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PHAR350 > Diabetes in Older Adults > Flashcards

Diabetes in Older Adults Flashcards

1
Q

How should diabetes care be handled in older adults?

A

individualized approach that considers:
-duration of diabetes/presence of complications
-comorbid health conditions and medications
-functional status
-cognition
-availability of supports

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2
Q

What are some considerations to keep in mind with diabetes and aging?

A

kidney function declines
brain becomes more sensitive to low blood sugar levels
increased rates of:
-multimorbidity, polypharmacy
-cognitive impairment and dementia
-altered senses - decreased vision and hearing, peripheral neuropathy
-reduced mobility, falls
-inadequate nutrition
-financial constraints

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3
Q

What is the take home message regarding the ACCORD trial?

A

there is a risk of harm when aggressively lowering blood glucose levels
targets and treatments must be individualized

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4
Q

Describe the balancing act with pursuing glycemic targets.

A

intensive treatment (A1c < 6.5-7%):
-less nephropathy, neuropathy, retinopathy, CV events
-5yrs+ for microvasc benefit, 10yrs+ for CV benefit
middle ground (A1c < 7.5-8.5%):
-minimal hypoglycemia
-decreased medication side effects and regimen complexity
undertreatment (A1c > 8.5-9%):
-polyuria, urinary incontinence
-polydipsia
-poor wound healing

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5
Q

Which diabetes medications only lower blood glucose? Which ones improve outcomes in addition to lowering blood glucose?

A

lower blood glucose:
-insulin
-sulfonylureas
-thiazolidinediones
-DDP4-inhibitors
improve outcomes + lower blood glucose:
-metformin
-GLP1 RAs
-SGLT-2 inhibitors
despite this, SU and insulin remain the most used antihyperglycemics in older adults (after metformin)

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6
Q

What are some considerations in setting glycemic targets?

A

duration of diabetes
risk of cardiovascular events
risk of hypoglycemia
functional capacity
other comorbidities
available resources and supports

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7
Q

In general, how do we treat healthy older adults with diabetes?

A

can be treated to the same blood glucose, blood pressure, and cholesterol targets as younger individuals
-functionally independent (CFS 1-3)
-few comorbidities, no cognitive concerns
-10+ years of healthy life expectancy

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8
Q

What are the blood glucose targets for functionally independent older adults?

A

A1c: < 7%
preprandial BG targets: 4-7 mmol/L
postprandial BG targets: 5-10 mmol/L

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9
Q

What are the blood glucose targets for older adults with a CFS score of 4-5?

A

A1c: 7.1-8%
preprandial BG targets: 5-8 mmol/L
postprandial BG targets: < 12 mmol/L

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10
Q

What are the blood glucose targets for older adults who are severely frail or with dementia?

A

A1c: 7.1-8.5%
preprandial BG target: 6-9 mmol/L
postprandial BG target: < 14 mmol/L
severely frail is a CFS of 6-8

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11
Q

What are the blood glucose targets for end of life?

A

A1c: N/A
preprandial BG target: avoid symptomatic hypoglycemia
postprandial BG target: avoid symptomatic hyperglycemia

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12
Q

What remains common regarding diabetes management in long-term care?

A

overtreatment remains common
-high rates of insulin/SU use
-high rates of hypoglycemia
quality of life is paramount
-avoid diabetic diets
-avoid hypoglycemia

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13
Q

What is hypoglycemia?

A

blood glucose < 4 mmol/L
- < 5 mmol/L for some older adults

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14
Q

What are the consequences of hypoglycemia in older adults?

A

falls, injuries
confusion
seizure, coma
cardiovascular events
increased mortality

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15
Q

What are the risk factors for hypoglycemia?

A

more intensive blood glucose control
previous severe hypoglycemia or recurrent hypoglycemic episodes
hypoglycemia unawareness
cognitive impairment, dementia
decreased mobility, dexterity
unpredictable eating patterns
autonomic neuropathy
medications

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16
Q

Which medications are risk factors for hypoglycemia?

A

diabetes meds:
-basal-bolus > NPH > long acting basal ~ sulfonylureas > repaglinide
beta blockers
quinolones
alcohol

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17
Q

What are the symptoms of hypoglycemia?

A

autonomic:
-shaking
-anxiety
-palpitations
-sweating
-hunger
-dry mouth
-pallor
-nausea
neuroglycopenic:
-difficulty concentrating
-confusion
-irritability
-headache
-vision changes
-difficulty speaking
-weakness, decreased coordination, falls
-strange dreams, night sweats

18
Q

Describe asymptomatic hypoglycemia.

A

associated with older age, longer duration of diabetes, repeated episodes of hypoglycemia
also associated with cognitive impairment
more frequent with intensive blood glucose control

19
Q

What is an acronym to help in assessing for hypoglycemia?

