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NR601 Caring for the Older Adult > Week 5 Diabetes and Obesity > Flashcards

Week 5 Diabetes and Obesity Flashcards

1
Q

Comorbidities related to obesity

A

DM, HTN, metabolic syndrome, OSA, osteoarthritis, CAD, stroke, dyslipidemia, CKD, fatty liver disease, varicose veins, GERD, gallbladder disease, certain cancers, sexual dysfunction, lower urinary tract symptoms, impaired cognitive function and dementia

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2
Q

Underweight BMI Classification

A

< 18.5

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3
Q

Normal BMI Classifications

A

18.5 - 24.9

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4
Q

Overweight BMI Classification

A

25.0-29.9

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5
Q

Class I Obesity

A

30.0-34.9

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6
Q

Class II Obesity

A

35.0-39.9

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7
Q

Class III Extreme Obesity

A

> 40.0

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8
Q

Type I Diabetes Related Genetics

A

HLA-DQ and HLA-DR

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9
Q

Signs of Type I Diabetes

A

polyphagia, polyuria, polydipsia, nocturnal enuresis, polyphagia with paradoxical weight loss, visual changes, fatigue, weakness and anorexia

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10
Q

Percentage of Diabetics with T1DM

A

5%

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11
Q

Percentage of Total Population with DM

A

9.4%

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12
Q

Adults 65 years and older with diabetes?

A

25.2%

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13
Q

T2DM is the ____ leading cause of death in the US.

A

7th

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14
Q

T1DM most common ethnicity

A

Caucasians of European descent

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15
Q

T2DM most common ethnicity

A
  1. Native Americans and Alaskan Natives

2. African American and Hispanics

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16
Q

Risk Factors for T1DM

A
  • Caucasian
  • Rubella infection, Coxsackie B4 virus, cytomegalovirus, adenovirus, mumps
  • Genetic predisposition
  • Cow’s milk protein
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17
Q

Risk Factors for T2DM

A
  • 1st degree relative with T2DM
  • BMI > 25
  • Age > 45
  • Hx of GDM, HTN, HLD,
  • Women w/ PCOS
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18
Q

Medications that can cause hyperglycemia

A
  • glucocorticoids
  • hormonal therapies (oral contraceptives)
  • immunosuppressants tacrolimus and cyclosporine
  • nicotinic acid
  • antiretroviral protease inhibitors for HIV
  • several atypical antipsychotics: clozapine and olanzapine
  • certain antihypertensives: beta blockers, calcium channel blockers, clonidine, thiazide diuretics
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19
Q

HgbA1c Diagnostic Criteria for Diabetes

A

6.5% or higher

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20
Q

HgbA1c Diagnostic Criteria for Prediabetes

A

5.7-6.4%

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21
Q

Fasting Glucose Diagnostic Criteria for DM

A

126 or higher on 2 occasions

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22
Q

Random Plasma Glucose Level Diagnostic Criteria for DM

A

200 or higher with symptoms of hyperglycemia (polyuria, polydipsia, weight loss)

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23
Q

2-hr Post Prandial Glucose Diagnostic Criteria

A

200 or higher during OGTT with 75 gram load

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24
Q

C-Peptide Levels in T1DM

A

decreased

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25
Q

C-Peptide Levels in T2DM

A

normal or elevated

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26
Q

First-line Treatment for T1DM

A

intensive insulin regimens to achieve glucose management goals

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27
Q

Goals of Glucose Management

A

before meals: 80-120
PP: < 180
A1c: < 7%

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28
Q

Medical Nutritional Therapy for DM

A

Mediterranean diet
Dietary Approaches to Stop HTN
Plant-based diets
Eating plan that maintains a healthy body weight, supports glycemic control, facilitates BP and lipid goals, and delays or prevent complications of DM

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29
Q

Hypoglycemia S/Sx

A

diaphoresis, tachycardia, shakiness, altered mentation, slurred speech, seizures, coma

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30
Q

Somogyi effect

A

patient develops hypoglycemia during the night with rebound hyperglycemia in the AM

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31
Q

Exercise in T1DM

A
  • Check BS before exercise, every 30-60 minutes during and after exercise
  • Avoid exercise if fasting glucose > 250 and ketosis is present or if the glucose level is > 300 regardless of whether ketosis is present
  • Consume additional carbs if glucose less is < 100 and as needed to avoid hypoglycemia
    Identify when changes in insulin dose or food intake are necessary
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32
Q

Urine Ketone Testing in T1DM

A
  • Presence of hyperglycemia and/or stressful events that can lead to hyperglycemia (illness, N/V)
  • BS > 240 check for ketones q 4 hrs
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33
Q

T2DM Physical Activity

A
  • Increasing general movement through ADLs and decreasing sedentary behaviors
  • 150 minutes of exercise a week of moderate to intensive physical activity at least 3 days a week; no more than 2 consecutive days without exercise
  • Resistance training 2 days a week improves A1c control
    Flexibility and balance training 2-3x a week in older adults
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34
Q

SMBG in T2DM on Insulin

A

2-3x/day

increase monitoring during illness, changes in diet and exercise or a change in medications

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35
Q

SMBG in T2DM not on Insulin

A

2-3x/week alternating before breakfast, evening meal and at bedtime with occasional 2hr PP
increase monitoring during illness, changes in diet and exercise or a change in medications

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36
Q

1st line Treatment for T2DM

A

metformin

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37
Q

AACE Recommends adding a 2nd agent if A1c is ______.

