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 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

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

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.

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.

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.

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.

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.

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.

Hypoglycemia in Elderly 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

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.