study is not fully understood. Unfortunately the reported lower A1C levels could not explain the excess mortality. Conversely, data from long-term follow-up investigations indicate that the time frame to attain CVD benefit from glycemic control may be decades. The United Kingdom Prospective Diabetes Study (UKPDS), at the conclusion of the original 10-year trial, conducted a 10-year follow-up of T2DM patients to determine if improved glucose control may have an effect on macrovascular outcomes. During the orginal study, the A1C differed by approximately 1% , whereas in the follo-up study, tha A1C in the intensive and standard therapy groups was not significantly different. Early intensive glycemic control (study specifically used sulfonylurea-insulin combinations) significantly reduced the risk of myocardial infarction, any diabetes-related endpoint and death from any cause. Lowering Cholesterol and BP - lowering effect on mortality and morbidity microvascular complications take many years to develop. Therefore, if a person's life expectancy is < 5 years, it is not beneficial to use a treatment modality that will produce its benefit after 10 years |
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~ ___ of nursing facility residents with DM2 have evidence of coronary artery disease, stroke, and/or peripheral vascular disease (Resnick B. Diabetes management: the hidden challenge of managing hyperglycemia in long-term care setting
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90%
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ADA Glycemic Recommendations for Adults with T2DM
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ADA recommends a goal A1c <7.0% for most adults with DM
Goal A1c of < 8.0% should be considered when: Duration of DM, Age > 65/decreased life expectancy, Known CAD, Dementia, Advanced complications Individualize goal using shared decision making Call to action to initiate or change therapy if A1c ≥ 9% no A1c in the calendar year |
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what influences how tightly A1C is controlled in the elderly
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Duration of diabetes
Age/life expectancy Comorbid conditions Known CVD or advanced microvascular complications Hypoglycemia unawareness |
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American Geriatrics Society Guidelines Recommendations for glycemic control
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For older persons, target hemoglobin A1c (A1C) should be individualized. A reasonable goal for A1C in relatively healthy adults with good functional status is 7% or lower.
For frail older adults, persons with life expectancy of less than 5 years, and others in whom the risks of intensive glycemic control appear to outweigh the benefits, a less stringent target such as 8% is appropriate. |
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is life expectancy greater or less with those who have dementia
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less
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Hypoglycemia in the Older Adult
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Hypoglycemia is More Frequent and More Dangerous in the Elderly
Differs in elderly patients compared with younger patients Fewer adrenergic symptoms (such as sweating or tremor) More neuroglycopenic symptoms (such as confusion) Confusion or lethargy Poor concentration and coordination Hallucinations Aggression or irritability Blurred Vision Falling Slurred speech |
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Goals for limited life expectancy and glycemic control
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Avoid hypoglycemia and symptomatic hyperglycemia. Get symptoms at earlier states
Presentation of hypoglycemia differs in elderly patients compared with younger patients: the elderly exhibit fewer adrenergic symptoms (such as sweating or tremor) and more neuroglycopenic symptoms (such as confusion) at earlier states. This tendency is exacerbated by diabetic neruopathy, resulting in significant hypoglycemic unawareness among elderly patients. Because the elderly are unable to tolerate hypoglycemia as well as younger patients, severe hypoglycemia should be avoided if possible and risk of hypoglycemia should be a consideration when selecting pharmacologic therapy for diabetes in the elderly Because of the dangers associated with cognitive impairment and falls amoung the elderly, and because of the potential risk of follow-up cardiovascular event, severe hypoglycemia should be vigorously avoided in elderly patients. Hypoglycemia is the primary limiting factor in the achievement of tight glycemic control whether in older or younger individuals. However, complicating the picture is that neuroglycopenic symptoms are less likely to be recognized. These symptoms are subtle, especially in older adults. For example, hypoglycemia might become manifest as falls. Several physiological changes in carbohydrate metabolism occur with aging that affect diabetes management. Older adults with diabetes: tend to have a poorer glucagon response to hypoglycemia are more likely to have neuroglycopenic symptoms of hypoglycemia compared with the adrenergic symptoms[11] have a frequency of severe hypoglycemic episodes. |
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Hyperglycemia can worsen Geriatric conditions such as....
