Diabetes and chronic kidney disease in the elderly

Older adults with diabetes and chronic renal failure (CKD) are at increased risk of cognitive impairment and dementia, frailty, dysglycemia, and polypharmacy.

A recent review article published on February 15, 2019 addressed the complexity of older people with diabetes and chronic kidney failure. The risk of dementia increases with decreased renal function, duration of diabetes, hypoglycemia, and HbA1c levels greater than 7% in patients with mild cognitive impairment. In a cross-sectional study of 1,358 older adults with diabetes and chronic renal failure, compared to individuals without diabetes or renal failure, patients with both conditions had a multi-adjusted odds ratio of 4.23 for cognitive impairment. Mechanisms common to diabetes and CKD, such as inflammation, peripheral vascular disease and cardiovascular disease, could explain these findings. In clinical badessments, providers can periodically screen for cognitive dysfunction and depression, or use geriatric teams to help with this screening.

Sarcopenia and fragility are another complication. In early diabetes, poor glycemic control, oxidative stress, and inflammation have been postulated to play a role in the development of sarcopenia, whereas in the advanced stages of diabetes, complications, including peripheral neuropathy, play a role. most important. Insulin resistance, even in nondiabetic patients, has also been badociated with the wasting of protein energy and sarcopenia in patients with chronic kidney disease. Vitamin D deficiency is also a risk factor for frailty and is particularly apparent in patients with diabetes and CKD. There are several frailty measures available, many of which require minimal training for a specific use. Good nutrition with vitamin D and protein has been badociated with improvements in muscle mbad and muscle function. Physical rehabilitation programs and multi-component exercises, including balance exercises, walking rehabilitation and strength, strength and resistance training, are able to address frailty deficits.

Elderly people with diabetes and CKD are at risk for hyperglycemia and hypoglycemia. Even without underlying diabetes, eGFR <60 ml / min / 1.73 m2 was badociated with insulin resistance and reduced insulin secretion. The reasons for hypoglycemia in the elderly with diabetes and CKD could be numerous. Many antihyperglycemic drugs are eliminated by the kidneys, increasing the risk of drug-induced hypoglycemia in patients with CKD. Muscle wasting and dysfunction could also help reduce insulin clearance. Patients with chronic kidney disease and diabetes also have more medical comorbidities, which could increase their susceptibility to hypoglycemia. In addition, they often suffer from long-standing diabetes, known risk factor for hypoglycemia.

These patients require specific diabetes surveillance, which includes monitoring of kidney function and glycemic control.

Among the difficulties of surveillance is the fact that the use of equations such as Cockcroft – Gault to estimate creatinine clearance has not been specifically developed in the elderly. In addition, the use of creatinine to estimate glomerular filtration rate (GFR) in elderly patients is limited. Creatinine production depends on muscle mbad, and in the elderly, creatinine production can be heterogeneous. Patients may also have variable creatinine secretion. Therefore, despite the fact that creatinine is normal, older people may have "concomitant kidney failure" with a decrease in GFR. When HbA1c is suggested for control of glycemic control in most healthy individuals, it is affected by reduced red blood cell survival, the use of erythropoietin, modification of hemoglobin and mechanical destruction of blood cells. These diseases are often present in chronic kidney disease and the correlation between HbA1c and fasting glucose levels weakens with lower kidney function. The attention to capillary and venous glycemia is important in older people with diabetes and CKD.

Another issue to consider is polypharmacy. Before providers prescribe new drugs, the drug lists of older people with CKD should be reviewed. When patients are at increased risk for polypharmacy, their need for prescribed treatments can be re-evaluated and medications reconciled. Providers can also search for nephrotoxic drugs and use drug interaction checkers when reviewing their drug lists.

Glycemic targets should be based on the individual patient. Given the heterogeneity of older people with diabetes, there is no specific age-specific recommendation for glycemic control. Targets should depend on their function, their life expectancy and the risk of hypoglycemia. It is also important to identify overtreatment and to de-emphasize and reduce the prescription in order to minimize the damage.

Providers could also involve multidisciplinary care teams in the care of older people with diabetes and MRC. Geriatricians can provide expertise in managing multi-morbidity, prescription medication, reducing risk of falls and rehabilitation. In the elderly, multidisciplinary teams (geriatricians, diabetes educators, dietitians) can improve blood glucose management and personal care behaviors compared to traditional diabetes care.

The article concluded by suggesting an individualized approach to their better patient-centered management. Where the number of patients living with these conditions will continue to increase, additional efforts could be made to understand their outcomes and the ideal therapies and targets to use in this population.

Pearls of practice:

• Older people with chronic kidney disease and diabetes face many challenges, including cognitive impairment and dementia, frailty, dysglycemia, and polypharmacy.
• Providers should pay particular attention to their co-morbidities and functional status, apply safe and prudent prescriptions, individualize their glycemic goals, monitor them closely, involve other health professionals in their management, and provide them with care. centered on the patient.
• Further research is needed to identify the ideal therapies and targets to use in this population.

References:

Clemens KK, O'Regan N, Rhee Judges. Diabetes management in elderly people with chronic kidney disease. Curr Diab Rep. 2019 February 15, 19 (3): 11.

Yin Z, Yan Z, Liang Y, Jiang H, Cai C, Song A, et al. Interactive effects of diabetes and kidney failure on cognitive performance in the elderly: population-based study. BMC Geriatr. 2016 16: 7

Dahlia Elimairi, Pharm D Student, UC Denver Skaggs School of Pharmacy