A

> 7.5%

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38
Q

ADA Recommends adding a 2nd agent if A1c is _____.

A

> 9%

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39
Q

AACE recommends starting insulin when A1c is _____.

A

9% or higher and pt is symptomatic

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40
Q

ADA recommends starting insulin when A1c is _____.

A

10% or higher with symptoms

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41
Q

What dose is basal insulin started at?

A

0.1-0.2 units/kg/day

42
Q

How much do you increase the dose of insulin and based on what?

A

10-15% or 2-4 units once or twice a week based on FBS

43
Q

What is the normal FBS target for T2DM

A

<140

44
Q

Basal Insulins

A

NPH - intermediate
Glargine (Lantus), detemir (Levemir) - long acting
degludec (Tresiba) - ultra-long acting

45
Q

Mealtime Bolus Insulins

A

Regular human insulin
Aspart (Novolog)
Glulisine (Apidra)
Lispro (Humalog)

46
Q

Sliding scale for T2DM mealtime bolus insulins is based on:

A

preprandial glucose of next meal

47
Q

Metformin Side Effects

A

GI disturbances and metallic taste

48
Q

Metformin Prescribing Considerations

A
  • watch for hypoglycemia, especially in older adults

- contraindicated in renal disease, renal function should be assessed before starting

49
Q

First Generation Sulfonylureas (no longer recommended)

A

chlorpropamide (Diabinese)
tolbutamide (Orinase)
safety profile worse than 2nd generation

50
Q

Second Generation Sulfonylureas

A

Glimepiride (Amaryl)
Glipizide (Glucotrol)
Glyburide (Diabeta, Micronase)

51
Q

Sulfonylureas Side Effects

A 
HYPOGLYCEMIA
weight gain
nausea
weakness
photosensitivity
52
Q

Sulfonylureas Contraindications

A

DKA
Allergy to Sulfa
decreased renal function

53
Q

Meglitinides

A

nateglinide (Starlix)

repaglinide (Prandin)

54
Q

Meglitinide Contraindications

A

liver insufficiency

55
Q

Meglitinide Side Effects

A

hypoglycemia, headache, upper respiratory infection, N/V/D, constipation, muscle aches and chest pain

56
Q

Thiazolidinediones (TZDs)

A

pioglitazone (Actos)

rosiglitazone (Avandia)

57
Q

TZDs Side Effects

A

Headache, weight gain, edema and anemia

58
Q

TZDs Contraindications

A

Heart failure, bladder cancer, osteoporosis and liver disease

59
Q

DPP-4s

A

sitagliptin (Januvia), linigliptin (Tradjenta), saxagliptin (Onglyza), and alogliptin (Nesina)

60
Q

DPP-4s Contraindications

A

pancreatitis

61
Q

DPP-4 Side Effects

A

upper respiratory infection, nasopharyngitis and headache

62
Q

Alpha-glucosidase Inhibitors

A

acarbose (Precose)

miglitol (Glyset)

63
Q

Alpha-glucosidase inhibitor side effects

A

flatulence, diarrhea, abdominal pain and rash

64
Q

Alpha-glucosidse inhibitor contraindications

A

ketoacidosis, irritable bowel disease, intestinal obstruction or renal impairment

65
Q

SGLT2 Inhibitors

A

dapagliflozin (Forxiga), canagliflozin (Invokana), empagliflozin (Jardiance), ertugliflozin (Steglatro)

66
Q

Canagliflozin (Invokana) black box warning

A

2-fold increase of leg and foot amputations in those patients with T2DM and cardiovascular disease

67
Q

SGLT2 Inhibitor Side Effects

A

acute renal failure, ketoacidosis, hypotension, urinary and/or genital fungal infections and nauseas

68
Q

SGLT2 Inhibitors Contraindicated in:

A

CHF, nephrotoxicity, volume depletion

69
Q

GLP-1 Receptor Agonist (Incretins) injected

A

exenatide (Byetta), liraglutide (Victoza), lixisenatide (Lyxumia), albiglutide (Tanzeum), dulaglutide (Trulicity) and semaglutide (Ozempic)
helps with weight loss

