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350 again > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Diabetes management in older adults requires an individualized approach that considers: (5)

A
  1. Duration of diabetes/presence of complications
  2. Comorbid health conditions and medications
  3. Functional status
  4. Cognition
  5. Availability of supports
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2
Q

What are kidney and brain considerations to take into account in diabetes with aging? (2)

A
  1. Kidney function declines
  2. Brain becomes more sensitive to low blood sugar levels
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3
Q

Diabetes and aging considerations - increased rates of: (6)

A
  1. Mutlimorbidity, polypharmacy
  2. Cognitive impairment and dementia
  3. Altered senses - decreased vision and hearing, peripheral neuropathy
  4. Reduced mobility, falls
  5. Inadequate nutrition
  6. Financial constraints
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4
Q

What is the cognitive impairment and diabetes triad?

A
  1. Cognitive decline –>
  2. Impacts ability to perform diabetes management/self-care tasks –>
  3. Hypo/hyperglycemia –> back to 1
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5
Q

True or False? There is risk of harm when aggressively lowering blood glucose levels

A

True - targets and treatments must be individualized

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6
Q

Undertreatment of blood sugar can lead to? (4)

A
  1. Polyuria
  2. Urinary incontinence
  3. Polydipsia
  4. Poor wound healing
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7
Q

In our era of diabetes treatment, we try to shift from just lowering blood glucose to improving outcomes (and lowering blood glucose). What meds are good for that? (3)

A
  1. Metformin
  2. GLP-1RA
  3. SGLT2-inhibitors
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8
Q

What are some considerations when setting glycemic targets? (6)

A
  1. Duration of diabetes
  2. Risk of CV events
  3. Risk of hypoglycemia
  4. Functional capacity
  5. Other comorbidities
  6. Available resources and supports
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9
Q

When can we treat older adults to the same blood glucose, BP, and cholesterol targets as younger individuals? (3)

A
  1. Functionally independent
    - Clinical Frailty Scale 1-3
  2. Few comorbidities, no cognitive concerns
  3. 10+ years of healthy life expectancy
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10
Q

In general, what would our A1C target be for a functionally independent older adult (frailty index 1-3)

A

<= 7%

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11
Q

In general, what would our A1C target be for a functionally dependent older adult (frailty index 4-5)

A

7.1-8%

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12
Q

In general, what would our A1C target be for a severely frail and/or with dementia older adult (frailty index 6-8)

A

7.1-8.5%

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13
Q

In general, what would our A1C target be for an end of life patient?

A

There is none. We want to avoid symptomatic hyperglycemia and hypoglycemia is all

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14
Q

What are some common problems seen in diabetes management in long-term care? (4)

A
  1. Overtreatment remains common
  2. High rates of insulin/SU use
  3. High rates of hypoglycemia
  4. Knowledge gaps in staff regarding diabetes care
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15
Q

What are some severe consequences of hypoglycemia in older adults? (5)

A
  1. Falls, injuries
  2. Confusion
  3. Seizure, coma
  4. CV events
  5. Increased mortality
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16
Q

What are some risk factors for hypoglycemia? (7)

A
  1. More intensive blood glucose control
  2. Previous severe hypoglycemia or recurrent hypoglycemia episodes
  3. Hypoglycemia unawareness
  4. Cognitive impairment, dementia
  5. Decreased mobility, dexterity
  6. Unpredictable eating patterns
  7. Autonomic neuropathy
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17
Q

What are some medications that increase risk of hypoglycemia? (4)

A
  1. Diabetes meds (basal-bolus insulin > intermediate-acting insulin (NPH) > long-acting basal insulin ~ sulfonylureas > repaglinide)
    Other:
  2. Beta-blockers
  3. Quinolones
  4. Alcohol intake
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18
Q

What are some autonomic signs and symptoms of hypoglycemia? (8)

