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1 2012 International Conference on Diabetes and Metabolism Diabetes Education Symposium 9 November, 2012 Grand Hilton Seoul Hotel, Seoul Geriatric Syndrome and Diabetes in Older Adults 서울의대 분당서울대학교병원 내과장학철

2 순 서 노인에서당뇨병이란? 노인증후군 (Geriatric syndrome) 노인당뇨병에서노인증후군관리

3 늙어가는대한민국, 고령사회진입

4 건강보험적자 : 노인의료비급증이원인

노인당뇨병의역학 Prevalence of diabetes mellitus according to age group among Korean adults in 2010. (KNHANES V-1) (DMJ 2012;36:336) Prevalence of diabetes inu.s. (aged 65 years): 22 to 33% The number of adults with diabetes.

5 노인당뇨병의역학 Prevalence of diabetes mellitus according to age group among Korean adults in (KNHANES V-1) (DMJ 2012;36:336) Prevalence of diabetes inu.s. (aged 65 years): 22 to 33% The number of adults with diabetes. aged 65 years will increase by 4.5-fold (compared to 3-fold in the total population) between 2005 and 2050.

6 노인당뇨병의역학 : KLoSHA % 31.4% ( 성남시 ) 남자 439 명 (75.9±8.6 세 ), 여자 561 명 (76.0±8.81 세 ) 75 g OGTT/ WHO 진단기준

7 노화에따른근육량, 근력, 운동능력의변화 Short KR, Vittone J, Bigelow ML,Proctor DN,Nair KS. Age and aerobic exercise training effects on whole body and muscle protein metabolism. Am J Physiol 2004;286:E

8 노화와인슐린저항성 Aging Muscle mass/ strength Muscle weakness Physical activity Endurance capacity Fatigability 근감소성비만 Energy expenditure Visceral obesity Insulin Resistance HTN T2DM Dyslipidemia

9 근감소성비만 (Sarcopenic Obesity):KLoSHA 60 ASM/Wt Index Men (n=228) Women (n=158) Prediction for metabolic syndrome ASM/Wt Index P e r c e n t a g e ( % ) SO Obese Sarcopenia 0 SO Obesity Sarcopenia Normal Normal Odds ratio (95% CI) ASM /bodyweightⅹ100 (%) < -1 SD of sex-specific mean for young reference group. Cutoff value: 29.85% (men) 25.09% (women) Visceral fat area 100 cm 2 Diabetes Care. 2010;33(7):1652-4

10 노인당뇨병의역학 노인당뇨병환자 : 하지절단, 심근경색, 시력장애, 만성신부전의발생률이제일높다. 특히 75 세이상의노인환자는 세노인환자에비하여합병증의발생률이더높다. 비록최근 20 년간고혈당위기로인한사망률이감소하였지만, 노인당뇨병환자에서고혈당위기로인한사망률이제일높다. 75 세이상의노인당뇨병환자는저혈당으로인한응급실방문빈도가 2 배높다. Diabetes Care, epub October 25, 2012

11 노인당뇨병환자에서신체기능장애의발생위험이높다 노인당뇨병에서신체기능장애발생위험 배증가 (NHANES, ; Kalyani et al., 2010) 위험인자 : CVD, Complications, Obesity, A1C, Depression 신체기능장애 건강수명, 의료비용 신체기능장애 당뇨병관리의어려움 질병의악화

12 심한고혈당은근육의질을저하시키고, 일상생활수행능력을감소시킨다. SPPB, short physical performance battery KLoSHA data, Submitted

13 노인에서당뇨병이있으면? 사망률증가 기능감소, 또는장애증가 요양시설에입원할위험증가

14 순 서 노인에서당뇨병이란? 노인증후군 (Geriatric syndrome) 노인당뇨병에서노인증후군관리

15 노인병과노인증후군 노인병 Disease in the elderly Common diseases in older adults 동맥경화, 고혈압, 당뇨병, 빈혈, 치매 Specific diseases in older adults 노인증후군 (Geriatric syndrome) Previous disease in adult age

16 Symbolic presentation of disease, syndrome and geriatric syndrome pulmonary Tbc chronic fatigue syndrome Cushing s syndrome Marfan s syndrome (Neth J Med 2003;61:83 87)

