Diabetes in Older Adults and Youth

Diabetes in Older Adults

• Most commonly Type 2 diabetes
• Prevalence increased by 62% between 1997-2010 in the U.S.
• 21.4% of U.S. adults aged 65+ have a known diagnosis
• 16% are unaware of their diabetes
• Older diabetic population is diverse in race/ethnicity, diabetes duration, comorbidity, and functional status
• Diabetes increases the risk of mortality, cardiovascular and microvascular complications, cognitive impairment, frailty, unintentional weight loss, polypharmacy, and functional impairment
• No current recommendations for routine screening
• Screening is dependent on improving overall quality of life or life expectancy
• Consider screening to prevent complications leading to functional impairment (ADA)
• Decisions regarding treatment should be made based on age, life expectancy, functional status, and chronic comorbidities

Diabetes in Children and Adolescents

• Type 1 diabetes
• Type 2 diabetes
• Maturity-onset diabetes of the young (MODY)

Maturity-Onset Diabetes of the Young (MODY)

• Consider genetic testing and referral to endocrinologist/clinical genetics consultant
• Accurate diagnosis determines treatment and management plan
• Lack of evidence from randomized trials to show early diagnosis and therapy improve patient outcomes

Gestational Diabetes

• Screen women during their first trimester if risk factors are present: such as obesity, advanced maternal age (>35 years old), history of gestational diabetes, family history of diabetes, high-risk ethnicity
• Screen all asymptomatic patients at or after 24 weeks’ gestation
• Complications - gestational hypertension, preeclampsia, Cesarean delivery, shoulder dystocia, macrosomia, and birth defects
• Increased risk of Type 2 diabetes for mothers, increased risk of childhood/adolescent obesity for children
• In high-risk populations, diabetes develops in up to 50% of women with gestational diabetes
• Screen women at 6-12 weeks postpartum with a fasting glucose measurement or a 75g 2-hour glucose tolerance test
• Up to 36% of women with gestational diabetes may have persistently abnormal glucose tolerance

Type 2 Diabetes

• Screen asymptomatic adults BMI ≥ 25 kg/m2, and one or more additional risk factors
  • A1c > 5.7%
  • Impaired glucose tolerance
  • Impaired fasting glucose
• Screening IS recommended (USPSTF)
• Lifestyle changes and medications can reduce disease progression

Type 2 Diabetes: Signs and Symptoms

• Weight gain
  • Overweight or obese
  • Centripetal fat distribution
  • Waist circumference >40 inches for men, >35 inches for women
• Obstetrical complications
  • Consider Type 2 diabetes in women who have delivered babies over 9 lb (4.1 kg) or have had polyhydramnios, preeclampsia, or unexplained fetal losses

"Metabolic Syndrome"

• Individuals at higher risk for developing diabetes and cardiovascular disease
• Preeclampsia, caesarean delivery, congenital malformations, macrosomia, childhood or adolescent obesity, nerve palsy, bone fracture, jaundice, and infant death

Secondary Causes of Diabetes

• Exocrine pancreas diseases
• Endocrinopathies
• Drug- or chemical-induced insulin resistance
• Genetic diseases
• Any disorder that damages the pancreas can result in diabetes
• E.g. liver cirrhosis, hemochromatosis, hemosiderosis

Secondary Causes of Diabetes: Examples

• Exocrine Pancreas Diseases - Pancreatitis, Cystic Fibrosis
• Endocrinopathies - Somatostatinoma, Pheochromocytoma, Acromegaly, Cushing syndrome, Glucagonomia
• Drug- or Chemical-induced Insulin Resistance - Corticosteroids, Sympathomimetics, Niacin, Alpelisib, Sirolimus, Thiazide diuretics, Phenytoin, Atypical antipsychotics
• Genetic Syndromes - Down, Klinefelter, Turner, Wolfram syndrome, Type A insulin resistance, Leprechaunism, Rabson-Mendenhall syndrome, Lipoatrophic diabetes

Diagnostic Tests

• Fasting Plasma Glucose (FPG)

  • 100-125 mg/dL (5.6-6.9 mmol/L) = impaired fasting glucose tolerance, increased diabetes risk
  • ≥126 mg/dL (7.0 mmol/L) on more than one occasion, after at least 8-hour fasting = Diagnostic
  • Diagnosis may be made with hyperglycemia signs and symptoms, PLUS >200 mg/dL (11.1 mmol/L) – and testing should be repeated to confirm
  • Pros: may identify one-third more undiagnosed cases than A1c
  • Cons: fasting is required

• Oral Glucose Tolerance Test (OGTT)

• Glycated hemoglobin (HbA1c)

• Additional tests (urine, self-monitoring, continuous glucose monitoring, autoantibody, genetic)

Type 1 Diabetes: Clinical Features at Diagnosis

• Polyuria and thirst (++ )
• Weakness or fatigue (++ )
• Polyphagia with weight loss (++ )
• Recurrent blurred vision (+)
• Vulvovaginitis or pruritis (+)
• Peripheral neuropathy (+)
• Nocturnal enuresis (++ )

Type 2 Diabetes: Clinical Features at Diagnosis

• Polyuria and thirst (+)
• Weakness or fatigue (+)
• Polyphagia with weight loss (-)
• Recurrent blurred vision (++ )
• Vulvovaginitis or pruritis (++ )
• Peripheral neuropathy (++ )
• Nocturnal enuresis (-)
• Often asymptomatic (++ )

Explore the impact of diabetes on different age groups with a focus on older adults and children. This quiz covers the prevalence, risks, and considerations for treatment and screening for both Type 2 and Type 1 diabetes. Understand the diversity in diabetes diagnosis and management across various populations.