A
  1. Shaking
  2. Anxiety
  3. Palpitations
  4. Sweating
  5. Hunger
  6. Dry mouth
  7. Pallor
  8. Nausea
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19
Q

What are some neuroglycopenic signs and symptoms of hypoglycemia? (8)

A
  1. Difficulty concentrating
  2. Confusion
  3. Irritability
  4. Headache
  5. Vision changes
  6. Difficulty speaking
  7. Weakness, decreased coordination, falls
  8. Strange dreams, night sweats
20
Q

What is asymptomatic hypoglycemia more associated with? (5)

A
  1. Increased age
  2. Longer duration of diabetes
  3. Repeated episodes of hypoglycemia
  4. Cognitive impairment
  5. More frequent with intensive blood glucose control
21
Q

When assessing for hypoglycemia, TASTE is an acronym for questions to ask. What does it mean?

A

Total # of episodes?
Administered carbs?
Symptoms & severity?
Timing? (e.g., nocturnal, mid-day…)
Explainable? (e.g., lack of food, extra activity…)

22
Q

When addressing hypoglycemia risk, patient +/- caregiver education is key. What to tell them? (3)

A
  1. Skip prandial insulin/repaglinide dose if missing a meal
  2. Importance of eating regularly
  3. Ensure hypoglycemia management plan in place
23
Q

When addressing hypoglycemia risk, need to review glycemic targets/consider therapy modification. What to know? (3)

A
  1. Adherence to medications (inadvertent double-dosing)
  2. Reassess medications likely to contribute to hypoglycemia
  3. Is this a one-time event or is there a pattern of lows?
24
Q

What are 2 ways to manage hypoglycemia?

A
  1. Administer 15-20g of carbs
    - 4 tabs of glucose 4g chewable
    - 3 tsp sugar dissolved in warm water
    - 120mL juice
  2. Glucagon
    - Should be available to all pts at risk of hypoglycemia
    - Severe hypoglycemia (BG < 2.8), loss of consciousness
    - 1 mg subcut/IM or 3mg intranasal
25
Q

Who is continuous glucose monitoring recommended for? (2)

A
  1. Older adults with type 1 diabetes or those with type 2 diabetes on basal-bolus insulin regimens
    - Asymptomatic or recurrent hypoglycemia
  2. May also be useful for older adults in care home settings
26
Q

Remember, diabetic patients after 40 years old should be on these 2 medications for sure

A
  1. Statins for all pts with diabetes >=40
  2. ACEi/ARB for all pts with diabetes >=55
27
Q

What are some considerations for diabetes and CV risk? (5)

A
  1. Quality of the evidence
    - Limited in those >= 75 years of age, frail
  2. Comorbidities and other medications
  3. Frailty/functional status
  4. Risks/benefits of the intervention
  5. Time to benefit of these medications:
    - Statins ~2+ years
    - ACEi/ARBs ~3-5 years
28
Q

Aspirin for primary prevention of CV events. Yay or nay?

A

Nay

29
Q

What are some general considerations to know for diabetes medications in older adults? (4)

A
  1. Medications with a low risk of hypoglycemia are preferred
  2. Consider comorbidities
    - SGLT2i preferred for pts with HF
    - GLP-1RA or SGLT2i preferred for pts with CVD
    - SGLT2i preferred for pts with CKD
  3. Avoid overtreatment
  4. Re-evaluate treatment goals and regimens as health, functional status, or social supports change
30
Q

What is the approximate A1C lowering effect of nutrition and exercise?

A
  1. Nutrition = 1-2%
  2. Exercise = 0.5-0.7%
31
Q

What is the approximate A1C lowering effect of most hypoglycemic meds?