17 Geriatric syndrome- heterogeneous Geriatric syndromes are used as nosological entities patients who are suffering from one or more geriatric syndromes as too frail to have a life-prolonging therapy. ECWG of AGS: 13 most common geriatric syndromes dementia, inappropriate prescribing of medications, incontinence, depression, delirium, iatrogenic problems, falls, osteoporosis, sensory alterations including hearing and visual impairment, failure to thrive, immobility and gait disturbances, pressure ulcers, and sleep disorders Harrison s Principles of Internal Medicine dementia, delirium, falls, urinary incontinence, pressure ulcers

18 노인증후군의통합개념모델 5 geriatric syndromes (common, associated with a high degree of morbidity, demonstrated to be preventable in some cases, and investigated with multiple previous risk factor studies): pressure ulcers, incontinence, falls, functional decline, and delirium Risk factors were identified for each geriatric syndrome Shared risk factors identified consistently across all geriatric syndromes: older age, functional impairment, cognitive impairment, and impaired mobility Inouye SK et al., J Am Geriatr Soc. 2007;55:

19 노인증후군의통합개념모델 Multiple risk factors or etiology contribute to geriatric syndrome Some geriatric syndromes might share underlying factors Frailty and the other geriatric syndromes may also feed-back to result in the development of more risk factors and more geriatric syndromes. These pathways in turn lead to the final outcomes of disability, dependence, and death. Older age Functional impairment Cognitive impairment Impaired mobility Inouye SK et al., J Am Geriatr Soc. 2007;55:

20 노인증후군 노인에서분리된질병으로구별되지않는임상증후군을노인증후군으로정의 섬망 (delirium), 낙상, 노쇠 (frailty), 어지럼증, 실신 (syncope), 뇨실금 노인, 특히노쇠한노인에서흔히발생함 삶의질이나신체장애에미치는영향이큼 여러장기에, 또다양한기저원인에의하여발생 원인을규명하기위한진단적검사가비효율적이거나부담스러울때가있음. 확진이나, 원인규명없이임상상에따라치료하는것이도움이됨. J Am Geriatr Soc. 2007, 55(5):

21 순 서 노인에서당뇨병이란? 노인증후군 (Geriatric syndrome) 노인당뇨병진료지침에서노인증후군

22 노인증후군이당뇨병진료지침에반영 - CHF & AGS, Six geriatric syndromes were selected for inclusion in these DM guidelines Polypharmacy Depression Cognitive Impairment Urinary Incontinence Injurious Falls Pain JAGS, 2003;51:

23 Depression 노인당뇨병진료지침중노인증후군 The older adult with DM is at increased risk for major depression and should be screened for depression during the initial evaluation period (first 3 months) and if there is any unexplained decline in clinical status. (IIA) The older adult with DM who presents with new-onset or a recurrence of depression should be treated or referred within 2 weeks of presentation, unless there is documentation that the patient has improved. (IIIB) The older adult who has received therapy for depression should be evaluated for improvement in target symptoms within 6 weeks of the initiation of therapy. (IIIB) JAGS, 2003;51:

24 노인당뇨병진료지침중노인증후군 Polypharmacy The older adult who has DM should be advised to maintain an updated medication list for review by the clinician. (IIA) The medication list of an older adult with DM who presents with depression, falls, cognitive impairment, or urinary incontinence should be reviewed. (IIA) JAGS, 2003;51:

25 노인당뇨병진료지침중노인증후군 Cognitive Impairment The clinician should assess the older adult with DM for cognitive impairment using a standardized screening instrument during the initial evaluation and with any significant decline in clinical status.(iiia) If there is evidence of cognitive impairment in an older adult with DM and delirium has been excluded as a cause, then an initial evaluation designed to identify reversible conditions that may potentially cause or exacerbate cognitive impairment should be performed promptly after diagnosis. (IIIA) JAGS, 2003;51:

26 노인당뇨병진료지침중노인증후군 Urinary Incontinence The older adult who has DM should be evaluated for symptoms of urinary incontinence during annual screening. (IIIA) If there is evidence of urinary incontinence in the evaluation of an older adult with DM, then an evaluation designed to identify treatable causes of urinary incontinence should be pursued. (IIIB) JAGS, 2003;51:

27 Injurious Falls 노인당뇨병진료지침중노인증후군 The older adult with DM should be asked about falls. (IIIB) If an older adult presents with evidence of falls, the clinician should document a basic falls evaluation, including an assessment of injuries and examination of potentially reversible causes of the falls (e.g., medications, environmental factors). (IIIB) Pain The older adult who has DM should be assessed during the initial evaluation period for evidence of persistent pain. (IIIA). JAGS, 2003;51:

