Académique Documents
Professionnel Documents
Culture Documents
Older Adults
http://diabetescare.nshealth.ca/sites/default/files/LTCPocketRefNOV2016_0.pdf
Targets for
Glycemic
Control
Medications:
What do the guidelines say?
Avoid hypoglycemia
• Reconsider need for sulfonylureas
§ Will depend on how high the blood sugars are
• Reconsider A1c target
§ To reduce the risk of hypoglycemia
Why avoid hypoglycemia?
• Asymptomatic in this patient population
• Age related reduction in glucagon secretion
• Altered psychomotor performance limits ability to treat
hypoglycemia
Medications
• DPP-4 inhibitors should be used over sulfonylureas as second
line therapy to metformin, because of a lower risk of
hypoglycemia
diabetes 24.0%
23.0%
Feb-13
Feb-14
Feb-15
Feb-16
Feb-17
Feb-18
Oct-12
Jun-13
Oct-13
Jun-14
Oct-14
Jun-15
Oct-15
Jun-16
Oct-16
Jun-17
Oct-17
Looking at the CPG in Practice
• We typically target Clinical Frailty Scale for 59 T2DM
Residents - March 2018
HbA1c <8.5, as 60.0%
40.0%
moderately frail (>6). 30.0%
20.0%
10.0%
Diabetes in Older People. Graydon S. Meneilly MD, FRCPC, MACP,
Aileen Knip RN, MN, CDE, David B. Miller MD, FRCPC, Diana
0.0%
Sherifali RN, PhD, CDE, Daniel Tessier MD, MSc, FRCPC, Afshan
Zahedi BASc, MD, FRCPC. Table 1 & Figure 1 pages Canadian 5 6 7 8 9
Journal of Diabetes April 2018; 42: S284-S286. Mildly Frail Moderately Severely Very Terminally Ill
Frail Frail Severely
Frail
they
treated?
How are
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
0.0%
Oct-12
Jan-13
Apr-13
Jul-13
Oct-13
Jan-14
Apr-14
Jul-14
Oct-14
Jan-15
Apr-15
Jul-15
Oct-15
Jan-16
Apr-16
Jul-16
Looking at the CPG in Practice
Oct-16
Jan-17
Apr-17
Jul-17
Oct-17
Jan-18
% Ins
% diet
% O&I
% OHA
Considerations: Intake
• Menu & food service operations
• Recreation Therapy!! They get to have all the fun!
• “Cheating”, “Treats” & food in room
• Family & friends: compassionate treats
• Varied intake
• Resident choice
Considerations: Health Condition
• Frailty Score / Dependence
• Goals of Care / Level of Care
• LTC Medication Formulary
• Cognitive impairment
• Infection, colonization
• Wound healing
• Supplementation
Considerations: Health Condition
• Degree of hyperglycemia
• Hypoglycemia risk
• Cost
• Adherence
• Comorbidities
Considerations: Medications
Medication Characteristics
• How effective is it at lowering blood glucose?
• What outcomes have been achieved?
• How long has the medication been around?
• What is the safety profile?
• Cost
• Adherence
Monitoring Outcomes
• Lab ordering practices by lab or region: Limited or no
values for comparison
• HbA1c vs RBG
• Goals of Care: Often no blood work or RBG for QOL
• Weight management: stability, planned weight change
• Physical Function and independence
• Other indicators: wounds, infections, comorbidities
We heard you.
• Case studies and practice questions submitted by
members.
Carb Overload
Guidelines for Monitoring A1C for the Frail Elderly with Known Diabetes in or
Awaiting Long-Term Care (LTC)
• http://diabetescare.nshealth.ca/sites/default/files/files/Phase2LTCDraftMay2016.
pdf