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Polyuria, Nocturia → Falls, Incontinence
Fatigue → Frailty, loss of function Weight loss → Frailty, loss of function Problems with cognitive function Problems with wound healing |
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older adults with DM tend to be.....
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tend to be leaner and have a lesser insulin secretory response to a glucose load[10]
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Therapeutic Options for DM in the elderly
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Metformin
Sulfonylurea (SU) Thiazolidinedione (TZD) Alpha glucosidase inhibitor Insulin Glinides GLP1 mimetic Amylin mimetic DPP-4 inhibitor 9 different classes consisting of over 25 different medications |
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dont forget
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to look at cases from 02-07 DM stuff
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A1C% lower potential of DM drugs
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liraglutide 0.5-1
exenatide 0.5-1 glipizide up to 2 metformin up to 2 repaglinide 1.5 pioglitazone 05.-1.4 stitagliptin 0.6-0.8 |
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hypoglycemia risk for DM meds
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liraglutide none
exenatide none glipizide high risk metformin none repaglinide some pioglitazone none stitagliptin none |
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disadvantages of liraglutide
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GI
$$$$$ |
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disadvantages of exenatide
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GI
$$$$$ |
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disadvantages of glipizide
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falls
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disadvantages of metformin
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GI
CI; CrCl <30 ml/min |
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disadvantages of repaglinide
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falls
a little expensive |
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disadvantages of pioglitizone
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CHF
$$$$$ |
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disadvantages of sitagliptin
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no long term data
$$$$$ |
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Biguanides (metformin)
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Almost no hypoglycemia
Can cause anorexia and weight loss Diarrhea → Falls Contraindication to START metformin SCr ≥ 1.4 (women) and ≥ 1.5 (men) Fluctuating or bump in SCr HOLD metformin Recheck in 1 week Worry about lactic acidosis (very rare) with worsening kidney function; Can use with caution for GFR 30-60ml/min; Do not use if GFR<30ml/min |
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what do you do with metformin when there in a flutuating bump in SCr
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HOLD metformin
Recheck in 1 week |
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Sulfonylureas (chlorpropamide, glyburide, glipizide)
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Avoid Long-acting
Chlorpropamide – on “Beer’s List” to avoid in the elderly Glyburide Observational study in patients over age 65 Hypoglycemia similar with glyburide or chlorpropamide Glipizide – Drug of choice Presence and frequency of hypoglycemia should be assessed with each visit Weight Gain Dementia → skipping meals; doubling doses Falls |
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what is the SU of choice
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Glipizide – Drug of choice
Presence and frequency of hypoglycemia should be assessed with each visit |
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Meglitinides (repaglinide and nateglinide)
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May be used in patients with allergy to sulfonylurea
Weight gain ? Less hypoglycemia Dosed TID 15-30 minutes before meals (Adherence) Prefer repaglinide over nateglinide > A1C lowering with repaglinide Repaglinide 1.5% Natelinide 1.0% Renal Impairment repaglinide metabolized primarily by the liver – OK in patients with renal insufficiency |
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what metaglitinide is prefered
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Prefer repaglinide over nateglinide
> A1C lowering with repaglinide Repaglinide 1.5% Natelinide 1.0% Renal Impairment repaglinide metabolized primarily by the liver – OK in patients with renal insufficiency |
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Thiazolidinediones (rosiglitazone, pioglitazone) advantages
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OK with impaired renal function
Does not cause hypoglycemia Well tolerated |
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Thiazolidinediones (rosiglitazone, pioglitazone) disadvantages
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A1C lowering 0.5-1.4% High cost
Use with caution in patient with congestive heart failure (even well compensated CHF) and known CVD Weight gain, fluid retention, peripheral edema Increased risk of fracture |
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The thiazolidinediones may be considered for some older patients, particularly those with ....
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initial A1C values, if there are specific contraindications to sulfonylureas or if they are not able or willing to consider insulin. They can be given to patients who have impaired renal function, are well tolerated in older adults, and do not cause hypoglycemia
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When are TZDs CI
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thiazolidinediones should not be used in patients with class IIII or IV heart failure. In addition, limited experience, high cost, and concerns regarding fluid retention, congestive heart failure, MI, and fractures limit their usefulness, particularly in the elderly. If a thiazolidinedione is to be used as therapy, pioglitazone is preferred because of the greater concern about atherogenic lipid profiles and a potential increased risk for cardiovascular events with rosiglitazone.