A

TASTE
total # of episodes?
administered carbs?
symptoms and severity?
timing?
explainable?

20
Q

What are some important education points to provide patient/caregiver to minimize hypoglycemia risk?

A

skip prandial insulin or repaglinide if missing a meal
importance of eating regularly
ensure hypoglycemia management plan is in place

21
Q

How is hypoglycemia managed?

A

15-20 of CHO
glucagon
-should be available to all patients
-severe hypoglycemia (<2.8), loss of consciousness

22
Q

What is the role of continuous glucose monitoring in older adults?

A

recommended for older adults with type 1 diabetes or those with type 2 diabetes on basal-bolus insulin regimens
also helpful in care home settings

23
Q

What are some considerations to keep in mind before making CV interventions for older adults with diabetes?

A

quality of the evidence
-limited in those > 75 yrs of age, frail
comorbidities and other medications
frailty/functional status
risks/benefits of the intervention
time to benefit
-statins ~2+ yrs for primary prevention
-ACEI/ARB ~3-5 yrs

24
Q

What is the role of ASA for primary prevention in older adults?

A

not recommended

25
Q

What are some considerations to keep in mind when choosing diabetes medications in older adults?

A

medications with a low risk of hypoglycemia are preferred
consider comorbidities:
-SGLT2 inhibitors preferred if HF
-SGLT2 inhibitors or GLP1-RA preferred if CVD
-SGLT2 inhibitors preferred if CKD
avoid overtreatment
re-evaluate treatment goals and regimens as health, functional status, or social supports change

26
Q

What are the pros of metformin?

A

effective first line agent (A1c lowering ~1%)
low risk of hypoglycemia
affordable

26
Q

Describe the role of lifestyle/non-pharm in diabetes management in older adults.

A

nutrition education remains important
weight loss generally not recommended in frail older adults
exercise helpful as well
-medical evaluation to ensure safety
-resistance training most associated with blood glucose lowering
challenging to maintain outside of a supervised setting/program

26
Q

What are the cons of metformin?

A

renal elimination/risk for accumulation in kidney disease
not recommended if eGFR < 30 ml/min
GI upset/diarrhea
should be held in acute illness (SADMANS)
monitor for B12 deficiency periodically

27
Q

What are the pros of SGLT2 inhibitors?

A

CV and renal outcome benefits
low risk of hypoglycemia
less effective for blood glucose/A1c lowering

28
Q

What are the cons of SGLT2 inhibitors?

A

risk of orthostatic hypotension, volume depletion
genital fungal infections
UTIs, worsening urinary incontinence
cost

29
Q

What are the pros of GLP1-RAs?

A

CV outcome benefits
effective blood glucose/A1c lowering (1-1.5%)
weight loss (if desirable)
low risk of hypoglycemia
once weekly injections available

30
Q

What are the cons of GLP1-RAs?

A

cost/coverage restrictions
NVD and decreased appetite
weight loss and decreased appetite may compound frailty
requires injection

31
Q

What are the pros of DPP4 inhibitors?

A

low risk of hypoglycemia
well-tolerated, weight-neutral
convenient
moderate effect on blood glucose (~0.8%)

32
Q

What are the cons of DPP4 inhibitors?

A

cost/coverage restrictions
no established outcome benefit in CVD or CKD
avoid saxagliptin and alogliptin in HF

33
Q

What are the pros of sulfonylureas?

A

effective blood glucose/A1c lowering (~1%)
inexpensive
convenient

34
Q

What are the cons of sulfonylureas?

A

hypoglycemia risk
weight gain
no established outcome benefits, some signals of increased CV risk
BEERS DRUG

35
Q

Which insulin regimens are associated with the highest risk of hypoglycemia in older adults?

A

multiple-daily insulin injections

36
Q

Which insulin regimens are associated with the lowest risk of hypoglycemia in older adults?

A

once-daily basal insulin
-long acting insulin analogues associated with less hypoglycemia than NPH

37
Q

What are some tips for insulin dose adjustments?

A

fix the lows first and the highs later
adjust insulin dose by 1-2 units at a time
adjust one insulin at a time
pre-prandial BG levels best for checking for lows
post-prandial BG levels help assess adequacy of bolus insulin

38
Q

How frequently should blood glucose be monitored in older adults?

A

needs to be individualized
-overmonitoring is common and increases burden and stress
-is it actionable by patient or HCP?
-consider stability of treatment and risk of hypoglycemia
A1c every 3-6 months

39
Q

What are the SADMANS drugs?

A

sulfonylureas
ACEIs
diuretics
metformin
ARBs
NSAIDs
SGLT2 inhibitors

PHAR350 (17 decks)

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