Studies show that diabetes technology such as insulin pumps and continuous glucose monitors (CGM) can benefit some older adults with the disease, but clinicians must determine who gains the biggest benefits versus risks to achieve the best outcomes.
“The thing with technology is that you have the shoe, but it must fit for the right outcome,” said Medha Munshi, MD, Director of the Geriatric Diabetes Program for Joslin Diabetes Center and Associate Professor of Medicine at Harvard Medical School. “So how do we make the shoe fit? Well, I think there is no need to go back to reinventing the wheel. We do have a framework in older adults with diabetes and how we establish goals and how we use medications. So why don’t we use the same framework and figure out how to use technology in this population?”
Dr. Munshi spoke during the Sunday, June 5, symposium, Improving Diabetes Care for Older Adults. The session was livestreamed and can be viewed on-demand by registered meeting participants at ADA2022.org. If you haven’t registered for the 82nd Scientific Sessions, register today to access the valuable meeting content.
She discussed studies that show older adults with type 1 diabetes who use a pump rather than multiple daily doses of insulin (MDI) report similar metrics as younger adults, including improvement in A1C levels and hyperglycemia indices. Other studies looking at CGM data found older adults had improved time in range during the critical limb ischemia stage compared to those who used MDI or closed-loop systems.
Additional research found that patients using MDI are more likely to have cognitive dysfunction and hypoglycemia fears, and less likely to use personal CGMs than those who used insulin pumps, Dr. Munshi said. And while CGM users were more likely to have better glycemic control, they also had hypoglycemia unawareness and more diabetes distress.
To help increase the use of diabetes technology among older adults, Dr. Munshi said several factors must be taken into consideration at each level of care. Systemic factors involve understanding the laws and policies where patients live. Caregiver-related factors include knowing about the availability of help for troubleshooting technology.
The patient’s cognitive function also is a significant factor, as it declines with age, impacting the patient’s ability to learn and use the technology, Dr. Munshi said.
Elbert Huang, MD, MPH, FACP, Professor of Medicine and of Public Health Sciences, University of Chicago, spoke about the ADA Guidelines for Managing Diabetes in Older Adults and ways to risk-stratify patients to help tailor goals and treatment plans.
He stressed the importance of regular overall assessment of patients using tools like the Lawton Brody Instrumental Activities of Daily Living Scale, noting other chronic conditions, and screening for geriatric syndromes such as polypharmacy, cognitive impairment, depression, incontinence, falls, and persistent pain.
“Can they adhere to oral medications, can they inject medications, can they do self-glucose monitoring?” Dr. Huang asked. “And then in the social domain of assessment, we need to understand who supports the patient, who is around in the social network of the given patient. So it’s just practical in terms of if you want your premium plan to be implemented, how is it going to be implemented?”
Data from the assessment can be fed into a risk stratification scheme of healthy, complex/intermediate, or very complex/poor health as determined by the ADA Standards of Medical Care in Diabetes.
The Standards of Care were updated this year and recommend that healthy older patients with fewer than five other health conditions who have a longer life expectancy be treated like middle aged or younger adults with type 2 diabetes. The goal should be to get their A1C below 7.5.
For complex/intermediate patients who have multiple chronic conditions and impairments of instrumental activities of daily living, an A1C of less than 8 is recommended. And for patients who are very complex, such as those in long-term care with dementia, the Standards of Care recommend against measuring A1C because of unreliability and a higher prevalence of chronic kidney disease and anemia. Instead, glucose control recommendation goals should be based on actual glucose measurement.
Maria Llorente, MD, Deputy to the Assistant Under Secretary for Health for Patient Care Services for the Veterans Health Administration and Professor of Psychiatry at Georgetown University School of Medicine, addressed the challenges of caring for older adults with diabetes and multimorbidity with a focus on psychiatric illness.
Because of the high prevalence of multimorbidity, screening for depression and anxiety should occur in primary care patients, she said, noting that psychiatric illness frequently has a co-bidirectional relationship with diabetes in older adults. Additionally, comorbid psychiatric illness prompts poor response and adherence to diabetes treatment and high health care use. Being aware of it helps the clinician anticipate complications.
A single-disease model of health care delivery is ineffective in the context of multimorbidity, Dr. Llorente continued, but collaborative care approaches that include frequent contact, shared care plans and measurement based targets are effective.
Studies show that as many as 90-95% of older primary care patients will exhibit multimorbidities. Older patients who are females, have lower socioeconomic status, and the presence of psychiatric disorders including depression run a higher risk of multimorbidities, Dr. Llorente said. Smoking, physical inactivity, and body mass index are almost always associated with multimorbidity, including psychiatric disorders.
Challenges associated with working with patients who have co-occurring psychiatric illness and diabetes include a fragmented health care system where primary care physicians, endocrinologists and mental health teams each have their own perspectives and biases and don’t always communicate well, Dr. Llorente said. She proposed a collaborative or integrated care model where a mental health provider is embedded in a primary care setting or vice versa.