Mr. AH is a 70-year-old man who was diagnosed with T2DM 10 years ago. He was initially treated with lifestyle management and metformin. 3 years later, his doctors advised him to add long acting basal insulin analogue to metformin, reached to 40U/day . Other current medical conditions include: hypertension, hypothyroidism, and mild osteoporosis without fracture history. Current medications; Metformin 1000 mg bid, long acting basal insulin analogue 40U/day , Candesartan 16 mg qd, Alendronate 70 mg once weekly, Levothyroxine 100 mg qd. Physical exam: BMI 26 kg/m2, BP 140/80 mmHg, otherwise unremarkable. His current FPG 140 mg/dL and HbA1c 8.5%. Kidney and liver functions are normal.

1. Case Study of Elderly patient
with Long Standing Diabetes
Prof. Alaa Wafa

2. Mr. AH
 Mr. AH is a 70-year-old man who was diagnosed with T2DM 10 years
ago. He was initially treated with lifestyle management and metformin.
 3 years later, his doctors advised him to add long acting basal insulin
analogue to metformin, reached to 40U/day .
 Other current medical conditions include: hypertension, hypothyroidism,
and mild osteoporosis without fracture history.
 Current medications; Metformin 1000 mg bid, long acting basal insulin
analogue 40U/day , Candesartan 16 mg qd, Alendronate 70 mg once
weekly, Levothyroxine 100 mg qd.
 Physical exam: BMI 26 kg/m2, BP 140/80 mmHg, otherwise
unremarkable.
 His current FPG 140 mg/dL and HbA1c 8.5%. Kidney and liver
functions are normal.

3. Does his age should be a
concern and why ?

4. What Kind of Care should this
patient receive specifically ?

5. Q1. Based on the patient's age, physical examination, history,
and laboratory values, what is an appropriate glycemic target
for him?
A. 9.0%
B. 8.0%
C. 7.0%
D. 6.5%
E. 7-8%

6. Q2. Do you think increasing insulin dose is the best
choice for Mr. A.H.?
A. Yes
B. No

7. Data Support Benefits of
Vildagliptin in Newly Diagnosed
Diabetes Or Patients with Short
History of Diabetes
Do you think that, Using Vildagliptin is useful
with patient with longstanding diabetes?

8. Adapted from http://www.indexmundi.com/egypt/demographics_profile.html , https://www.cia.gov/library/publications/the-world-factbook/geos/eg.html , http://en.worldstat.info/World
accessed 22-2-2014

9. 0.2
2.1
7.9
17.6
14.9
0
2
4
6
8
10
12
14
16
18
20
12-19 20-39 40-59 60-74 ≥75
National Health and Nutrition Examination Survey (NHANES) 2005-2006.
T2DM=type 2 diabetes mellitus.
Adapted from Cowie CC, et al. Diabetes Care. 2009; 32: 287–294.
%
Age (years)
Worldwide, the
elderly population in
developed regions
will nearly double by
2050

10. 2013
≥60 Years
≤60 Years
International Diabetes Federation. Managing Older People with Type 2 Diabetes Global Guidelines.
http://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Older%20People.pdf accessed 15-12-2013
2050
≥60 Years
≤60 Years
These changes present significant challenges to welfare, pension, and
healthcare systems in both developing and developed nations

11. • Diabetes-related complications are the major
causes of morbidity, disability and mortality in
older patients with type 2 diabetes:
• There is now overwhelming evidence that the
level and duration of glycemia influences the
development of diabetes-related complications
Sinclair 2004. Clinical guidelines for type 2 diabetes mellitus. EDWOP 2004
Microvascular:
Neuropathy,Retinopathy,Nephropathy
Macrovascular: Cardiovascular disease,
Stroke

12. • The Diabetes and Aging Study:
To contrast the rates of diabetes complications and mortality
across age and diabetes duration categories.
• Design:
This cohort study (2004-2010) included 72 310 older (60 years)
patients with type 2 diabetes enrolled in a large, integrated
health care delivery system.
Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study.
2013 Dec 9. [Epub ahead of print]

13. 0
5
10
Age 60-69 y
Age 70-79 y
Age ≥80 y
Eventsper1000Person-years
Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study.
2013 Dec 9. [Epub ahead of print]
*P Value < 0.0001
All groups VS No morbidities

14. 0
20
40
60
80
100
120
Age 60-69 y
Age 70-79 y
Age ≥80 y
Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study.
2013 Dec 9. [Epub ahead of print]
Eventsper1000Person-years
*P Value < 0.0001
All groups VS No morbidities