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Meglitinides
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Repaglinide and nateglinide are short-acting glucose-lowering drugs that act similarly to the sulfonylureas and have similar or slightly less efficacy in decreasing glycemia. Meglitinides are pharmacologically distinct from sulfonylureas and may be used in patients who have allergy to sulfonylurea medications. They have a similar risk for weight gain as sulfonylureas but possibly less risk of hypoglycemia. Unlike nateglinide, repaglinide is principally metabolized by the liver, with less than 10 percent renally excreted. Dose adjustments with this agent do not appear to be necessary in patients with renal insufficiency. In addition, repaglinide is somewhat more effective in lowering A1C than nateglinide. Thus, repaglinide could be considered as initial therapy in a patient with chronic kidney disease who is intolerant of metformin and sulfonylureas. Lexi says contra in CrCl <20%
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Alpha-glucosidase inhibitors (acarbose, miglitol)
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Low incidence of hypoglycemia and weight neutral
A1C lowering capacity only 0.5-0.8% and high cost Dosed TID (? Adherence); Only simple sugars to tx hypoglycemia Contraindication in chronic kidney disease GI side effects |
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acarbose
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Acarbose is a less attractive option in this case given its HbA1c-lowering capacity of 0.5-0.8%.[19] In addition, its cost, gastrointestinal side effects such as flatulence, contraindication to its use in chronic kidney disease, and the requirement of premeal dosing limit the utility of this agent.
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DPP-IV inhibitors (sitagliptin)
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Low incidence of hypoglycemia and weight neutral
A1C lowering capacity 0.6-0.8% and high cost Lack of long-term safety Adjust dose in renal insufficiency |
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Exenatide
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Twice daily SQ injections
Nausea, vomiting and diarrhea – dose realted Do not use if est. CrCl <30 ml/min |
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Liraglutide
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Once daily SQ injection
Nausea, vomiting and diarrhea – less persistent than exenatide No dosage adjustment needed with renal insufficiency |
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what class of drug are exenatide and liraglutide
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GLP-1
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Insulin
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Provides a treatment regimen that can be easily titrated to changing physiology in the elderly
There are no physiologic contraindications to insulin (Just have to get the dosing right) |
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Indications for the initiation of Insulin:
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Failure of oral antiglycemic agents
Intolerance to oral antiglycemic agents Comorbid conditions that are contraindications to the use of other antiglycemic agents Acute illness or perioperative period Cost Considerations |
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Points to consider before initiation of Insulin Therapy
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Determining the need to start insulin is not different in older adults than in younger adults
The use of different insulin preparations depends on fasting and daytime blood glucose levels, the patient’s willingness for frequent monitoring of blood glucose, comorbidities, and available resources The patient’s living situation (alone or with caregiver) and nutritional intake should be considered Visual and physical abilities are needed to draw up and inject insulin Cognitive skills are needed to interpret and react to self-monitored glucose readings Individualized glycemic targets to prevent hypoglycemia must be established |
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Insulin Pearls
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Remember 3 F’s = fix fasting first
Basal insulin (glargine, detemir, NPH) target fasting blood sugars Fasting goal is 100-160 mg/dl After Meals goal is <180-250 mg/dl Fasting and after meal goals should be individualized based on: Risk of nocturnal hypoglycemia Hypoglycemia unawareness Other comorbid conditions Living situation |
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Adding and Titrating Basal Insulin
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Treat to Target – Nocturnal Hypoglycemia
33.2% NPH and 26.7% glargine (p = 0.05) Start with 10 U/day bedtime basal insulin and adjust weekly |
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how often is basal insulin adjusted
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weekly
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Mean of self-monitored FPG values from preceding 2 days
>/= 180 mg/dl |
increase by 8 units per day
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Mean of self-monitored FPG values from preceding 2 days
140-180 |
increase by 6 u/day
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Mean of self-monitored FPG values from preceding 2 days
120-140 |
increase by 4 units per day
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Mean of self-monitored FPG values from preceding 2 days
100-120 |
increase by 2 units per day
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what percentage is basal insulin adjusted on a weekly basis
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10-20% dose adjustments with
~ 10% adjustments if near BG goals ~ 20% adjustments if BGs very elevated |
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Injecting of Basal Insulin
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With fasting hyperglycemia – basal insulin in the morning would NOT be the first option
Give Basal Insulin in AM if: Daytime Hyperglycemia Nocturnal Hypoglycemia If it occurs after evening or bedtime administration of insulin despite dose reduction QHS |
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Premixed Insulin
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Those with hyperglycemia around the clock who are not candidates for multiple daily doses of insulin injection
Those with persistent hyperglycemia despite being on a combination of bedtime insulin and oral agents Those who cannot perform frequent blood glucose monitoring Those with a consistent carbohydrate intake who do not miss meals at breakfast and supper Stop the use of insulin secretagogues when starting prandial or premixed insulin |
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Premixed insulin twice daily with breakfast and supper would be a good option for individuals who .......
