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CDCES > Older adults > Flashcards

Older adults Flashcards

1
Q

What geriatric syndromes should be screened for that may affect QOL & DSMES ability?

A 
Depression
Polypharmacy
Chronic pain
Cognitive impairment
Falls
Urinary incontinence
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2
Q

What % of older adults over age 65 have pre-DM and DM?

A

Pre-DM 50%

DM 25%

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3
Q

What complications are most likely to impair functional status?

A

Visual

Lower extremity complications (neuropathy)

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4
Q

When should cognitive status be assessed in older adults with DM?
What screening tests can be used?
Why is screening important
If screening is positive, what next?

A
  • at age 65 and older
  • annually
  • at initial visit
  • if there is a decline in clinical status/self care (skipped meals, skipped insulin, difficulty ID/prevent/treat hypo, errors calculating insulin dose, errors counting CHO)
  • Mini cog, mini mental state exam, Montreal cognitive assessment
  • poor glycemic control associated with decline in cognitive function
  • longer duration DM= worsening cognitive function
  • Positive screen –> referral to behavioral health
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5
Q

What does cognitive impairment challenge?

A
  • reaching glycemic, BP, lipid goals
  • performing complex tasks (using glucometer, insulin adjustment)
  • hinders timing and content of meals
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6
Q

Why is hypo common in the elderly?

A
  • taking insulin

- impaired renal function (meds take longer to be excreted from the body)

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7
Q

Treatment goals in elderly
Healthy, few illnesses, intact cognitive ability
vs
multiple medical conditions, cognitive impairment, functional decline

A

healthy- <7-7.5%; can have goals similar to younger adults if they are expected to live long enough to reap benefits

not healthy <8-8.5%

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8
Q

What is important to do when elderly person is dx with DM?

A

assess health literacy, mathematical literacy, DSMES knowledge

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9
Q

If it’s determined that it’s appropriate to relax glycemic goals what should be considered?

A
  • avoid hypo

- avoid hyper that could –> HHS, dehydration, poor wound healing

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10
Q

What gives the greatest reduction in morbidity and mortality?

A

Controlling CV risk factors
Meeting BP targets is important for most older adults
Meeting lipid targets/taking aspirin has less evidence than meeting BP targets

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11
Q

Why are older individuals w/ DM at increased risk for sarcopenia & osteopenia?

A

DM associated w/ frailty, poor muscle qualit, reduced muscle strength
Frail- decreased physical performance, risk of adverse outcomes, poor nutritional intake esp protein

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12
Q

How to manage frailty in the elderly?

A

Improve nutrition intake and protein intake

cardio + resistance training

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13
Q

Medication choice considerations in elderly

A
  • avoidance of hypo
  • cost (Fixed income)
  • effect on weight/appetite
  • frequency/method/difficulty of administration
  • polypharmacy
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14
Q

Medication choices in elderly

oral meds

A
  • Metformin- appropriate for most, can use if GFR >30, careful with liver dz/HF due to risk of lactic acidosis; first line agent in older adult w/ T2DM
  • TZD- caution- may –> HF, osteoporosis, falls/fractures, macular edema
  • sulfonyurea- increased risk for hypo, avoid glyburide due to long acting nature
  • DPP- expensive
  • SGLT2i-caution due to volume depletion
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15
Q

Injectable meds

A

basal insulin- easy, once daily, low risk for hypo
GLP-1- may cause n/v/d
MDI- may be too complex for older adults
need to have cognitive, motor, visual skills to inject

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16
Q

DM considerations for LT care facilities

  • when to inject insulin
  • when to call provider
A
  • may inject insulin after eating if poor/variable carbohydrate intake
  • provider only has to see pt 1x every 30 days x first 3 months, then 1x every 60 days after
  • call provider
    BG <70- immediately
    BG 70-100- ASAP
    BG >250 x 1 day
    BG >300 x 2 days
    BG too high for glucometer
    sick, vomiting, symptomatic hyper, poor oral intake
17
Q

Why are older adults in LTC at high risk for hypo

A

impaired cognition
impaired renal function
slowed counterregulation
slowed intestinal absorption

18
Q

End of life care

A
  • T2DM- may d/c fingersticks, all oral meds

- T1D- no consensus but may do basal to prevent acute hyper

19
Q

How to deintensify tx regimen?

A
  • decrease dose
  • d/c some meds
  • reduce hypo, reduce DM distress
  • match pt’s SM/support abilities
20
Q

Older adults w/ DM are at higher risk for:

A
  • premature death
  • institutionalization
  • cognitive decline
  • functional disability
  • co-existing illnesses (CHD, stroke, HTN)
21
Q

Reducing risk of hypo in T1DM

A

-CGM is covered by Medicare & Medicaid

22
Q

How to deintensity basal insulin in older adult w/T2DM

A
  • give in AM not bedtime
  • look at fasting BG x 7 days; if 1/2 values are above target of 90-150, increase by 2 units
  • look at fasting BG x 7 days; if >2 are below 90, decreased by 2 units
23
Q

How to deintensify meal time insulin in T2DM?

A
  • if on >10 units, decrease by 50% and add noninsulin agent with aim to d/c meal time insulin
  • if on <10 units, d/c meal time insulin and give noninsulin agent
  • if choosing metformin, start at 500 mg, increase dose q 2 weeks as tolerated
  • if 50% of premeal checks are >150, increase dose or add another agent
  • if <2 premeal checks are <90, decrease dose
24
Q

How to switch from premixed insulin to basal to deinensify in T2DM?

A

give 70% TDD as basal and only in AM

25
Q

Tx goals in healthy adults w/ few other medical conditions, intact cognitive & functional status

A 
A1c <7-7.5%
Fasting/pre-meal 80-130
Bedtime 80-180
BP <140/90
statin unless contraindicated or not tolerated
26
Q

Tx goals in adults w/ complex/intermediate

(3 or more coexisting conditions) or 2+ ADL impairments or mild to moderate cognitive impairment

A 
A1c <8%
Fasting 90-150
Bedtime 100-180
BP <140/90
statin unless contraindicated or not tolerated
27
Q

Tx goals for those in very poor health (LTC or end stage chronic illnesses) or moderate-severe cognitive impairments

A 
don't use A1c
Fasting/pre-meal 100-180
Bedtime 110-200
BP <150/90
consider benefit of statin
28
Q

Simplified meal time sliding insulin scale

A

> 250- 2 units of short/rapid acting
350- 4 units of short/rapid acting
d/c when no longer needed daily

CDCES (13 decks)

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