Addressing Primary Care Challenges in T2 Diabetes Management of Older AdultsCynthia Gerstenlauer, ANP-BC, GCNS-BC, CCD

Epidemiology of Older Adults (age >65) in US with Diabetes1,2

• >90% have T2D

• Prevalence of 33%

• Nearly 50% meet criteria for Prediabetes

• Incidence of newly diagnosed highest age 65 to 79

• Prevalence projected to increase dramatically during the next 30 years, especially in those >75

• T2DM prevalence increases with aging• Insulin production decreases, insulin resistance increases, impaired hepatic glucose metabolism

• ¼ are undiagnosed; almost 50% of Asian and Hispanic Americans are undiagnosed

• Most are diagnosed from routine screening or is delayed until the identification of diabetic complications

• Cost of diabetes in 2017 was $327B3

Older Adults with Diabetes4

• Have higher rates of premature death, functional disability, accelerated muscle loss, comorbidities: hypertension, coronary heart disease, stroke

• At greater risk of geriatric syndromes: polypharmacy, cognitive impairment, depression, urinary incontinence, falls, persistent pain

• Impacts their diabetes self-management abilities and quality of life

• At higher risk of institutionalization

Complexity of Assessing Older Adults with Diabetes1

• Functional Status

• Cognitive Dysfunction

• Depression

• Alcohol use

• Tobacco Use

• Nutritional status

• Medication review/polypharmacy

• Fall risk

• Sensory Impairment

• Comorbid conditions

• Frailty/physical performance/sarcopenia

Screening Tools to Assess Older Adults

Functional Status ADLs/IADLs Deficits should trigger a more in-depth evaluation

Cognitive impairment MMSEMOCA

Simplify medication regimensTailor glycemic targetsMay need to involve caregiverAssociated with poorer diabetes self-management & glycemic control, increased frequency of hospitalizations, occurrence of severe hypoglycemic episodes, MACE and death

Depression Geriatric Depression ScalePatient Health QuestionnaireDiabetes Distress Scale

At risk poor nutritionTreat

Sensory deficits (vision, hearing, smell, taste)

Specialty providersProvider assessment

Detect and manage malnutritionTargeted glucose monitor selection

Screening Tools cont.

Comorbid conditions Renal Impairment(urinary albumin >300 mg/g creatinine and/or eGFR 30-60 mL/min/1.73 m2)

Affects pharmacokinetics and pharmacodynamics specific agentsOptimize glucose control to reduce or slow progressionConsider use of SGLT2

Heart disease Avoid hypoglycemia due to potential arrhythmias and stroke

Obesity (BMI) Nonjudgmental languageAssess diet, physical activity, behaviorsDiscuss health outcomes of weight lossConsideration of social determinants of health

Screening cont.

If at risk

Nutritional status Mini Nutritional AssessmentShort Nutritional Assessment Questionnaire

Diets rich in protein and energyEmphasize portion control and healthful food choicesAvoid restrictive dietsLimit consumption of simple sugarsMonitor glycemic responses to changes in diet closely

Physical impairment Timed “get-up and go” test4-m Gait speedGrip strength

Physical therapyOccupational therapy

Sarcopenia Dual-energy X-ray absorptiometry (DXA) scan Sarc-F

Nutritional therapy and exercise trainingMeasure 25-hydroxyvitamin D levels and replace if lowProtein intake of at least 1.5g/kg/d (15 to 20% of total caloric intake)

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Hypoglycemia and Older Adults1

• May cause confusion, delirium, dizziness, weakness, and traumatic falls

• Bidirectional relationship with cognitive dysfunction

• If severe:• Doubles the risks of major macrovascular and microvascular events

• Deaths from a cardiovascular cause

• Death from any cause

• Associated with respiratory and gastrointestinal conditions

Hyperglycemia and Older Adults1

• Definition: Blood glucose levels consistently over the renal threshold for glycosuria (~>200)

• Increases the risk of dehydration, electrolyte abnormalities, urinary infections, dizziness and falls

