ADA 2012 Conference, presented by Jamehl Demons, MD
-
Diabetes – Risk factor for cognitive impairment
o
Known risk factors for cerebrovascular disease
§
RR 1.51 for developing vascular dementia
o
DM and Alzheimer’s dementia – RR 1.21 for AD (10
out of 19 studies showed it was a risk factor
o
DM associated with cognitive decline
-
Does treating DM prevent dementia?
-
AGS guidelines for care of the older people with
DM
o
Importance of individualized goal-setting
o
Frail older adults and life expectancy < 5
yrs
§
Risks of intensive glycemic control may outweigh
benefits
§
Consider HbA1c target of 8%
-
Stages of Dementia
o
Mild
§
Stage 1: no difficulty
§
Stage 2: forgetting location of objects
o
Moderate
§
Stage 3: difficulty traveling to new places
§
Stage 4: IADLS
§
Stage 5: needs assistance to choose clothing
o
Severe
§
Stage 6: need help with ADLS
§
Stage 7: loss of speech, mobility, change in
consciousness
-
Dementia patients in nursing homes
o
Most are in severe stages of disease
o
Frail: accumulation of multiple chronic
illnesses associated with vulnerabilities including but not limited to dementia
and cognitive impairment
o
Poor life expectancy: average life expectance
from diagnosis 4.5 years
-
Individualized treatment plan
o
Multidisciplinary team approach
o
Assessment of prior treatment approach
§
Cognitive status
§
Ability to note hypoglycemia symptoms
-
Hyperglycemia
o
Dehydration
§
Increased risk in elderly; decreased intake,
decreased thirst mechanism
o
Visual disturbances
o
Confusion
-
Hypoglycemia
o
Risk factors
§
Age
§
Renal insufficiency
§
Long acting oral agents
§
Poor nutrition – decreased muscle mass
§
CHF
§
Recent hospitalization
§
Polypharmacy
o
Decreased balance and falls
o
Cardiovascular events may be precipitated in
prolong hypoglycemia
o
Altered renal function may later breakdown of
medications
-
Persons
with dementia are less able to communicate symptoms
-
Nutritional intake
o
Variable intake – may require adjustments to
medications
o
Dysphagia
§
Often less hydrated leading to renal
insufficiencies
§
Pre-mixed thickened foods have increased
carbohydrate load
o
Tube feeding
§
Adjust the formula to provide low carbohydrate
load
-
Treatment guideline (American Medical Directors
Association)
o
Treatment goals should be more relaxed if:
§
Severe dementia
§
Life expectancy < 5 years
§
Anorexia or inability to feed self
§
Malignancy
§
Lack of awareness of hypoglycemia
-
Nursing Home management of DM
o
Insulin sliding scale not effective
§
More hypoglycemia by treating blood sugar now
based on prior treatment rather than future need
§
Insulin sliding scale is still be used (54% in
chart review of 5000 NH pts)
Starting insulin without sliding scale
|
Step
|
Insulin
|
Oral Medications
|
Advance to Next stop when A1c > 7.0% and:
|
|
1
|
Start glargine, detemir or evening NPH.
Titrate dose until Fasting PG < 120mg/dL (6.7mmol/L)
|
Continue all
|
Fasting PG at target but prandial or postprandial is
higher than target
|
|
2
|
Add bolus insulin before main meal (usually evening meal)
|
Continue metformin
Continue TZDs?
Stop SUs?
|
Capillary glucose before main meal is higher than fasting
value
|
|
3
|
Add bolus insulin before a second meal (usually first meal
of the day)
|
Same
|
Capillary glucose highest after third (uncovered) meal
|
|
4
|
Add bolus insulin before remaining meal.
Adjust dosages based on home PG
|
Same
|
-
|
NPH=neutral protamine Hagedorn; PG=plasma glucose,
SUs=sulfonylureas, TZDs=thiazolidinediones
Adapted from Karl DM. The use of bolus insulin and advancing
insulin therapy in type 2 diabetes. Curr Diab Rep. Philadelphia. Current
Medicine Group, LLC. 2004
J Am Med Dire Assoc 2007;8:502-10.
The sad reality of dementia is that the dementia patient gradually starts to forget. At first it seems like stress or fatigue may be the cause, but as the forgetfulness increases and other symptoms become evident the dementia caregiver may become nervous about some of the important information that could be lost in their loved one's memory.
ReplyDeleteDementia Clinic