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fasting and postprandial hyperglycemia. Glipizide should be stopped when twice-daily premixed insulin is used. Currently, there is no strong rationale to favour bedtime insulin alone or in combination with oral agents over twice-a-day premixed insulin therapy. However, many older adults would prefer to have a once-daily injection than twice-daily injections. Premixed insulin preparations are more convenient and less prone to errors in dosing, but they limit flexibility in diet and lifestyle. The premixed insulin analogues are preferable to premixed human insulin preparations because they can be taken within 15 minutes of a meal and have better postprandial coverage.[26] However, they are more costly.
Premixed insulin therapy is initiated at a dose of 10-12 U administered prebreakfast and presupper. The presupper dose is titrated on the basis of fasting blood glucose levels, and the prebreakfast dose is titrated on the basis of presupper levels to achieve the target blood glucose value.[23] |
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Basal and Prandial Insulin Regimen
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Ideal regimen – Mimics endogenous insulin secretion
Not appealing to most older adults and geriatricians: Can be intense and complex Multiple daily injections (4-5/day) Frequent monitoring of blood glucose Skills in carbohydrate counting |
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Paired Testing in DM2:
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Day 1: Check BG before breakfast and 2 hours after breakfast
Day 2: Check BG before lunch and 2 hours after lunch Day 3: Check BG before dinner and 2 hours after dinner |
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Sliding Scale Insulin
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Sliding scale does not decrease fasting or premeal BS and therefore is not effective in keeping BS from rising between meals.
Can cause low BG if given too frequently or in to high a dose Avoid using sliding scale insulin at bedtime to avoid overnight hypoglycemia |
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Sliding Scale regular Insulin
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Dosing - do NOT dose more frequently than every 6-8 hours
Retesting blood glucose – recheck blood glucose 4 hours to make sure BG is coming down (not to re-dose) |
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Sliding Scale aspart, glulisine or lispro
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Dosing - do NOT dose more frequently than every 3-4 hours
Retesting blood glucose – recheck blood glucose 2 hours to make sure BG is coming down (not to re-dose) |
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DO NOT GIVE SLIDING SCALE AT _______
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bedtime
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Converting sliding scale insulin NPH and regular
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Calculate total “sliding scale” insulin requirements over stable 24 hour period
Give 66% of that total daily dose in the AM Give 66% as NPH and 33% as Regular Give 33% of that total daily dose in the PM Give 50% NPH and 50% as Regular Give Regular before Dinner and NPH before bedtime 2/3 in the am and 1/3 in the pm |
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Converting sliding scale insulinglargine and aspart/lispr
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Calculate total “sliding scale” insulin requirements over stable 24 hour period
Give 50% of that total daily dose as glargine Give 50% of that total daily dose as aspart/lispro Give 33% aspart/lispro before each meal (breakfast, lunch and evening meal) |
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Pre-drawn insulin for future use fro patients who are
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Offer more accurate and convenient administration for patients who are
Traveling Eating in restaurants Visually impaired Dependent on others for drawing or mixing their insulin Pre-drawn syringes of a single formulation or pre-mixed insulins may offer more accurate and convenient administration for patients who are traveling, eating in restaurants, or like many of our patients who are visually impaired, or dependent on others for drawing or mixing their insulin. Pre-drawn syringes have been utilized in clinical practice for the advantages listed above; upon consulting with their provider, patients may elected to employ this strategy based a favorable risk-benefit ratio. |
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Pre-drawn insulin for future use
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Closely Monitor glycemic control
Periodically verify mixing technique Pre-drawn syringes should be stored with the needle pointing upward or lying flat Gently roll between the hands prior to administration Patients’ glycemic control should be monitored closely and mixing technique should be verified periodically when pre-drawn syringes are utilized. Pre-drawn syringes should be stored with the needle pointing upward or lying flat so that suspended insulin particles do not clog the needle. All pre-drawn syringes should be gently rolled between the hands prior to administration to warm the insulin and/or re-suspend the particles. |
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Pre-drawn Novolin® NPH and regular insulins
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either as a single formulation or mixture, may be stored for future use if used within 30 days when kept refrigerated
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Pre-drawn Humulin® NPH and regular insulins
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either as a single formulation or mixture, should be kept refrigerated and may be stored for future use within 21 days
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Novolog®, Humalog®, and Lantus® are ____ recommended in pre-drawn syringes for future use
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NOT
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insulin pens
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Turbo Pen: Humulin NPH & 70/30, Humalog, Humalog 75/25 & Mix 50/50
Flex Pen: Novolog, Novolog 70/30, Levemir Solostar: Lantus and Apidra Autopen (Aventis and Lilly) and Disetronic Pen: Cartridge-based pen NovoPen Junior: Cartridge-based pen, ½ unit doses, max dose 35 units Opticlick: Cartridge-based pen, Lantus, Apidra New Pens: Humalog KwickPen, Humalog Memoir, Humalog Luxura HD, NovoPen 3 |
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Meters
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Prodigy Autocode - Patients with visual impairment
talking blood glucose meter Ascensia Breeze2 and Accucheck Compact ® - Patients with dexterity impairment No coding of test strips Pre-loaded “drum or disc” of strips Large display Gives time to add more blood |
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The Prodigy Voice, manufactured by Diagnostic Devices Inc
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is the first completely non-visually accessible talking blood glucose meter.
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The ACCU-CHEK Voicemate blood glucose monitoring system
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manufactured by Roche Diagnostics, is no longer in production because essential meter components became unavailable from their suppliers. However, retailers will continue to sell systems that are in their inventory.
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People With Limited Dexterity and DM
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If you have arthritis or neuropathy, injured or malformed hands, or live with multiple sclerosis, Parkinson’s disease, or muscular dystrophy, simply holding a meter steady or loading a test strip or lancing device can be challenging Home blood glucose monitor w integrated lancing/blood collection (for manual dexterity impairment) The Breeze 2 meter holds a disk that lasts for 10 tests. There are also blood glucose monitoring systems designed especially for use by those with visual or manual dexterity impairments. The monitors used in such systems are identical in terms of reliability and sensitivity to the standard blood glucose monitors described above. They differ by having such features as voice synthesizers, automatic timers, and specially designed arrangements of supplies and materials to enable patients with visual or manual dexterity impairment to use the equipment without assistance.
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Monitoring with DM meds
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Recommended Monitoring
Oral: twice per week, with the times being rotated Insulin: at least twice per day, with times rotated before meals and at bedtime Medical Nutrition therapy/Prediabetes: at least monthly at rotating times, or given quarterly A1C tests Medicare Part B ICD-9 Code: 250.02 (uncontrolled type 2) No insulin: 1x/day Insulin: 4x/day A stable patient on oral therapy may be tested twice per week, with the times being rotated A stable patient on insulin should be tested at least twice per day, with times rotated before meals and at bedtime Residents treated with medial nutrition therapy only should be tested at least monthly at rotation times, or given quarterly A1C tests. Such patients are typically prediabetic patients and very stable |
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Glucocorticoids affect on DM meds
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Hepatic gluconeogenesis
Pancreatic beta cells Peripheral insulin resistance |
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Glucocorticoids affect on DM meds and patients can be put in 3 groups
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Managed with diet modification
Require oral hypoglycemic agents Adding or adjusting insulin |
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rule of thumb with GC and DM meds
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watch for BG to increase or decrease 3-7 days after adjusting steroid dose
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Several mechanisms for Glucocorticoid -induced hyperglycemia have been described.
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Glucocorticoids affect hepatic gluconeogenesis, pancreatic beta cells, and peripheral insulin resistance.
With regard to gluconeogenesis, GC upregulate key regulatory enzymes, including glucose-6-phosphatase and phosphoenolpyruvate carboxylase (PEPCK), that contribute to hyperglycemia In pancreatic beta cells, GC may suppress insulin release from the pancreas. GC may also affect peripheral insulin resistance by inhibiting glucose transporter production in adipose cells as well as in skeletal muscle cells Furthermore, it has been observed that GC raise both fasting blood glucose levels and increase blood glucose in the postprandial period. By understanding these mechanisms of glucocorticoid-induced diabetes, clinicians can target therapy to improve their patients' blood glucose status. |
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Diet-controlled type 2 diabetes
and GC |
Monitor BG once-daily while on GC therapy
Most patients in this category can be managed with regulation of caloric intake. Glipizide may be prescribed once or twice daily. Repaglinide may help with postprandial glucose elevations. Thiazolidinediones not recommended - can take up to 2 weeks to work Metformin and sitagliptin are often not potent enough to rapidly control blood glucose If this is not effective and the patient's fasting blood glucose is elevated, a sulfonylurea, such as glipizide, may be prescribed once or twice daily. If postprandial glucose elevations dominate the clinical picture, a short-acting insulin secretagogue, such as nateglinide (Starlix) or repaglinide (Prandin), may be employed. Thiazolidinediones (TZDs) can take up to 2 weeks to work and therefore are unlikely to be beneficial in this acute setting. Also, metformin is often not potent enough to rapidly control blood glucose and could be |
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Insulin and Steroids
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Patient may need short-term sliding scale insulin if oral therapy has been maximized
If pt on steroids < 2 weeks typically do not adjust insulin or provide pt with low dose supplemental sliding scale insulin to uses as needed If on steroids > 2 weeks and/or having symptomatic high BG will need to add insulin or adjust basal and bolus insulin based on BG |
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Adjusting the total daily dose of insulin when on GC
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Low-dose prednisone (10-20mg/day) increase by 20%
Medium-dose prednisone (21-40mg/day) increase by 30% High-dose prednisone (> 41 mg/day) increase by 50% Key is frequent BG checks and good follow-up while on steroid treatment |
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ABCDEFGs of the Care of the Older Diabetic As
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A-ASA and a tailored A1c: 7% if robust and good life expectancy; 8% for limited life expectancy
ASA - 2011 ADA and USPSTF guidelines GI prophylaxis – ACCF/ACG/AHA Recommendations ASA in patients at high risk for GI adverse events, i.e. patients on dual antiplatelet therapy or with more than 1 of the following risk factors: History of GERD or peptic ulcer, Age > 60 years, steroid use Recommendations: PPI Comments: The use of low-dose ASA increases risk of GI bleeds 2- to 4-fold GI risk increases with ASA dose escalation Enteric-coated ASA doesn’t reduce risk for GI bleeding |
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ABCDEFGs of the Care of the Older Diabetic Bs
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B-Blood Pressure
Balance between JNC goals and orthostasis/falls |
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ABCDEFGs of the Care of the Older Diabetic Cs
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C-Cholesterol and Cognitive screening
Cholesterol – ADA/NCEP guidelines Cognitive Impairment - Older adults are at increased risk Test at initial diagnosis and if any change in diabetes or self-care: Nonadherence with therapy Frequent episodes of hypoglycemia |
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ABCDEFGs of the Care of the Older Diabetic Ds
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D-Depression and Drugs (polypharmacy); Diabetic Education
Depression - associated with poor glycemic control Polypharmacy – increased risk for side effects, drug-drug and drug-disease interactions Increased risk for depression – often goes undetected and undertreated; associated with poor glycemic control |
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ABCDEFGs of the Care of the Older Diabetic Es
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E-Eyes and Exercise
Eyes – Retinopathy, cataracts and glaucoma Cataracts – twice as common in elderly diabetics (38.4 % vs 16.6% in non-diabetics) Glaucoma – three times more common (11.2% in elderly diabetics vs 3.8% in non-diabetics) Exercise – improves insulin sensitivity and decrease fall risk |
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The increased risk of falls in older adults with diabetes is multifactorial
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presence of peripheral and/or autonomic neuropathy, reduced renal function, muscle weakness, functional disability, loss of vision, polypharmacy, comorbidities like osteoarthritis and even mild hypoglycemia may contribute to falls in frail older adults
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ABCDEFGs of the Care of the Older Diabetic Fs
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F-Falls and Foot Care; Flu (and pneumococcal) vaccines
Falls – multifactorial; increased risk with intensive glucose control Foot Care - Vascular and neurologic disease 32% of diabetics overall have neuropathy 50% of patients > 60 years of age have neuropathy > 30% of older diabetics cannot see or reach their feet |
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ABCDEFGs of the Care of the Older Diabetic Gs
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G-Geriatric Giants (all geriatric syndromes can be affected, e.g. urinary incontinence)
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ABCDEFGs of the Care of the Older Diabetic S
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s-Stop Smoking!
