Diabetes in older adults Flashcards
Why should older diabetic adults be treated differently? What are they higher at risk for?
- 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
When is a person considered frail? (5)
WWWPE
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
Why is hypoglycemia a bigger concern for older adults?
- they are at a bigger risk of hypoglycemia
- More debilitating consequences
- Decreased awareness and recognition of hypo
- self-treatment is less feasible
What is considered in the geriatric syndrome?
- Depression
- Cognitive impairment
- urinary incontinence
- injurious falls
- persistent pain
- polypharmacy
What are the targets for the following clinical frailty index: Functionally Independent 1-3
A1C target
Pre-prandial
Post-prandial
A1C target: 7.0% or less
Pre-prandial: 4-7
Post-prandial: 5-10
What are the targets for the following clinical frailty index: Functionally dependent 4-5
A1C target
Pre-prandial
Post-prandial
A1C target: 7.1 - 8.0%
Pre-prandial: 5-8
Post-prandial: under 12
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
A1C target: 7.1 - 8.5%
Pre-prandial: 6-9 mmol/L
Post-prandial: under 14
What are the targets for the following clinical frailty index: End of life terminally ill 9
A1C target
Pre-prandial
Post-prandial
A1C target: not recommended
Pre-prandial: individualized
Post-prandial: individualized
BP target for: Functionally independent
<130/80 mmHg
BP target for: Functionally dependent
Individualized
LDL target for EVERYONE
Under 2.0 mmol/L
Clinical considerations for the following drugs in older adults
DPP4i
GLP1-RA
SGLT-2i
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
What drug is 2nd line to metformin in older adults?
DPP-4 (linaglitpin, sitagliptin)
If starting sulfonylurea what are the initial doses? What drugs should be used in this class?
Half the dose of younger people
- increase more slowly
Gliclazide, gliclazide MR and glimepiride should be used instead of glyburide
- reduced frequency of hypo
When should meglitinides be used in older adults?
Instead of glyburide in people with irregular eating habits
- less risk of hypoglycemia
What should you start in older people with no other comorbidities but CV disease and glycemic targets not reached w current AHA?
if eGFR >30
Start SGLT2 (empagliflozin) or
GLP1-RA (trajenta, liraglutide)
What test do you use to see who is likely to have problems with insulin therapy?
Clock drawing test
What type of insulins are preferred in older people?
Premixed insulins and prefilled insulins
- to reduce dosing errors
What type of insulins are used in older people to lower frequency of hypoglycemic events
Detemir
Glargine U-100 and U-300
Degludec
What are deprescribing considerations in T2DM and T1DM
Simplify insulin regimens
T1DM: consider replacing MDI with “basal plus”
T2DM: Consider basal with OHA or GLP1-RA
Reconsider blood pressure and statins
Can older people exercise if not CI
Yes
What are the main issues of diabetes in LTC
- undernutrition
- over aggressive glycemic control with A1C below 7
- frequent insulin use
- Polypharmacy
What interventional studies in LTC show about the following:
Diet
Insulin
basal vs OAHA
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
T/F sliding scale (reactive) and correction (supplemental) insulin protocols should be used in LTC homes
false