• If severe (diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome):• Higher mortality rates

Lifestyle Changes: 1st Line Treatment for Ambulatory4

• If overweight, even 5% weight loss improves glycemic control

• Combination of physical activity and nutritional therapy

• Reduce sedentary behavior and moderate-intensity aerobic activity

• Activity plan should consider older adult’s abilities and aerobic fitness after careful medical evaluation, including exercise testing and heart rate/blood pressure monitoring as needed

• Activities aimed at increasing flexibility, muscle strength, and balance recommended

Pharmacologic Therapy for T2DADA Guidelines5

• Patient-centered approach to guide choice: effect on CV and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost, risk for side effects and patient preferences

• Early combination therapy can be considered based on A1c and is most likely needed

• If established atherosclerotic CV disease or high risk, established kidney disease, or heart failure: SGLT2 inhibitor or GLP-1 receptor agonist

• A GLP-1 is preferred to insulin when possible

• Treatment should be intensified for patients not meeting treatment goals

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The long-practiced glucocentric paradigm has become antiquated6

“Evidence-based medicine (UPKDS) has taught us that sequential therapy with metformin followed by sulfonylurea addition with subsequent insulin addition represents the treat to fail approach, and we do not recommend this approach unless cost is the overriding concern”

Defronzo R, Eldor R, Abdul-Ghani M. Pathophysiologic Approach to Therapy in Patients With Newly Diagnosed Type 2 Diabetes. Diabetes Care, 2013;36(2);S127-137

Drug Therapy for HyperglycemiaRx A1c % Advantages Disadvantages

Metformin 1.0 – 2.0 Proven effectiveness as 1st line therapyNo risk of hypoglycemiaNeutral weight effectLong term clinical experiencesLow costImproves CV outcomes, regression of atherosclerosis

CI when serum creatinine >1.5 mg/dL in men or >1.4 mg/dL in women; liver failure & advanced heart failureGI side effects may cause poor appetite & malnutritionConcerns of vitamin B12, folate deficiencyAvoid use in patients with severe CHF to avoid lactic acidosis

Sulfonylureas 1.0 – 2.0 Proven glucose lowering efficacyLong term clinical experiencesRelatively low cost

Frequent hypoglycemiaWeight gainGlyburide: avoid if eGFR <60Glimepiride: avoid if eGFR <30Glipizide: use with caution of eGFR <30

Meglitinides/Glinides

0.3 – 1.5 Rapid onset of action timeFlexible dosing for those with irregular eating habits

HypoglycemiaWeight gainFrequent dosingRelatively high costNateglinide: stop if eGFR <60 (can use if on dialysis)

DPP-4 inhibitors 0.5 – 0.8 No risk of hypoglycemiaWeight neutralityDose adjustments for renal insufficiencyWell tolerated

Limited efficacyRelatively high costLimited long-term dataSaxagliptin can increase the risk of heart failure

Alpha glucosidase inhibitors

0.5 – 0.8 Effectively reduce postprandial glucoseNo hypoglycemia

Only modest efficacyFrequent GI side effects – flatulence and diarrheaFrequent dosingRelatively high costAvoid if serum creatinine >2.0

Thiazolidinediones 0.3 – 1.4 Reduce insulin resistanceDurable effects on glycemic controlDoes not cause hypoglycemiaPioglitazone reduces CVD mortality

Weight gainFluid retention, which may precipitate or worsen heart failureIncreased risk of bone fractures and bone loss in womenConcern of bladder cancer

Drug Therapy for Hyperglycemia cont.Rx A1c % Advantages Disadvantages

Insulin 1.5 – 3.3 Proven effectivenessNo-dose limitation

Need a parental injectionFrequent hypoglycemiaWeight gainNeed glucose monitoring & adjusting the doseRequire patient’s executive functioning

GLP-1 receptor agonists

0.3 – 1.0 Increase insulin release, decrease glucagon secretion, delay gastric emptying, suppress appetiteNo risk of hypoglycemiaWeight reduction (beneficial in obese patients)Liraglutide and semaglutide reduce MACENo dosage adjustment needed for renal insufficiency except for Lixisenatide: avoid if eGFR <15

