Do Not Harm: Special Considerations In The Diabetic Frail Elderly Patient

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 786-805-Diabetes & Obesity Therapeutics
Bench to Bedside
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-805
Halis Sonmez*1, Konstantinos Leventakos2 and Nadia Marsh3
1George Washington University, Washington, DC, 2Medstar Washington Hospital Center, Washington, DC, 3Geriatrics and Extended Care, Department of Veterans Affairs Medical Center, Washington, DC, United States., Washington
Introduction: More than 25% of the US population over 65 has diabetes mellitus (DM).  The elderly population will double in the next four decades, and DM will triple. DM in older adults is associated with higher morbidity, mortality, and financial burden. Despite the high prevalence of diabetes in this group, they have often been excluded from randomized controlled trails. (Especially those over 75). There is a paucity of evidence to determine DM management strategies for these patients. Current guidelines are based on expert opinion and do not address the impact of multiple comorbidities or psychosocial variables.

1st case:  76 yo man with hx of DM for 20 years, peripheral and autonomic neuropathy, ESRD on HD, CAD, HTN,  s/p B/L BKA, and gout presents with uncontrolled DM. He was prescribed insulin glargine (IG) 10 units TID, and insulin aspart (IA) sliding scale. He has been using (IG) and (IA) as a sliding scale but does not know the insulin doses secondary to cognitive impairment. He also has hypoglycemia unawareness. He presents with repeated ER visits for hypoglycemia.

2nd case:  83 yo veteran with hx of DM for 30 years, peripheral neuropathy, HTN, CHF, CAD, CVA, metastatic prostate cancer, glaucoma, and poor appetite with a 23 lb weight loss over 5 months. He is under hospice care. He was prescribed (IG) 80 units BID and (IA) 5 units BID.   The hospice physician decreased IG dose to 15 units due to severe hypoglycemia, blood sugars were erratic, alternating between hyper and hypoglycemia.

Conclusion: DM management in elderly people is complex, and the evidence base is lacking for treatment in this population. Due to multiple factors: cognitive deficits and dementia, (leading to inappropriate doses of hypoglycemic agents), renal disease (causing decreased clearance  of insulin leading to hypoglycemia),  visual and auditory impairment (causing errors in self administration of drugs), polypharmacy (causing  adverse effects of hypoglycemic agents and higher risk of patient errors), decreased po intake at the-end-of-life (causing dehydration and hypoglycemia), and lack of family support (leading to irregular meal preparation and risk for hypoglycemia.) Due to the impact of multiple comorbidities and social factors, there is a need to individualize diabetic therapy in the frail older person to avoid hypoglycemia, while maximizing quality of life.  This requires a multidisciplinary approach, as well as more research in this vulnerable population.

Nothing to Disclose: HS, KL, NM

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