|
||||||
|
|
|
|
|||||||||||
|
|||||||||||||
| ||||||||||||||||||||||||||||||||||||||
Physicians have a whole host of methods for helping most patients lowertheir risks associated with diabetes, obesity, and cardiovasculardisease.
When it comes to older patients, however, issues are not always soclear.
"We can't lose sight of the fact that, as patients get older, theirbodies work differently in many ways than those of middle-aged adults,"says Osama Hamdy, MD, PhD, of the Joslin Diabetes Center at HarvardUniversity.
Fortunately, senior-focused research is starting to add to theliterature.
PHYSICAL FITNESS
Among fitness researchers and clinicians, the vote is nearly unanimous:It's never too late to start exercising.
"There is no age that we have found where you can no longer reap thebenefits of physical activity," says Jerome Fleg, MD, of the NationalHeart, Lung, and Blood Institute (NHLBI).
Walking programs for seniors look particularly useful.
The Women's Health Initiative Observational Study, which followed 73,743postmenopausal women aged 50 to 79 years, found that moderate walking andvigorous exercise led to substantial risk reductions for coronary andcardiovascular events, regardless of age or body massindex.1
And in the Honolulu Heart Program Study, elderly men (aged 71 to 93 years)who walked 1.5 miles per day had half the risk of coronary heart disease ofmen who walked less than a quarter-mile per day, regardless of age or otherrisk factors.2
Although many studies suggest regular exercise is important, evenoccasional activity may be better than nothing. A 12-year study of 3,206Swedish adults over age 65 found that those engaging in as little as a weeklybout of moderate physical activity had a 40% lower risk of all-cause mortalitythan inactive seniors, after adjusting for age, body mass, and diseasefactors.3
"Whether it's aerobic or strength training, exercise is alwaysuseful, especially where diabetes is concerned," says Timothy Church,MD, medical director at the Cooper Institute in Dallas.
Once older patients are cleared for exercise with a stress test, Churchrecommends helping them find an exercise professional to gradually introduceexercise. Cardiac rehabilitation programs may be a good start, although notall elderly are eligible. Effective programs introduce exercise and monitorhealth parameters, then slowly assist the patient in increasing his or hertolerance by expanding duration and intensity.
DIETARY CHANGES
Concerted dietary interventions also are beneficial in overweight olderadults, evidence suggests, particularly when combined with moderateexercise.
In the Diabetes Prevention Program clinical trial, 3,200 overweight adultsaged 25 to 85 years with impaired glucose tolerance were followed for anaverage of 2.8 years. Patients were randomized to either placebo, the oraldiabetes drug metformin (Glucophage, Bristol-Myers Squibb), or a superviseddiet/exerciseprogram.4
The lifestyle intervention group members over age 60 reduced theirdevelopment of type 2 diabetes by 71%, reports study chair David Nathan, MD,of Massachusetts General Hospital in Boston.
On average, these participants decreased daily food intake by 450 caloriesand fat intake by 7%, losing an average of 5% to 7% (or 12 pounds) of theirbody weight. About half met the activity goal of 2.5 hours per week of walkingor other moderate exercise.
"Lifestyle intervention worked as well in men and women and in allthe ethnic groups," Nathan says, while "metformin was relativelyineffective in the older volunteers and in those who were lessoverweight."
Other clinical research has shown benefits of Mediterranean-style diets aswell as limited red meat and high cereal-fiber consumption to reducecardiovascular disease in olderadults.5–7
"An improved diet can always have a benefit, provided people eatnutrition-dense food and cut calories," Hamdy says.
The accompanying exercise component appears to be key, he continues,because it helps adults keep weight off and preserve muscle while theirvisceral abdominal fat decreases.
"Skeletal muscle is the biggest consumer of glucose in the body, soif you can keep that healthy or improve [muscle] volume and quality, you standto benefit," Hamdy says.
STATINS
Cholesterol-lowering statins help prevent heart disease and stroke for manyadults. But the picture is less clear in the case of prescribing statins forthe elderly.
"Just as there are populations who can clearly benefit from statins,so are there groups that have greater expected harm," says BeatriceGolomb, MD, PhD, of University of California-San Diego. "Right now, forthe elderly and for women, there is no evidence that the benefits of [statin]treatment exceed the risks, even for those at somewhat high cardiovascularrisk."
The interest in statins stems primarily from several large clinical studiesof middle-aged men, who derive significant benefits of cardiovascular-diseaseprevention.
But little evidence supports their use in the elderly, who are morevulnerable to adverse effects and to risks associated with low cholesterol,such as rhabdomyolysis, or muscle degeneration, risks associated with lowantioxidant-carrying capacity (cancer), neurodegenerative disease, and reducedenergy and mitochondrial function.
In the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER),2,804 men and 3,000 women aged 70 to 82 years with histories or risk factorsfor cardiovascular disease were randomized to a daily treatment of 40 mg ofpravastatin (Pravachol, Bristol-Myers Squibb) orplacebo.8 Comparedwith the placebo group, pravastatin users had a 19% lower risk of coronarydeath and nonfatal myocardial infarction, and coronary-disease mortality was24% lower in the treated group. Stroke risk was not significantly affected,but new cancer diagnoses were 25% more frequent in the statin users.
Although the PROSPER trial indicated some cardiovascular benefits withstatins, Golomb points out that "this study showed no hint of amortality benefit, although it showed no harm."
"Any cardiovascular benefits (in the pravastatin group) werecountered by an increase in deaths from other causes," says Golomb."The evidence is thus neutral when the whole person rather than just theheart is taken into account."
Cost issues are also of significant concern to the elderly, and if a statinis of neutral benefit, the cost factor could tip the scale to notprescribing.
BARIATRIC SURGERY
Thousands of people undergo bariatric surgery in order to lose weight.However, many medical experts are calling for more research to clarify thepotential benefits of weight-loss surgery for older seniors.
"Because there are age-related differences in underlying physiologyin general, and fat distribution in particular, one should be cautious aboutgeneralizing the findings in the younger population to those above 65,"says Josef Fischer, MD, spokesman for the American College of Surgeons.
A few small studies, conducted at Mayo Clinic and Virginia CommonwealthUniversity, show weight loss and reduced comorbidities in older patients(>60 years) who underwent bariatricsurgery.9,10Other studies, however, noted fewer benefits for older patients compared withyounger adults and a clear association between increasing age and operativemortalityrisk.11
"The age at which the risks of this surgery outweigh benefits issomething we don't know at this point," says Harvey Sugerman, MD,president of the American Society of Bariatric Surgeons. "We need moredata in national combined series, and we're working on trying to set that upwith Medicare."
There is increasing recognition that recruiting only younger individualsfor research when many physicians treat older patients is shortsighted, saysFleg of NHLBI.
"Diabetes, for instance, is primarily a disease of olderindividuals," he says. "So it makes sense that that's where theresearch be directed."
Bear in mind, many older patients (age 65–80) are more fit and activeand have less disease than younger patients (age 45–55). Decisionsshould not always be made on chronological age but also on body age anddisease process. 
TIPS FOR TREATING ELDERS
Physical fitness: Encourage all older patients to getevaluated and get moving. Discuss the benefits of weight-loss interventionswith overweight seniors and help them locate programs that offer professionalguidance and support, a key to success.
Dietary changes: Adherence to a diet based on plant foods andunsaturated fats that resembles the Mediterranean diet is associated withreduction in overall mortality in elderly inEurope.1 TheMediterranean diet is characterized by a high intake of vegetables, legumes,fruits and cereals; a moderate to high intake of fish; a low intake ofsaturated fats, with a high intake of unsaturated fats such as olive oil; alow intake of dairy products (primarily cheese and yogurt) and meat; and amodest intake of alcohol, mostly as wine.
Statins: Approach statin prescription for older patients withcaution until more credible data assesses the benefits versus risks of thesedrugs. Closely monitor older statin users for potential adverseeffects—including muscle problems, irritability, and cognitive effects.Consider cost.
Bariatric surgery: Because relatively few seniors have undergone thesurgery to date, data on their outcomes is scant. Wait for more long-term datato clarify the benefit versus risk of bariatric surgery for elderly obesepatients. For older patients who previously underwent bariatric surgery,monitor for common micronutrient deficiencies, such as calcium and vitaminB12.
References
2. Hakim AA, Curb JD, Petrovitch H, et al.: Effects of walking oncoronary heart disease in elderly men: The Honolulu Heart Program.Circulation 100:9–13, 1999.
3. Sundquist K, Qvist J, Sundquist J, et al.: Frequent and occasionalphysical activity in the elderly: A 12-year follow-up study of mortality.Am J Prev Med 27:22–27, 2004.[Medline]
4. Knowler WC, Barrett-Connor E, Fowler SE, et al. for the DiabetesPrevention Program Research Group: Reduction in the incidence of type 2diabetes with lifestyle intervention or metformin. N Engl JMed 346:393–403, 2002.
5. Knoops KT, de Groot LC, Kromhout D, et al.: Mediterranean diet,lifestyle factors, and 10-year mortality in elderly European men and women:The HALE project. JAMA 292:1433–1439, 2004.
6. Mozaffarian D, Kumanyika SK, Lemaitre RN, et al.: Cereal, fruit,and vegetable fiber intake and the risk of cardiovascular disease in elderlyindividuals. JAMA 289:1659–1666, 2003.
7. Song Y, Manson JE, Buring JE, et al.: A prospective study of redmeat consumption and type 2 diabetes in middle-aged and elderly women: TheWomen's Health Study. Diabetes Care 27: 2108–2115, 2004.
8. Shepherd J, Blauw GJ, Murphy MB, et al.: Pravastatin in elderlyindividuals at risk of vascular disease (PROSPER): A randomised controlledtrial. Lancet 360:1623–1630, 2002.[Medline]
9. St. Peter SD, Craft RO, Tiede JL, et al.: Impact of advanced age onweight loss and health benefits after laparoscopic gastric bypass.Arch Surg 140:165–168, 2005.
10. Sugerman HJ, DeMaria EJ, Kellum JM, et al.: Effects of bariatricsurgery in older patients. Ann Surg 240: 243–247, 2004.[Medline]
11. Fernandez AZ Jr., DeMaria EJ, Tichansky DS, et al.: Experience withover 3,000 open and laparoscopic bariatric procedures: Multivariate analysisof factors related to leak and resultant mortality. SurgEndosc 18:193–197, 2004.[Medline]
1. Trichopoulou A, Orfanos P, Norat T, et al.: Modified Mediterraneandiet and survival: EPIC-elderly prospective cohort study.BMJ 330:991, 2005.
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||
|
||||||
|
| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