A

1-1.5%

32
Q

What are some lifestlye/non-pharmacological ways to manage diabetes in older adults? (4)

A
  1. Nutrition education remains important
  2. Weight loss generally not recommended in frail older adults
  3. Exercise helpful as well
    - Medical evaluation to ensure safety
    - Resistance training most associated with blood glucose lowering
  4. Challenging to maintain outside of a supervised setting/program
33
Q

What are the pros of metformin? (3)

A
  1. Effective first-line agent (decrease A1C ~1%)
  2. Low risk for hypoglycemia
  3. Affordable
34
Q

What are the cons of metformin? (5)

A
  1. Renal elimination/risk for accumulation in kidney disease
  2. Not recommended if eGFR < 30 mL/min
  3. GI upset/diarrhea
  4. Should be held in acute illness (SADMANS)
  5. Monitor for vitamin B12 deficiency periodically
35
Q

What are the pros of SGLT2is (-gliflozins) (3)

A
  1. CV and RENAL OUTCOME BENEFITS - shown to decrease risk of CV events, HF, and adverse renal outcomes
  2. Low risk of hypoglycemia
  3. Less effective for blood glucose/A1C lowering (particularly with reduced renal function)
36
Q

What are the cons of SGLT2is? (4)

A
  1. Risk of orthostatic hypotension, volume depletion
  2. Genital fungal infections
  3. UTIs, worsening urinary incontinence
  4. Cost
37
Q

What are the pros of GLP-1RAs (-tides) (5)

A
  1. CV OUTCOME BENEFITS - shown to decrease risk for CV events
  2. Effective blood glucose/A1C lowering (1-1.5%)
  3. Weight loss (if desirable)
  4. Low risk of hypoglycemia
  5. Once weekly injectable forms available
38
Q

What are the cons of GLP-1RAs? (4)

A
  1. Cost/coverage restrictions
  2. NVD and decreased appetite
  3. Decreased appetite, weight loss may compound frailty (muscle loss)
  4. Requires injection
39
Q

What are the pros of DPP4 inhibitors? (-gliptins) (4)

A
  1. Low risk of hypoglycemia
  2. Well-tolerated, weight-neutral
  3. Convenient
  4. Moderate effect on blood glucose (decreased A1C ~0.8%)
40
Q

What are the cons of DPP4 inhibitors? (3)

A
  1. Cost/coverage restrictions
  2. No established outcome benefit in CVD, CKD
  3. Avoid saxagliptin and alogliptin in heart failure
41
Q

You see sulfonylurea what are you thinking?

A

BEERS criteria

42
Q

What are the pros of sulfonylureas? (3)

A
  1. Effective blood glucose/A1C lowering (decrease A1C ~1%)
  2. Inexpensive
  3. Convenient (once-daily, oral)
43
Q

What are the cons of sulfonylureas? (3)

A
  1. Hypoglycemia Risk - especially with erratic eating habits
  2. Weight gain
  3. No established outcome benefits, some signals of increased CV risk
44
Q

What to know about insulin in older adults? (3)

A
  1. Requires adequate cognitive, visual, and motor skills
  2. Once-daily basal insulin therapy is the lowest-risk insulin regimen
    - Long-acting insulin analogues (e.g., basaglar) associated with less hypoglycemia than NPH
  3. Multiple-daily insulin injections are associated with the highest risk of hypoglycemia
    - May need re-evaluation in older adults with cognitive decline, limited function, or life-limiting illness
45
Q

What are some tips for insulin dose adjustment? (5)

A
  1. Fix the lows first and highs later
  2. Adjust insulin dose by 1-2 units at a time
  3. Adjust one insulin at a time (i.e., basal or bolus)
  4. Pre-prandial BG levels best for checking for lows
  5. Post-prandial BG levels help assess adequacy of bolus insulin
46
Q

How often should BG levels be monitored in older adults? (2)

A
  1. Needs to be individualized
    - Overmonitoring is common in older adults and can increase treatment burden and stress
  2. A1C every 3-6 months
47
Q

What are the SADMANS drugs?

A

Sulfonylureas
ACEis
Diuretics
Metformin
ARBs
NSAIDs
SGLT2is

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