Relatively high-costNeed a parental injectionGI side effects may not be tolerated (nausea)High-costLimited long-term experienceExenatide: avoid if eGFR <30

SGLT2 inhibitors 0.8% Does not cause hypoglycemiaEmpagliflozin and canagliflozin have been demonstrated to reduce MACE and CHF, reduce progression of CKDCan reduce weight

Volume depletion adverse effects more common in older patients (limit canagliflozin to 100 mg/d)Avoid dapagliflozin and ertugliflozin if eGFR <60, empagliflozin if eGFR <45Canagliflozin may increase fracture risk, associated with increased risk of toe and foot amputationsCanagliflozin and dapagliflozin have been associated with acute kidney injuryIncrease in urogenital candida infectionsRare cases of diabetic ketoacidosis

Bromocriptine 0.4% Does not cause hypoglycemia Not studied in CKDMay cause nausea

Colesevelam 1% Does not cause hypoglycemia May cause GI side effects

HbA1c1

• Blood glucose concentrations over 3-4 months

• Convenient and validated method for determining overall glycemic status

• Strongly associated with chronic diabetic vascular complications

• Influenced by conditions that affect survival of RBC independent of glycemia (anemia, CKD, GI bleeding, VHD); also, by glycation rates, uremia, smoking, ethnicity

• Higher in minorities, mainly African Americans

• Does not assist in identifying hypoglycemia, glucose patterns• Older adults with T2D tend to have more postprandial hyperglycemia than fasting

hyperglycemia

International Consensus in Time in Range (IC-TIR) for Patients Using CGM7

T1DM and T2DM T1DM and T2DM “fragile”

Time in Range (TIM) >70% (70-180 mg/dL) >50% (70-180 mg/dL)Time in Hypoglycemia <4% below 70mg/dL

<1% below 54 mg/dL<1% below 70 mg/dL

Time in Hyperglycemia <25% >90% below 250 mg/dL

Battelino T, Danne T, Phillip M; for the International Consensus on TIR Targets. CGM-based clinical targets: recommendations from the International Consensus on Time-in-Range (TIR). Presented at: American Diabetes Association 79th Scientific Sessions; June 7-11, 2019; San Francisco, CA. Poster 2-LB

Diabetes Technology8

• Hardware, devices, and software that provides diabetes self-management support

• Insulin administered by syringe, pen, aerosol, or pump

• BGM by meter (SMBG) or Continuous Glucose Monitoring (CGM)

• Hybrid devices: monitor glucose and administer insulin, software that serves as a medical device

• Needs education and follow-up

Self-monitoring of blood glucose (SMBG) recommended for all8

• Individualized based on patient dexterity, adequate circulation, sufficient vision, hearing, cognition, comorbidities, caregiver support, glycemic goals, type of diabetes management

• Ask patients to demonstrate the use of the meter

• Understanding the significance of the result, what is high or low, when to test, what action should be taken (adjust food intake, exercise or pharmacologic therapy to achieve specific goals)

• Ability to obtain affordable supplies (testing is a MC benefit)

SMBG cont.

• Accuracy dependent on the device and user

• Use only unopened and unexpired test strips

• Medications, high-dose vitamin C, hypoxemia can interfere with glucose meter accuracy

• Correlation between SMBG frequency and lower A1C in DT1, mixed with DT2 not on insulin

• Every patient visit, review and interpret data, adjust therapy, ongoing need and frequency

• If on basal insulin, at least check FBG

• If on intensive insulin therapy: check prior to meals and snacks, bedtime, occasionally postprandially, prior to exercise, when suspect low blood glucose, after treating low blood glucose till normoglycemic, prior to performing critical tasks like driving; 6-10 times daily

Continuous Glucose Monitoring (CGM) Devices8

Types of CGM DescriptionReal-time (rtCGM) Measure and display glucose levels continuouslyIntermittently scanned (isCGM)

Measure glucose levels continuously but only display glucose values when swiped by a reader or smartphone

Professional Placed on the patient in the provider’s office (or with remote instruction), worn for 7-14 days to assess glycemic patterns and trends; device owned by the office

Continuous Glucose Monitoring (CGM)

• Requires robust competent diabetes education, training, and ongoing support

• Device companies offer online tutorials, training videos, written materials, often available to implement with patients

Improved Diabetes Outcomes with CGM8

• Identifies high-risk glycemic patterns

• Can assist in adjusting diabetes regimens to achieve lower targets without increasing hypoglycemia risk

• In the older adult cohort of the DIAMOND study, (N=116 >60), CGM vs SMBG, CGM group demonstrated high use (97%), >HbA1c reduction, less glycemic variability1

• Multiple studies have shown benefit with reduced A1Cs, time in hypoglycemia, absenteeism, hospitalizations; increased Time in Range (TIR), improved quality of life, treatment satisfaction, preferred to SMBG`

• The FreeStyle Libre users, compared to the Dexcom users, were generally more diverse, older, more likely to live outside a metropolitan area, have comorbidities9

Optimal Diabetes Management3www.cdc.gov/diabetes/ndep/training-tech-assistance/index.html

• Organized, systematic approach; patient-centered, high-quality care

• Involvement of a coordinated, complementary team of dedicated hcp

• Use evidence-based guidelines

• Implement electronic health record tools

• Diabetes Technology

• Remove financial barriers

• Utilize community resources

• Patient Centered Medical Home programs foster comprehensive primary care

• Telemedicine increases access to care, clinical health status

Summary

• Older Adults with diabetes have a pluralistic of needs and face constant challenges over the course of disease management

• Diabetes is associated with disease burden and financial implications

• T2DM is a multifactorial, multiorgan disease, and antidiabetic medications should address underlying pathogenic mechanisms rather than solely reducing the blood glucose concentration. Emphasis should be placed on medications that ameliorate insulin resistance and prevent b-cell failure.

• Patients with diabetes are at high risk for cardiovascular events, and comprehensive evaluation/treatment of all cardiovascular risk factors is essential. Base selection of drugs not only on the drug’s glucose-lowering efficacy/durability but also on its effect on weight, blood pressure, lipids, cardiovascular protection, and side effect profile, especially hypoglycemia.

• Seniors may be hesitant to use technology and will require time and patience to teach, but it can make it easier and more effective to do diabetes self-management, improve quality of life, forestall feeling of isolation and loneliness, bring family members together

References

1. LeRoith D, Biessels G, Braithwaite S, et al. Treatment of Diabetes in Older Adults. J Clin Endocrinol Metab, 2019;104(5):1520-1574. Published online 2019 Mar 23. https://doi: 10.121-/jc.2019-00198

2. Bigelow A and Freeland B. Type 2 Diabetes Care in the Elderly. The Journal for Nurse Practitioners, 2017;13(3):181-189.

3. American Diabetes Association. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes—2021. Diabetes Care,2021;44(1); p.S8

4. American Diabetes Association. Older Adults: Standards of Medical Care in Diabetes—2021. Diabetes Care 2021;44(1);S168-179.

5. Defronzo R, Eldor R, Abdul-Ghani M. Pathophysiologic Approach to Therapy in Patients With Newly Diagnosed Type 2 Diabetes. Diabetes Care, 2013;36(2);S127-137.

6. `American Diabetes Association. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2021. Diabetes Care, 2021;44(1);S111-124.

7. Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diab Care, 2019;1(42):1593-603.

8. American Diabetes Association. Diabetes Technology: Standards of Medical Care in Diabetes—2021. Diabetes Care 2021;44(Supl.1);S85-S99. https://doi.org/10.2337/dc21-S007

9. Dunleavy, D. Next steps in the Advancement of Solutions for the Treatment o Diabetes. Webinar live, 11/3/2021, sponsored by Medtronics Technology.