Diabetes in older adults

Question 1

Why should older diabetic adults be treated differently? What are they higher at risk for?

Answer 1

• Higher risk of cognitive impairment and dementia
• higher risk of depression
• higher risk of side effects (hypo, GI)

Altered kidney and liver function
More comorbidities/polypharmacy

Question 2

When is a person considered frail? (5)
WWWPE

Answer 2

If 3 or more of the following are present
1. Unintentional weight loss (4.5+ kg/year)
2. Self-reported exhaustion
3. Weakness
4. Slow walking speed
5. Low physical activity

Question 3

Why is hypoglycemia a bigger concern for older adults?

Answer 3

• they are at a bigger risk of hypoglycemia
• More debilitating consequences
• Decreased awareness and recognition of hypo
• self-treatment is less feasible

Question 4

What is considered in the geriatric syndrome?

Answer 4

• Depression
• Cognitive impairment
• urinary incontinence
• injurious falls
• persistent pain
• polypharmacy

Question 5

What are the targets for the following clinical frailty index: Functionally Independent 1-3
A1C target
Pre-prandial
Post-prandial

Answer 5

A1C target: 7.0% or less
Pre-prandial: 4-7
Post-prandial: 5-10

Question 6

What are the targets for the following clinical frailty index: Functionally dependent 4-5
A1C target
Pre-prandial
Post-prandial

Answer 6

A1C target: 7.1 - 8.0%
Pre-prandial: 5-8
Post-prandial: under 12

Question 7

What are the targets for the following clinical frailty index: Functionally dependent w/ dementia and/or frail 6-8
A1C target
Pre-prandial
Post-prandial

Answer 7

A1C target: 7.1 - 8.5%
Pre-prandial: 6-9 mmol/L
Post-prandial: under 14

Question 8

What are the targets for the following clinical frailty index: End of life terminally ill 9
A1C target
Pre-prandial
Post-prandial

Answer 8

A1C target: not recommended
Pre-prandial: individualized
Post-prandial: individualized

Question 9

BP target for: Functionally independent

Answer 9

<130/80 mmHg

Question 10

BP target for: Functionally dependent

Answer 10

Individualized

Question 11

LDL target for EVERYONE

Answer 11

Under 2.0 mmol/L

Question 12

Clinical considerations for the following drugs in older adults
DPP4i
GLP1-RA
SGLT-2i

Answer 12

DPP4i
- Lower risk of hypoglycemia
- 2nd line over sulfonylurea

GLP1-RA
- lower risk of hypo
- weight loss if its an advantage
- higher risk of GI

SGLT-2
- less effective in terms of reduction in A1C since they have lower GFRs
- they can be more susceptible to dehydration
- CV benefit

Question 13

What drug is 2nd line to metformin in older adults?

Answer 13

DPP-4 (linaglitpin, sitagliptin)

Question 14

If starting sulfonylurea what are the initial doses? What drugs should be used in this class?

Answer 14

Half the dose of younger people
- increase more slowly

Gliclazide, gliclazide MR and glimepiride should be used instead of glyburide
- reduced frequency of hypo

Question 15

When should meglitinides be used in older adults?

Answer 15

Instead of glyburide in people with irregular eating habits
- less risk of hypoglycemia

Question 16

What should you start in older people with no other comorbidities but CV disease and glycemic targets not reached w current AHA?

Answer 16

if eGFR >30
Start SGLT2 (empagliflozin) or
GLP1-RA (trajenta, liraglutide)

Question 17

What test do you use to see who is likely to have problems with insulin therapy?

Answer 17

Clock drawing test

Question 18

What type of insulins are preferred in older people?

Answer 18

Premixed insulins and prefilled insulins
- to reduce dosing errors

Question 19

What type of insulins are used in older people to lower frequency of hypoglycemic events

Answer 19

Detemir
Glargine U-100 and U-300
Degludec

Question 20

What are deprescribing considerations in T2DM and T1DM

Answer 20

Simplify insulin regimens
T1DM: consider replacing MDI with “basal plus”
T2DM: Consider basal with OHA or GLP1-RA

Reconsider blood pressure and statins

Question 21

Can older people exercise if not CI

Answer 21

Yes

Question 22

What are the main issues of diabetes in LTC

Answer 22

• undernutrition
• over aggressive glycemic control with A1C below 7
• frequent insulin use
• Polypharmacy

Question 23

What interventional studies in LTC show about the following:
Diet
Insulin
basal vs OAHA

Answer 23

Diet
- regular diet is fine, no need a diabetic diet
- did not modify level of glycemic control

Insulin
- substitute regular insulin with insulin lispro
- less number of hypoglycemia

basal vs OAHA
- similar glycemic control

Question 24

T/F sliding scale (reactive) and correction (supplemental) insulin protocols should be used in LTC homes

Answer 24

false