7/28/17 Hypoglycemia Unawareness in the Geriatric Patient: A Safety Concern 29TH ANNUAL TNP CONFERENCE TRANSFORMING HEALTHCARE IN TEXAS SEPTEMBER 8, 2017 AUSTIN, TEXAS Kenneth Lowrance, DNP, APRN, CNS, FNP-BC, NEA-BC, FAANP Associate Professor of Professional Practice Director, Post-Master’s DNP and CNS Programs Texas Christian University Disclaimer: The presenter has no conflicts of interest to declare. Objectives: • Describe the concept of hypoglycemia unawareness • Articulate and identify physiologic, sensory, and cognitive changes associated with aging that contribute to hypoglycemia unawareness • Analyze the relationship of hypoglycemia to frailty and dementia • Formulate implementation strategies to mitigate hypoglycemic episodes in the elderly 1 7/28/17 Definition of Hypoglycemia Unawareness Onset of neuroglycopenia before the appearance of autonomic warning symptoms (palpitations, sweating, hunger, anxiety, tremors, etc.) Impairment or inability of an individual to recognize the presence of hypoglycemia (Elliott & Heller, 2011) Definition of Neuroglycopenia Neuroglycopenia refers to a shortage of glucose in the brain. (Martin-Timon & Canizo-Gomez, 2015) The brain uses glucose as an exclusive energy source, using up to 25% of the total glucose in the body. (Cryer, 2012) Diabetes Facts: • 29.1 million people in the US have diabetes (1 of 11 people) • 1 of 4 do not know they have it • 86 million people have prediabetes • 9 of 10 do not know they have it • 5% of people with diabetes have Type 1; 95% have Type 2 • Annual cost of care of diabetes in 2012: $245 billion (CDC, 2017) 2 7/28/17 Classification of Hypoglycemia vSEVERE: an event requiring assistance of another person (glucose levels may not be available) vDOCUMENTED HYPOGLYCEMIA: symptoms are present and confirmed with a glucose of ≤ 70 mg/dL vASYMPTOMATIC HYPOGLYCEMIA: no symptoms present, but glucose < 70 mg/dL vPROBABLE SYMPTOMATIC HYPOGLYCEMIA: typical symptoms but not confirmed with glucose readings vPSEUDOHYPOGLYCEMIA: typical symptoms with glucose readings > 70 mg/dL (American Diabetes Association Workgroup on Hypoglycemia, 2013) Incidence and Prevalence of Hypoglycemia Unawareness More likely in Type 1 Diabetes, but also occurs in Type 2, particularly those on insulin. Type 1: 20-40% Type 2: 10-20% The literature varies widely in this regard. (Martin-Timon & Canizo-Gomez, 2015) Regulation of Glucose Levels Hypoglycemia generally results from excess insulin or the inability to raise blood glucose through endogenous or exogenous methods. Regulation is a complex interaction between the liver, kidneys, muscles, pancreas, and neuroendocrine system. 3 7/28/17 Regulation of Glucose Levels The liver is responsible for about 80% of endogenous glucose release. Kidneys are responsible for about 20%. (Kreider, Padilla, & Pereira, 2017) Physiology of Hypoglycemia Glucose approaches ~80-85 mg/dL Body attempts to restore glucose control First counter-regulatory measure is halting insulin production Physiology of Hypoglycemia Glucose approaches 65-70 mg/dL Second counter-regulatory measure occurs as alpha cells of pancreas begin to release glucagon. Body releases epinephrine, cortisol, and growth hormone. 4 7/28/17 Physiology of Hypoglycemia All of these mechanisms are dependent upon proper functioning of pancreatic alpha cells, the liver, and the kidneys. Impairment of any of these elements effect glucose control. (Kreider, Padilla, & Pereira, 2016) In individuals with repeated episodes of hypoglycemia, normal protective mechanisms sometimes will not be triggered at normal thresholds, but at lower numbers before recognizable autonomic symptoms occur (palpitations, sweating, hunger, anxiety, tremors, etc.) resulting in hypoglycemia unawareness. This is referred to as Hypoglycemia-associated Autonomic Failure (HAAF). (Kreider, Padilla, & Pereira, 2016) Contributing Factors to Hypoglycemia