28 미국당뇨병학회 / 미국노인병학회 Comorbidities and geriatric syndromes Geriatric syndromes also occur at higher frequency in older adults with diabetes and may affect self-care abilities and health outcomes including quality of life. Cognitive dysfunction Functional impairment Falls and fractures Polypharmacy Depression Vision and hearing impairment Other commonly occurring medical conditions: pain, urinary incontinence Diabetes Care, epub October 25, 2012

29 노인증후군 : 인지장애 Alzheimer s-type and multi-infarct dementia are approximately twice as likely to occur in those with diabetes. In the ACCORD trial, neither intensive glycemic control nor blood pressure control to a target SBP <120 mmhg was shown to prevent a decline in brain function. Cross-sectional studies have shown an association between hyperglycemiaand cognitive dysfunction; Hypoglycemiais linked to cognitive dysfunction in a bidirectional fashion. It is important to periodically screen for cognitive dysfunction In older patients with cognitive dysfunction, regimens should be simplified, caregivers involved, and the occurrence of hypoglycemia carefully assessed. Diabetes Care, epub October 25, 2012

30 노인증후군 : 기능장애 After controlling for age, people with diabetes are less physically active and have more functional impairment than those without diabetes. The etiology of functional impairment in diabetes may include interaction between coexisting medical conditions, peripheral neuropathy, vision and hearing difficulty, and gait and balance problems. Peripheral neuropathy, present in 50 70% of older patients with diabetes, increases the risk of postural instability, balance problems, and muscle atrophy, limiting physical activity and increasing the risk of falls. Diabetes Care, epub October 25, 2012

31 노인증후군 : 낙상및골절 Functional impairment are associated with the higher risk of falls and fractures. Women with diabetes have a higher risk of hip and proximal humeral fractures after adjustment for age, BMI, and bone density. It is important to assess fall risks and perform functional assessment periodically in older adults. Avoidance of severe hyperglycemia and hypoglycemia can decrease the risk of falls. Physical therapy should be encouragedin patients who are at high risk or who have experienced a recent fall. Diabetes Care, epub October 25, 2012

32 노인의영양문제 Older adults may be at risk for undernutrition due to anorexia, altered taste and smell, swallowing difficulties, oral/dental issues, and functional impairments leading to difficulties in preparing or consuming food. Mini-Nutritional Assessment, specifically designed for older adults, is simple to perform and may help determine whether referral to a registered dietitian for medical nutrition therapy (MNT) is needed. MNT has proven to be beneficial in older adults with diabetes.

33 information:

34 근감소성비만 Overweight and obesity are prevalent among older adults. BMI may not be an accurate predictor of the degree of adiposityin some older adults due to changes in body composition with aging. Obesity exacerbates decline in physical function due to aging and increases the risk of frailty. Strategies that combine physical activity with nutrition therapy to promote weight loss may result in improved physical performance and function and reduced cardiometabolic risk in older adults.

35 신체활동과체력 People with diabetes of longer duration and those with highera1c have lower muscle strength per unit of muscle mass. In the Look AHEAD (Action for Health in Diabetes) study, participants aged years had lower gains in fitness with the intensive lifestyle intervention than younger patients, but still improved their measures of fitness by a mean of over 15%. In older adults, even light-intensity physical activity is associated with higher self-rated physical health and psychosocial well-being.

Exercise Training and Nutritional Supplementation for Frailty in very Elderly People Randomized, placebo controlled trial comparing resistance

36 Exercise Training and Nutritional Supplementation for Frailty in very Elderly People Randomized, placebo controlled trial comparing resistance exercise training, and/or nutrient supplementation in 100 frail nursing home residents (87.1 yrs) over a 10 weeks period. N Engl J Med 1994;330:1769

37 요약 고령자의급격한증가가예상되는현실을고려할때, 노인증후군, 근감소증, 노쇠에대한임상적관심이필요함. 노인당뇨병에서노인증후군연구가필요함. 위험인자의발견과예방적조치가필요함 당뇨병교육자로서노인에서 삶의질, 육체적-사회적기능 을고려해야함.

38 감사합니다 Irisin: A PGC1-a-dependent myokine that drives brown-fatlike development of white fat and thermogenesis (Nature, 2012) 유재근 (69), 이계남 (71), 서영갑 (75)

한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -