ADA 2012 Conference, presented by Jamehl Demons, MD
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Diabetes – Risk factor for cognitive impairment
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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
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Does treating DM prevent dementia?
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AGS guidelines for care of the older people with
DM
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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%
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Stages of Dementia
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Mild
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Stage 1: no difficulty
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Stage 2: forgetting location of objects
o
Moderate
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Stage 3: difficulty traveling to new places
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Stage 4: IADLS
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Stage 5: needs assistance to choose clothing
o
Severe
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Stage 6: need help with ADLS
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Stage 7: loss of speech, mobility, change in
consciousness
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Dementia patients in nursing homes
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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
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Individualized treatment plan
o
Multidisciplinary team approach
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Assessment of prior treatment approach
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Cognitive status
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Ability to note hypoglycemia symptoms
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Hyperglycemia
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Dehydration
§
Increased risk in elderly; decreased intake,
decreased thirst mechanism
o
Visual disturbances
o
Confusion
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Hypoglycemia
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Risk factors
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Age
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Renal insufficiency
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Long acting oral agents
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Poor nutrition – decreased muscle mass
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CHF
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Recent hospitalization
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Polypharmacy
o
Decreased balance and falls
o
Cardiovascular events may be precipitated in
prolong hypoglycemia
o
Altered renal function may later breakdown of
medications
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Persons
with dementia are less able to communicate symptoms
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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
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Treatment guideline (American Medical Directors
Association)
o
Treatment goals should be more relaxed if:
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Severe dementia
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Life expectancy < 5 years
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Anorexia or inability to feed self
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Malignancy
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Lack of awareness of hypoglycemia
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Nursing Home management of DM
o
Insulin sliding scale not effective
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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
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Step
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Insulin
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Oral Medications
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Advance to Next stop when A1c > 7.0% and:
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1
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Start glargine, detemir or evening NPH.
Titrate dose until Fasting PG < 120mg/dL (6.7mmol/L)
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Continue all
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Fasting PG at target but prandial or postprandial is
higher than target
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2
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Add bolus insulin before main meal (usually evening meal)
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Continue metformin
Continue TZDs?
Stop SUs?
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Capillary glucose before main meal is higher than fasting
value
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3
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Add bolus insulin before a second meal (usually first meal
of the day)
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Same
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Capillary glucose highest after third (uncovered) meal
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4
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Add bolus insulin before remaining meal.
Adjust dosages based on home PG
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Same
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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.