Independent risk factor for all-cause mortality – cardiovascular disease |
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Prevention/Delay of Type 2 Diabetes
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metformin and diet/lifestyle modifications
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Prevention/Delay of Type 2 Diabetes metformin benefits
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Decreased incidence of diabetes by 31% in DPP; may help decrease weight; CV benefits
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Prevention/Delay of Type 2 Diabetes metformin disadvantages
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Not as effective in patients > 60 years old, lower BMI, and/or higher FPG, or PPG; Caution if CrCl <60ml/min
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Prevention/Delay of Type 2 Diabetes lifestyle modifications advantages
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Decreased incidence of diabetes by 58% in DPP; More effective than pharmacologic therapy; Lower cost
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Prevention/Delay of Type 2 Diabetes lifestyle modifications disadvantages
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Patient adherence and maintenance of lifestyle modifications poor
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In the Diabetes Prevention Program (DPP) trial,
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metformin decreased incidence of diabetes by 31% (95% confidence interval 17% to 43%) in comparison to placebo. However, Metformin was not as effective in reducing the incidence of T2DM in older participants, those with lower BMI, or higher fasting plasma glucose and potsprandial glucose levels
The American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) consensus guidelines recommend lifestyle modification as first-line therapy for all patients with pre-diabetes, regardless of whether medications will be administered. Even a modest loss of body weight (7%) can significantly reduce the likelihood of developing diabetes. Data analysis of results from the Diabetes Prevention Program (DPP) trial shows that there is a 16% reduction in the risk of diabetes for every one kilogram of weight loss. |
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Summary of Dm in the elderly
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Interventions that target cardiovascular risks are more likely to reduce morbidity and mortality than intensive blood glucose management for most older adults
High-functioning older adults who are motivated and newly diagnosed with diabetes are most likely to benefit from intensive glucose control to prevent microvascular complications The type of regimen chosen to treat hyperglycemia should take into consideration cognitive skills, physical and visual limitations, living situations, available resources, cost issues and comorbidities. Start low and go slow to avoid hypoglycemia which manifests differently in older adults |
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what is happening to the us population
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more and more of the population is >65 due to the baby boomers
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do men or women live longer
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women and we are healthier as we age so we cost less
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Healthy People 2020
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Older Adults: Specific Objectives for prevention
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Older Adults: Specific Objectives for long term services and supports
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Example Objectives for healthy peps 2020
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U.S. Preventive Services
Task Force looks at what 3 areas for the elederly |
screening
modificaiton prevention |
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where does the pharmacist fit in to screening
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to detect disease
to limit illness |
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what disease do we screen for
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1. Condition associated with morbidity
2. Asymptomatic period where treatment results in better outcome than if treated later 3. Acceptable treatment available (not just drugs) 4. Incidence of population high enough to justify (not rare disease states) screening 5. Sensitive screening test available at reasonable cost |
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leading cause of death in those >/=65
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screeing should included these disease states.....