Unawareness • Long duration of diabetes • Sleep • Antecedent hypoglycemia • Polypharmacy (some drugs in particular) • Alcohol—inhibits counter • Multiple comorbidities regulation through effects on liver; reduces peripheral • Under nutrition autonomic responses such as • Obsession over tight control tremor and cognitive function • Increasing age • Antecedent exercise (Elliott & Heller, 2011) 5 7/28/17 Factors Affecting Recognition of Hypoglycemia in Older People • Symptoms may be nonspecific • Easily misdiagnosed: stroke, vertigo, or visual disturbance • Misinterpreted as dementia with related Sx of agitation/behavior changes • Atypical presentation: confusion or passive delirium • Little warning or awareness of autonomic symptoms • Patients with dementia are unable to communicate feelings or Sx (Abdelhafiz, Rodriguez-Manas, Morley, & Sinclair, 2015) Chronic Consequences Associated with Hypoglycemia in Older People Aging modifies cognitive, symptomatic, and counter- regulatory responses to hypoglycemia. Chronic Consequences Associated with Hypoglycemia in Older People • General physical functional decline • Increased risk of dementia • Reduced ability to perform ADLs • Increased fear & anxiety • Complete dependence • Increased social isolation • Frequent falls • Behavioral changes • Increased risk of Fx, (hip, etc.) • Increased panic attacks • Frequent hospitalizations • Increased risk of frailty • Increased risk of vascular disease • Increased risk of disability • Impaired cognitive function • Increased risk of mortality (Abdelhafiz et al., 2015) 6 7/28/17 Prevention and Management of Hypoglycemia Unawareness Some authorities speculate that if hypoglycemia could be prevented that this might lead to recovery of counter-regulatory measures and symptomatic awareness. (Elliott & Heller, 2011) Prevention and Management of Hypoglycemia Unawareness • Work with patients individually and use insulin therapy flexibility to match to eating and other activities • Education regarding insulin self-management (CDE) • Insulin pumps • Continuous Glucose Monitoring • Islet Cell Transplantation (Elliott & Heller, 2011) Prevention and Management of Hypoglycemic Unawareness Because of increased potential of hypoglycemia in older people with limited life expectancy or multiple comorbidities, the ADA recommends a higher A1C goal of <8%. (ADA, 2017) European Diabetes Working Group for Older People recommends A1C goals of 7.5%-9% for frail elders which includes those with multi-system disease or dementia or those in skilled nursing facilities. (Sinclair, Paolisso, Castro, Fourdel-Marchasson, Gadsby, & Manas, 2011) 7 7/28/17 Questions? References Abdelhariz, A., Rodriguez-Manas, L., Morley, J., & Sinclair, A. (2015). Hypoglycemia in older people—A less well recognized risk factor for frailty. Aging & Disease, 6(2), 156-167. American Diabetes Association. (2017). Standards of medical care in diabetes. Retrieved from https://doi.org/10.2337/dc17- 5003 Centers for Disease Control and Prevention (CDC). (2017). A snapshot of diabetes in the United States. Retrieved from https://www.cdc.gov/diabetes/pubs/statsreport14/diabetes-infographic.pdf Cryer, P. (2012). Hypoglycemia in diabetes: Pathophysiology, prevalence, and prevention. Alexandria, VA: American Diabetes Association. Elliott, J., & Heller, S. (2011). Hypoglycemia unawareness. Practical Diabetes, 28(5), 227-232. Kreider, K., Padilla, B., & Pereira, K. (2017). Hypoglycemia in diabetes: Challenges and opportunities in care. JNP, 13(3), 228- 234. Martin-Timon, I., & Canizo-Gomez, F. (2015). Mechanisms of hypoglycemia unawareness and implications in diabetic patients. World J Diabetes, 6(7), 912-926. Sinclair, A., Paolissa, G., Castro, M., Bourdel-Marchasson, I., Gadsby, R., & Manas, L. (2011). European diabetes working party for older people 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes metabolism, 37(S27-38). 8.