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Diabete ed anziano - CecchiniCuore.org
Diabete ed anziano
County-level Estimates of Diagnosed Diabetes for
Adults aged ≥ 20 years: United States 2007
Modificato da www. CDC.gov
Based on data derived from the National Health Interview Survey
(NHIS) and the Third National Health and Nutrition Examination
Survey (NHANES III), the CDC estimated that in 2000, the percentage of
adults with diabetes was 2.5% among 20 to 44 year-olds, 12.1% among
45 to 64 year-olds, 21.6% among 65 to 74 year-olds, and 18.5% among
those over 75.
The third National Health and Nutrition Examination Survey (NHANES III) was a
national examination study conducted in the United States with the goals of:
estimating the prevalence of selected diseases and risk factors; estimating
population reference distributions of certain health parameters; documenting
and investigating reasons for secular trends in selected diseases and risk
factors; contributing to an understanding of disease etiology; and investigating
the natural history of selected diseases. The NHANES III sample was selected
from 81 counties between 1988 and 1994.
Future Prevalence
Every 8 Seconds....
...a Baby Boomer turns 60.
By 2015, nearly 15% of our
population
will be over 65 years of age
Last time I watched was
Fonte: The American Geriatrics Society
Prevalence of type 2 diabetes by age from the Third National
Health and Nutrition Examination Survey (NHANES III). The
prevalence
of type 2 diabetes increases with advancing age. More than
20% of adults aged 60–74 yr have type 2 diabetes, including those
previously diagnosed with diabetes and those newly diagnosed
by
fasting (FPG) or oral glucose tolerance test (OGTT) criteria.
In italia…
Per quanto riguarda il diabete, i dati riportati nell’annuario
statistico Istat 2006 indicano che è
diabetico il 4,5% degli italiani (4,6% le donne e 4,3% gli
uomini). Numeri che segnano un aumento
rispetto all’indagine multiscopo del 1999-2000, secondo cui
era diabetico il 3,7% degli italiani (4%
• le donne e 3,5% gli uomini). In Italia, i pazienti diabetici
noti sono
• attualmente circa 2.200.000 e saliranno nel 2025 a
3.300.000
• Al contrario, i grandi studi di intervento sia sul diabete
tipo 1
• (DCCT), sia sul diabete tipo 2 (UKPDS) hanno
dimostrato che il mantenimento di un adeguato
• compenso metabolico, grazie a schemi intensivi di
trattamento, è in grado di ridurre l’incidenza
• delle complicanze. Una strategia di intervento, oramai
ineludibile, è quella della Gestione Integrata
• del paziente diabetico (individuabile nel “care
management program” della letteratura
• internazionale).
• Goals of therapy for elderly diabetic patients should
include an evaluation of their functional status, life
expectancy, social and financial support, and their own
desires for treatment. A full geriatric assessment
performed before establishing any long-term diabetes
therapy may aid in identifying potential problems that
could significantly impair the success of a given therapy.
Often, elderly patients have cognitive impairments,
limitations in their activities of daily living, undiagnosed
depression, and difficult social issues that need to be
addressed. The ideal HbA1c target of <7% may be
difficult to achieve in the elderly, but is recommended for
all adults. Research is lacking regarding the benefit of
tight control in the oldest elders (>80 years of age). Major
large prospective trials to date have not reported
conclusive data on intensive blood glucose control and
• improved vascular endpoints for the geriatric population.
Diabetes is associated with lower levels of cognitive
functioning and
• greater cognitive decline in elderly.
Nell’anziano si hanno alcune
caratteristiche peculiari, dovute
sia a cambiamenti di tipo
antropometrico che
fisiopatologico:
Aumento della massa adiposa
Riduzione della massa magra
Ridotta risposta della beta
cellula
boh
Model for age-related hyperglycemia.
AJP-Endocrinol Metab • VOL 284 • JANUARY 2003 •
www.ajpendo.org
Multiple risk factors for type 2
diabetes associated with aging predispose
older adults to develop glucose
intolerance and increased insulin
resistance.
However, in elderly humans,
β-cell function is impaired, and
compensatory
hyperinsulinemia does not
occur. With further loss of β -cell function,
impaired glucose tolerance (IGT)
and type 2 diabetes develop.
Valutazione multidimensionale
del soggetto diabetico anziano
• BADL (Katz, Barthel)
• IADL (Lawton-Brody)
• Funzioni cognitive (MMSE, SPMSQ)
• Stato affettivo (GDS)
• Comorbidità (indice di Charlson)
• Stato nutrizionale (MNA)
• Supporto sociale
EUGMS Linee Guida Cliniche per il Diabete Mellito Tipo 2
Gruppo di Lavoro Europeo sul Diabete nell’Anziano 2001-2004
50% degli anziani diabetici sono
ignari di esserne affetti
Sintomi dell’iperglicemia
raramente presenti
Deterioramento cognitivo
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Il diabete è associato a declino cognitivo / demenza
Il medico dovrebbe sempre valutare lo stato cognitivo
del paziente diabetico anziano usando un test
standardizzato nel corso della valutazione iniziale e
in caso di peggioramento delle condizioni cliniche
Un peggioramento dello stato cognitivo o funzionale
dovrebbe essere considerato di per sé come un
peggioramento delle condizioni cliniche (evidenza IIIA)
California Healthcare Foundation/American Geriatrics
Society Panel on improving care for elders with diabetes
JAGS 2003
Obiettivi del trattamento del diabete
IPOGLICEMIA
REAZIONI
AVVERSE DA
FARMACI
GARANTIRE LA
QUALITA’
DELLA VITA
pREVENZIONE
COMPLICANZE
A BREVE
TERMINE
PREVENZIONE
COMPLICANZE
A LUNGO
TERMINE (?)
For elderly patients who require medical therapy, the following options are available.
1. Alpha-glucosidase inhibitors (e.g., acarbose [Precose] and miglitol [Glyset]). These
agents delay digestion of complex carbohydrates and disaccharides. Although less
effective than other agents, they should be considered in all elderly patients with
mild diabetes. Gastrointestinal side effects may limit therapy or may benefit
those who suffer from constipation. Liver functioning may be impaired at high
doses, but this has not been a clinical problem.
•
2. Biguanides (e.g., metformin [Glucophage]). The benefit of metformin in the
elderly is that it does not cause hypoglycemia when used independently. However,
it is used with caution in the elderly because it can cause anorexia and weight
loss.Before starting therapy, all elderly patients should have their creatinine
clearance calculated. Serum creatinine is a poor correlate because of low muscle
mass in the elderly. Metformin should not be administered if the creatinine
clearance is <60 mg/dl.
•
3. Thiazolidinediones (e.g., rosiglitazone [Avandia] and pioglitazone [Actos]). These
are true insulin sentisitizers and enhance insulin effects by activating the PPAR
alpha receptor.18 Rosiglitazone has been shown to be safe
•
and effective in elderly patients. It does not cause hypoglycemia. However, it
should be avoided in patients with heart failure. Thiazolidinediones are
comparatively expensive drugs, but for elderly patients who can afford them,
•
they are potentially very useful.
•
4. Sulfonylureas (e.g, glipizide [Glucotrol], glyburide [Micronase, Diabeta, Glynase])
and other types of secretagogues (e.g., repaglinide [Prandin] and nateglinide
[Starlix]). Traditional sulfonylureas are still widely used as first-line therapy.