15. Cost in US$ millions
Institutional care Outpatient care
Outpatient medicines
and supplies
<45 years 45-64 years ≥65 years
American Diabetes Association. Diab Care 2008;31:596-615

16. 1. Stratton et al. BMJ 2000 ; 321 : 405-12 2. Turner et al. JAMA 1999 ; 281 : 2005-12
-43%
-37%
-21%
-50%
-40%
-30%
-20%
-10%
0%
Reduction in long-term complication with every 1% reduction
in HbA1c
Reduction
in peripheral
vascular disease
Reduction
in Microvascular
disease
Reduction
in death related
to type 2 diabetes

17. Ageing, diabetic microvascular and macrovascular complications,
hyperglycaemia, hypoglycaemia, multiple morbidity and lack of
social support are risk factors for the geriatric syndromes
T2DM=type 2 diabetes mellitus.
Araki A, Ito H. Geriatr Gerontol Int. 2009; 9: 105–114.
Ageing
Diabetes
complications
Comorbidity
Lack of social
support
Hyperglycaemia
Hypoglycaemia
Increased
mortality
Depression
Disability
Malnutrition
Urinary
incontinence
Cognitive
impairment
Falling
Risk factors Geriatric
syndromes

18. Cognitive decline
Depression
Intolerance
to side effects
PoorGlycemicControl
“Frailty”
Co-morbidities
Poly-pharmacy
Compromised
renal function
1. Gregg et al. Arch Intern med 2000 ; 160 : 174-80; 2. Ott et al. Diabetologia 1999 ; 53 : 1937-42
3. Rockwood et al. Drugs Aging 2000 ; 17 : 295-302; 4. Wolff et al. Arch Intern med 2002 ; 162 : 2269-76
5. Shorr et al. Arch Intern med 1997 ; 157 : 1681-6

19. • Advanced age
• Recent hospitalization
• Intercurrent illness
• Chronic liver, renal or
cardiovascular disease
• Endocrine deficiency
(thyroid, adrenal, pituitary)
• Loss of normal counter-
regulation
• Hypoglycaemic
unawareness
SU=sulfonylurea.
Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.
I. Patient risk factors
• Poor nutrition or fasting
• Prolonged physical
exercise
• Alcohol (ethanol)
• Use of SU and / or insulin
• Drug interactions with SUs
III. Drug risk factors
II. Lifestyle risk factors

20. T2DM=type 2 diabetes mellitus.
Greco D, et al. Exp Clin Endocrinol Diabetes. 2010; 118: 215–219.
Decompensated
diabetes
39%
Intercurrent
illness
14%
Acute
cardiovascular
events
13%
Chronic
complications
of diabete
s
1
Severe
hypoglycaemia
17%

21. MAOI=monoamine oxidase inhibitor; SU=sulfonylurea.
Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.
Displacement of
SUs from the
plasma proteins
Reducing the
hepatic
metabolism of
SUs
Decreasing the
urinary excretion
of SUs or their
metabolites

22. Cardiovascular
complications3
Weight gain by
defensive eating5
Coma3
Increased risk
of car accident6
Hospitalisation
costs4
Loss of
consciousness3
Increased risk
of seizures3
Death2,3
Increased risk
of dementia1
1Whitmer RA, et al. JAMA. 2009; 301: 1565–1572; 2Bonds DE, et al. BMJ. 2010; 340: b4909;
3Barnett AH. Curr Med Res Opin. 2010; 26: 1333–1342; 4Jönsson L, et al. Value Health. 2006; 9: 193–198;
5Foley JE, Jordan J. Vasc Health Risk Manag. 2010; 6: 541–548; 6Begg IS, et al. Can J Diabetes. 2003; 27: 128–140;
7McEwan P, et al. Diabetes Obes Metab. 2010; 12: 431–436.
Reduced
quality of life7
Hypoglycaemia

23. 1. Market research, data on file, Novartis.
2. Cryer PE. Diabetes 2008; 57: 3169-76
Hypoglycemia
Other factors
Glycemic targets
Managementchallenges

24. • Glycemic targets for elderly with long-standing or
more complicated disease should be less
ambitious than for the younger, healthier
individuals
• If lower targets cannot be achieved with simple
interventions, an HbA1c of 7.5–8.0% may be
acceptable, transitioning upward as age
increases and capacity for self-care decline

26. Older adults who are functional, cognitively
intact, and have significant life expectancy
should receive diabetes care with goals
similar to those developed for younger
adults. (E)
Glycemic goals for some older adults
might reasonably be relaxed, using
individual criteria, but hyperglycemia
leading to symptoms or risk of acute
hyperglycemic complications should be
avoided in all patients. (E)

27. ADA 2014: Treatment Goals
according to health status