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Objective 2

Objective 2 Discuss recent data, guidelines, and counseling points pertaining to the older adults with diabetes. Special Considerations. Poorer socioeconomic situation Greater social isolation and loneliness Nursing home residency Polypharmacy

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Objective 2

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  1. Objective 2 Discuss recent data, guidelines, and counseling points pertaining to the older adults with diabetes.

  2. Special Considerations • Poorer socioeconomic situation • Greater social isolation and loneliness • Nursing home residency • Polypharmacy • Increases the risk of drug side effects and drug-to-drug interactions • Higher frequency of depressive illness or cognitive impairment • Alzheimer’s-type and multi-infarct dementia are approximately twice as likely to occur in those with diabetes • Untreated depression • Difficulty with selfcare • Implementing healthier lifestyle choices • Higher risk of mortality

  3. Special Considerations • Decreased Renal & Hepatic Function • Increased risk of adverse drug events • Increased risk of hypoglycemia • Increased risk of under treating hyperglycemia • Presence of a geriatric syndrome: confused state, depression, falls, incontinence, immobility, pressure sores • Presence of disabilities resulting from lower-limb vascular disease or neuropathy requiring a rehabilitation program • Frailty and limited life expectancy

  4. ADA Guidelines • Treatment goals for older adults are the same as younger adults if they have: • 1. Physical and cognitive functionality • 2. Adequate life expectancy to see the benefits • May widen glycemic goals if individual criteria is not met in older adults • Caution: avoid hyperglycemia-related complications American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

  5. ADA Guidelines • Treat cardiovascular risk factors according to individual patient characteristics • Hypertension treatment in older adults shows value in clinical trials • Lipid and aspirin therapy should be considered in older adults with diabetes if their life expectancy within the time period of the primary and secondary prevention trials • Monitor for complications, especially ones that lead to functional impairment • Individualize screening schedules • Yearly foot exams and podiatrist visits American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

  6. ADA Guidelines • Metformin and lifestyle changes should be initiated at diagnosis • Contraindications to starting metformin: • Renal impairment with SCr ≥ 1.5mg/dL in males or ≥ 1.4mg/dL in females • Severe liver impairment • Acute or chronic metabolic acidosis (including DKA) • Undergoing radiographic dye studies • Hypoxemia • Sepsis • CHF American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

  7. ADA Guidelines • Insulin therapy should be considered at initial diagnosis, +/- oral agents, when patients are symptomatic with or without increased glucose levels or A1C • Second oral agent or insulin therapy can be added if noninsulin monotherapy is at max dose and is failing to achieve A1C goal over 3-6 months. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

  8. ADA Guidelines • Treat CV risk factors while considering: • Timeframe of benefit, individual patient characteristics • Hypertension treatment indicated in many older adults • Lipid lowering and aspirin therapy may benefit patients whose live expectancy is equal to timeframe of primary or secondary prevention trials • Individualize screening for complications that may lead to functional impairment • Age >64 is a high-priority population for depression screening and treatment and diabetes can make this condition worse American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

  9. Clinical Pearls • Considerations about specific pharmacologic therapy in older adults: • Insulin requires good visual, motor, and cognitive skills • Metformin is contraindicated in renal insufficiency and significant heart failure • TZDs can cause fluid retention may exacerbate or lead to heart failure • Sulfonylureas can cause hypoglycemia • DPP-4 Inhibitors may increase risk of heart failure hospitalization • SGLT-2 inhibitors may increase UTI and frequency of urination American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

  10. Hypoglycemia in elderly = increased risk of falls due to dizziness • Hypoglycemia in elderly can be masked if patient is also taking a beta-blocker. Mask symptoms except sweating • If insulin dependent and trouble with hands or vision, difficulty accurately drawing up correct amount of insulin. Too much = hypoglycemia • Hypoglycemia counseling • Glucose tablets Hypoglycemia in Elderly

  11. Counseling Points • Importance of taking their medications • Side effects • Signs/Symptoms of hypoglycemia • See Podiatrist each year • Update vaccinations American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

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