First-generation agents such as chlorpropamide should be avoided in the elderly
because of their long half-life and increased propensity for hypoglycemia in the
elderly. Although sulfonylureas can cause
•
hypoglycemia in the elderly, the incidence is relatively low if shorter- acting
agents are used.20,21
•
Repaglinide is unrelated to the sulfonylureas but also promotes insulin secretion
from pancreatic -cells. Unlike with sulfonylureas, in the absence of exogenous
glucose, insulin release is lessened with repaglinide. Nateglinide is unrelated to the
sulfonylureas and repaglinide, but it also acts on pancreatic –cells as an insulin
secretagogue. Both repaglinide and nateglinide are used around meal times and are
short-acting, which may lessen the risk of hypoglycemia. With the exception of
nateglinide, insulin secretagogues should be used with caution in patients with
renal dysfunction. All insulin secretagogues should be avoided in those with liver
disease.
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Sicuramente però tra le principali
cause di diabete nel paziente anziano dobbiamo
annoverare:
1) cause antropometriche età dipendententi;
2) variazioni età-dipendenti dello stile di vita;
3) cause iatrogene;
4) cause neuro-ormonali.
Per quanto riguarda le cause antropometriche con
l’avanzare dell’età si assiste ad un progressivo rimodellamento
della composizione corporea con
una riduzione della massa magra (metabolicamente
attiva) ed un aumento assoluto e relativo del
tessuto adiposo. Tale ridistribuzione età correlato
dei rapporti tra massa magra e tessuto adiposo
crea una situazione sfavorevole dal punto di vista
metabolico che sicuramente è foriera di alterata
omeostasi glicemica.
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Insulin. The risk of severe hypoglycemia
associated with insulin
increases with age.5,22 Initiation of
insulin in elderly type 2 diabetic
patients should be done with the
involvement of a multidisciplinary
team. A complete geriatric
assessment should be performed
first to assure that patients can
comply with their regimens and
to identify potential complicating
factors. If there are identified
caregivers, provisions for adequate
respite programs should be
offered to avoid caregiver
burnout.
• Third National Health & Nutrition
Examination Survey Public health A
population-based survey conducted by the
National Center for Health Statistics,
designed to assess the health and
nutritional status of the noninstitutionalized
Americans
•
The third National Health and Nutrition Examination Survey (NHANES III) was a
national examination study conducted in the United States with the goals of:
estimating the prevalence of selected diseases and risk factors; estimating
population reference distributions of certain health parameters; documenting
and investigating reasons for secular trends in selected diseases and risk
factors; contributing to an understanding of disease etiology; and investigating
the natural history of selected diseases. The NHANES III sample was selected
from 81 counties between 1988 and 1994. Approximately 40,000 people >2
months old were selected to be interviewed and have a physical examination in
a mobile examination center. Accordi
•
•
The Centers for Disease Control and Prevention (CDC) has compiled data
on diabetes in the United States obtained from several surveys, including
the National Health Interview Survey (NHIS), the third National Health and
Nutrition Examination Survey (NHANES III), the National Hospital Discharge
Survey, and surveys conducted through the Behavioral Risk Factor
Surveillance System (BRFSS). Based on data from these sources, the CDC
estimates that 17 million people, or 6.2% of the population, had diabetes in
2000. A third of these cases were undiagnosed. Almost 9% of people >20
years old and 20.1% of people >65 years old had diabetes.
The estimated worldwide prevalence of diabetes in 1997, derived from
World Health Organization (WHO) data, was 124 million people, with the
majority (97%) having type 2 diabetes. According to the same projections,
the number of people with diabetes is expected to increase to 221 million in
2010. Other less conservative projections by King et al used WHO data
combined with demographic estimates and projections issued by the United
Nations to place the number of people worldwide with diabetes at 135.3
million in 1995 and 300 million in 2025.
•
Based on data derived from the National Health Interview Survey
(NHIS) and the Third National Health and Nutrition Examination
Survey (NHANES III), the CDC estimated that in 2000, the percentage of
adults with diabetes was 2.5% among 20 to 44 year-olds, 12.1% among
45 to 64 year-olds, 21.6% among 65 to 74 year-olds, and 18.5% among
those over 75.
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