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Screening tests: CAD and CVD
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Screening for DM type 2
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2008 USPSTF recommends that all
asymptomatic adults with BP >135/80 mmHg be screened for Type 2 DM every 3 years |
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is everyone screened for type 2 DM
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no because only those with a BP greater than 135/80 is at risk
the risk of DM is low when BP is less then that so it is not cost effective |
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obesity screening
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Screening: Breast Cancer
ACS Guidelines |
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Screening: Cervical Cancer
ACS Guidelines |
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what does a total hysterectomy consist of
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removal fo the uterus and cervix
ovaries are optional |
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screening cognitive function
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(USPSTF if suspicion)
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screening for depression
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(USPSTF if resources)
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Screening: Prostate Cancer
ACS Guidelines |
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Screening: Colon Cancer
ACS Guidelines |
1. Colonoscopy Q10 yrs
2. Flexible sigmoidoscopy Q5yrs 3. Double-contrast barium enema Q5 yrs 4. CT colonography (virtual colonoscopy) Q5 years (this option does not give the option of a biopsy if there is a polyp) |
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Colon Cancer Screening in the Elderly
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screenings for visual impairment
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screening for hearing impairment
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screening for osteoprosis
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baseline DEXA >/= 65 (and Q2yrs as
appropriate) in women (USPSTF 2011) |
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other issues to screen for
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screening for falls
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screening for funcitoning
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Which of the following statements about
screening is correct? A. Everyone should be screened for Type 2 DM B. Only diabetics should be screened for obesity C. A colonoscopy Q20 yrs is appropriate for colon cancer screening D. Elderly should be screened to make sure they can complete activities of daily living |
D. Elderly should be
screened to make sure they can complete activities of daily living |
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WHERE DOES THE
PHARMACIST FIT IN in to counseling? |
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counseling: nutrition
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what nutritional state are we most worried about
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uundernourished
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Counseling: Healthy Diet
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counseling: exercise
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Cardiorespiratory fitness is a significant predictor of
mortality in older adults |
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U.S. Dept Health and Human Services
2008 Physical Activity Guidelines |
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exercise options for older adults
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counseling: tobacco cessation
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counseling: dental health
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counseling: sexual behavior
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Which of the following statements about
counseling is correct? A. Dietary counseling needs to be provided by a dietician B. It is too late for the elderly to benefit from smoking cessation C. Counseling on dry mouth should include instructions to see a dentist regularly D. Exercise counseling rarely benefits the elderly |
C. Counseling on dry mouth
should include instructions to see a dentist regularly |
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WHERE DOES THE
PHARMACIST FIT IN with prevention? |
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Injury: Falls prevention
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what is the mortality rate of hip fractures
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30%
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risk factors for driving
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risk factors for burns
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Risk factors for burns
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injury prevention falls
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injury prevention driving
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injury prevention fires/burns
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additional items for injury prevention
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Additional
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USPSTF 2009 Aspirin Guidelines primary or secondary prevention
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primary
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USPSTF 2009 Aspirin Guidelines age cut off
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>79
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USPSTF 2009 Aspirin Guidelines recommendaiton for those >80 yo
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none but does not mean cannot use must look at risk vs. benefit
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USPSTF 2009 Aspirin Guidelines risk at which CVD events prevented (benefits) exceeds harms in men (know)
|
10 year CHD risk
60-69 yo >/= 9% 70-79 yo >/= 12% |
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USPSTF 2009 Aspirin Guidelines risk at which CVD events prevented (benefits) exceeds harms in women (know)
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10 year stroke risk
60-69 >/=8% 70-79 >/= 11% |
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Prevention: Chemoprophylaxis
ASA primary prevention doses and guidelines |
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Prevention: Chemoprophylaxis
ASA secondary prevention doses and guidelines |
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Prevention: Chemoprophylaxis antioxidants
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prevention: immunization
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Which of the following statements about disease
prevention is correct? A. Routine driving tests are not important B. Aspirin dosing needs to be 325mg/d to be effective C. Vitamin C is helpful for preventing CVD D. The pneumococcal vaccine should be offered to all eldely |
D. The pneumococcal
vaccine should be offered to all eldely |
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Conclusions on screening, counseling and prevention
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dont forget
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the cases from 2/28
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