Older adults Flashcards
What geriatric syndromes should be screened for that may affect QOL & DSMES ability?
Depression Polypharmacy Chronic pain Cognitive impairment Falls Urinary incontinence
What % of older adults over age 65 have pre-DM and DM?
Pre-DM 50%
DM 25%
What complications are most likely to impair functional status?
Visual
Lower extremity complications (neuropathy)
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?
- 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
What does cognitive impairment challenge?
- reaching glycemic, BP, lipid goals
- performing complex tasks (using glucometer, insulin adjustment)
- hinders timing and content of meals
Why is hypo common in the elderly?
- taking insulin
- impaired renal function (meds take longer to be excreted from the body)
Treatment goals in elderly
Healthy, few illnesses, intact cognitive ability
vs
multiple medical conditions, cognitive impairment, functional decline
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%
What is important to do when elderly person is dx with DM?
assess health literacy, mathematical literacy, DSMES knowledge
If it’s determined that it’s appropriate to relax glycemic goals what should be considered?
- avoid hypo
- avoid hyper that could –> HHS, dehydration, poor wound healing
What gives the greatest reduction in morbidity and mortality?
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
Why are older individuals w/ DM at increased risk for sarcopenia & osteopenia?
DM associated w/ frailty, poor muscle qualit, reduced muscle strength
Frail- decreased physical performance, risk of adverse outcomes, poor nutritional intake esp protein
How to manage frailty in the elderly?
Improve nutrition intake and protein intake
cardio + resistance training
Medication choice considerations in elderly
- avoidance of hypo
- cost (Fixed income)
- effect on weight/appetite
- frequency/method/difficulty of administration
- polypharmacy
Medication choices in elderly
oral meds
- 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
Injectable meds
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
DM considerations for LT care facilities
- when to inject insulin
- when to call provider
- 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
Why are older adults in LTC at high risk for hypo
impaired cognition
impaired renal function
slowed counterregulation
slowed intestinal absorption
End of life care
- T2DM- may d/c fingersticks, all oral meds
- T1D- no consensus but may do basal to prevent acute hyper
How to deintensify tx regimen?
- decrease dose
- d/c some meds
- reduce hypo, reduce DM distress
- match pt’s SM/support abilities
Older adults w/ DM are at higher risk for:
- premature death
- institutionalization
- cognitive decline
- functional disability
- co-existing illnesses (CHD, stroke, HTN)
Reducing risk of hypo in T1DM
-CGM is covered by Medicare & Medicaid
How to deintensity basal insulin in older adult w/T2DM
- 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
How to deintensify meal time insulin in T2DM?
- 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
How to switch from premixed insulin to basal to deinensify in T2DM?
give 70% TDD as basal and only in AM
Tx goals in healthy adults w/ few other medical conditions, intact cognitive & functional status
A1c <7-7.5% Fasting/pre-meal 80-130 Bedtime 80-180 BP <140/90 statin unless contraindicated or not tolerated
Tx goals in adults w/ complex/intermediate
(3 or more coexisting conditions) or 2+ ADL impairments or mild to moderate cognitive impairment
A1c <8% Fasting 90-150 Bedtime 100-180 BP <140/90 statin unless contraindicated or not tolerated
Tx goals for those in very poor health (LTC or end stage chronic illnesses) or moderate-severe cognitive impairments
don't use A1c Fasting/pre-meal 100-180 Bedtime 110-200 BP <150/90 consider benefit of statin
Simplified meal time sliding insulin scale
> 250- 2 units of short/rapid acting
350- 4 units of short/rapid acting
d/c when no longer needed daily