70
Q

GLP-1 Side Effects

A

nausea and feeling of fullness that may dissipate after a few weeks
hypoglycemia when used with sulfonylureas or insulin, V/D, HA, nervousness and stomach discomfort, decreased appetite, acid reflux and increased sweating

71
Q

GLP-1 Contraindications

A

DKA

72
Q

GLP-1 Black Box Warning

A

medullary thyroid carcinoma or a family hx of that disease or with multiple endocrine neoplasia syndrome type 2

73
Q

A1c goal for healthy older adults

A

<7.5%

74
Q

Alc goal for complex/intermediate health older adults

A

<8.0%

75
Q

A1c goal for very complex/poor health older adults

A

<8.5%

76
Q

Healthy older adult means

A

few coexisting chronic illnesses, intact cognitive and functional status

77
Q

Complex/intermediate older adult means

A

multiple coexisting chronic illnesses or 2+ instrumental ADL impairments or mild-to-moderate cognitive impairment

78
Q

Very complex/poor health older adult means

A

LTC or end-stage chronic illnesses or moderate-to-severe cognitive impairment or 2+ ADL dependence

79
Q

Fasting or Preprandial Glucose Goal for Healthy Older Adults

A

90-130

80
Q

Fasting or Preprandial Glucose Goal for Complex/Intermediate Older Adults

A

90-150

81
Q

Fasting or Preprandial Glucose Goal for Very Complex/poor health Older Adults

A

100-180

82
Q

Bedtime Glucose Goal for Healthy Older Adults

A

90-150

83
Q

Bedtime Glucose Goal for Complex/intermediate Older Adults

A

100-180

84
Q

Bedtime Glucose Goal for Very Complex/poor health Older Adults

A

110-200

85
Q

HgbA1c Goal that indicated strong control

A

< 7%

86
Q

HgbA1c of < 6.5% has been shown to ___________________

A

significantly decrease the occurrence of complications, provided this can be achieved without hypoglycemia or other adverse effects

87
Q

Weight Loss Recommendations to decrease risks related to diabetes; what percentage?

A

5%

88
Q

What complications can occur due to diabetes/hyperglycemia?

A

loss of vision, renal failure, amputations, chronic foot ulcers, peripheral neuropathies, sexual problems, GU disorders, CVD. PVD, stroke, uncontrollable angina, bruits, EKG abnormalities, decreased immune system functioning, HHS and DKA
depression

89
Q

Diabetes is the leading cause of what complication?

A

end-stage renal disease and acquired blindness in the US

90
Q

Treatment of neuropathy

A

○ Non-opioid analgesics, TCAs, calcium channel blockers, narcotics, antiarrhythmics, local anesthetics
○ Pregabalin (Lyrica) and duloxetine (Cymbalta) FDA approved for treatment of neuropathic pain in DM
○ Opioid tapentadol (Nucynta, Palexia, Tapal) FDA approved as well but less evidence on effectiveness
○ Gabapentin, venlafaxine (Effexor), carbamazepine (Tegretol), tramadol (Ultram) and topical capsaicin

91
Q

Treatment of Cardiovascular Complications or Prevention

A

ASA 81-165 mg daily

92
Q

Treatment of Hyperlipidemia

A

statins

93
Q

Treatment of Diabetic Kidney Disease

A

ACE inhibitors and ARBs

94
Q

BP goal

A

BP < 140/90 is goal

95
Q

What complications require immediate action?

A

DKA
Fasting hyperglycemia > 300
HgbA1c > 13%
Severe hypoglycemia with changes in sensorium, altered behavior, seizures or coma

96
Q

Evaluations Required at EVERY Follow-Up Visit

A

Evaluate response (BS log/HgbA1c), tolerability to therapy, goal reassessment, and management of acute and chronic complications
○ BP
○ Review BS log
○ Review medications
○ Examination of feet for complications
○ Urinalysis, urine microalbumin/creat ratio
○ Serum creatinine levels and eGFR
○ HgbA1c q 3-6 months
○ Examine for neurovascular complications
○ Self-management education
○ Immunizations

97
Q

How often should a patient with DM follow-up?

A

every 3-6 months

monthly if sudden change in health status or treatment regimen follow-up

98
Q

Required Annual Evaluations of DM Patients

A

eye exam with dilation
EKG
Fasting lipids
Biannual oral examinations

99
Q

Ophthalmologist Referrals

A

Dilated comprehensive eye exam done within first 5 years of diagnosis for T1DM
No retinopathy detected = eye exam q 2 years
Retinopathy detected = eye exam at least annually

100
Q

Endocrinologist Referrals

A

T1DM

T2DM when FBS consistently > 300 and HgbA1c > 13%

NR601 Caring for the Older Adult (4 decks)

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