THE SHADOW OF DIABETES CARE IN OLDER ADULTS FRANCISCO DIAZ GNP-BC, CDE

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1 THE SHADOW OF DIABETES CARE IN OLDER ADULTS FRANCISCO DIAZ GNP-BC, CDE

2 OBJECTIVES 1- Name 3 geriatric syndromes that impact DM care 2- Name the targets glycemic goals of care for older adults as recommended by American Diabetes Association 3- Name 3 anti-diabetes medications with high risk for hypoglycemia 4- Able to assess and to manage a hypoglycemic episode

3 INTRODUCTION million adult New Yorkers diagnosed with diabetes and 760,000 may not know that they have it 5 million have prediabetes diabetes related costs In NY $1.2 billion 2013 death attributed to DM; likely under counted because the identified cause would be cardiovascular disease but diabetes contributes to it Between death per 100,000 5 th cause of death in NY. (DiNapoli, T, 2015; CDC, 2015)

4 STANDARDS OF CARE FOR OLDER ADULTS American Diabetes Association Clin Diabetes 2018;36:14-37

5 GOALS & SETTING CRITERIA FOR OLDER ADULTS Adapted from: American Diabetes Association Clin Diabetes 2018;36: s119-s125 Patient Characteristics / Health Status Rationale A1c goal Healthy: Few coexisting chronic illnesses intact cognitive and functional status Complex / Intermediate: Multiple co-existing chronic illnesses or 2+ instrumental ADL impairments or mild- to moderate cognitive impairment Very complex/ poor health : LTC or end-stage chronic illnesses or moderate to- severe cognitive impairment or 2+ ADS dependencies Longer remaining life expectancy < 7.5% Fingerstick: mgdl Intermediate remaining life expectancy high treatment burden hypoglycemia vulnerability fall risk Limited remaining life expectancy Makes benefit uncertain <8.0% Finger stick: mgdl <8.5% Finger stick: mgdl

6 HYPOGLYCEMIA

7 IDENTIFICATION OF HYPOGLYCEMIA IN OLDER ADULTS Difficulties recognizing hypoglycemia in older adults Symptoms are not specific Easily misdiagnosed : stroke, vertigo, visual disturbance Atypical presentation e.g confusion or hypoactive delirium Unawareness of symptoms Patient who have impaired cognition are unable to communicate their feelings or symptoms

8 CONSEQUENCES OF HYPOGLYCEMIA Consequences of hypoglycemia Physical cognitive and functional dependence Recurrent falls Increased risks for fractures, frailty, mortality Behavioral changes : anxiety, fears, social Isolation Recurrent hospitalizations Increased risks for institutionalization

9 WHY SHOULD WE CARE?

10 HOW TO MANAGE HYPOGLYCEMIA 4 OUNCES X3 The National Diabetes Education Initiative

11 MEDICAL MANAGEMENT OF DIABETES CONSIDERING HYPOGLYCEMIA : PATOPHYSIOLOGY GLP1 SU TZD DDP4 INS GLP1 TZD SGLT2 GLP1 MET TZD GLP1 MET INS

12 Medical Management of diabetes : New Paradigm Abdul-Ghani,M and DeFronzo, R Diabetes Care 2017 Aug; 40(8):

13 ANTI DIABETES MEDICATIONS PER HYPOGLYCEMIA RISK

14 INSULINS

15 MONITORING

16 INSULIN PUMPS

17 APPS. DMES

18 CONSIDERATIONS: Type of Diabetes, Presence of complications, years with diabetes, past treatments Medications: how glucose levels will be affected AFTER taking the medications, inconsistent eating Episodes of hypoglycemia: provide events medication use, changes in eating pattern or type, increased activities, constitutional symptoms, was it asymptomatic. Measuring, keeping track of : foods, medications, exercise Before an appointment to a professional that will assess diabetes: check fasting, pre- meal and/ or 2 hours post meal for 2 days Emergency: glucagon pen, Personal Emergency Response system and Medic Alert Bracelet Possibility of driving, operating machinery, living alone, support system

19 CONCLUSION For older adults the benefits vs risks ratio of diabetes care is rather narrow; but now a days there are less riskier alternatives and possibilities to tailor it to those who would stand to benefit the least. Presence of hypoglycemia should be consider seriously, treated, prevented and, eventually, it should lead to reconsideration of the diabetes care to older adults.

20 RESOURCES General information: Diabetes Care Supplies, Medication Coverage : MLN/MLNMattersArticles/downloads/SE1008.pdf Sick Days & Emergency Preparedness:

21 SUPREME VIGILANCE

22 REFERENCES Abdelhafiz, A., Rodríguez-Mañas, L., Morley, J., & Sinclair, A. (2015). Hypoglycemia in Older People - A Less Well Recognized Risk Factor for Frailty. Aging And Disease, 6(2), Abdul-Ghani, M., & DeFronzo, R. (2017). Is It Time to Change the Type 2 Diabetes Treatment Paradigm? Yes! GLP-1 RAs Should Replace Metformin in the Type 2 Diabetes Algorithm. Diabetes Care, 40(8), American Diabetes Association. (2017). 11. Older Adults: Standards of Medical Care in Diabetes Diabetes Care, 41(Supplement 1), S119-S Holst, J., & Orskov, C. (2004). The Incretin Approach for Diabetes Treatment: Modulation of Islet Hormone Release by GLP-1 Agonism. Diabetes, 53(Supplement 3), S197-S Kirsh, S., & Aron, D. (2011). Choosing Targets for Glycaemia, Blood Pressure and Low-Density Lipoprotein Cholesterol in Elderly Individuals with Diabetes Mellitus. Drugs & Aging, 28(12), Lipska, K., Krumholz, H., Soones, T., & Lee, S. (2016). Polypharmacy in the Aging Patient. JAMA, 315(10), Rawlings, K. (2013). Sonia Sotomayor: Her Life With Diabetes. Diabetes Forecast. Retrieved 11 February 2018, from Stats of the State of New York. (2018). Cdc.gov. Retrieved 25 February 2018, from

7/28/17. Objectives: Hypoglycemia Unawareness in the Geriatric Patient: A Safety Concern. Disclaimer:

7/28/17. Objectives: Hypoglycemia Unawareness in the Geriatric Patient: A Safety Concern. Disclaimer: Hypoglycemia Unawareness in the Geriatric Patient: A Safety Concern 29TH ANNUAL TNP CONFERENCE TRANSFORMING HEALTHCARE IN TEXAS SEPTEMBER 8, 2017 AUSTIN, TEXAS Kenneth Lowrance, DNP, APRN, CNS, FNP-BC,