Hello and welcome to today's webinar. I'm Dr. Ali Rizvi. I'm chair of the ADA Clinical Centers and Programs Interest Group Leadership Team, and we are excited to welcome Dr. Holly Devine here today to present on medication management for those with diabetes in the aging population. And here's a glance at today's agenda, the introduction and announcements will be followed by Dr. Devine's presentation, and there will be a question and answer session at the end. After the presentation, Dr. Devine will spend some time answering questions. You don't have to wait until the end of the session to send in your question. You can type your question into the Q&A box in the control panel, and we use the Q&A box for the question and answer session. The chat box is used to send you important links during this announcement segment. This is also where you can discuss related topics with other audience members. As I mentioned, I'm the chair of the ADA Clinical Centers and Programs Interest Group Leadership Team. I also wanted to take this moment to thank all the members of the leadership team for their work throughout the year to provide opportunities to the clinical centers and program interest group members. If you're not a professional member of the ADA, please consider joining. ADA members can be members of up to three interest groups and also have access to meeting discounts, member-exclusive webinars, and webinar recordings. You can use the link in the chat to learn more about ADA membership. Another benefit of ADA membership is the Diabetes Pro Membership Forum. Use this forum to connect with other ADA members in the interest groups. You can also see the link in the chat now. Here's a preview of the upcoming webinar. Two days from now, you will be reporting to stem cells for the treatment of type 1 diabetes. You can sign up for that in the link provided. We just had a previous webinar about five days ago on the standard of care. It is my distinct pleasure now to introduce today's presenter. Dr. Holly Devine is a PharmD and is distinguished as a clinical professor at the University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science in Lexington, Kentucky. She oversees the college's experiential educational curriculum as the director of external studies and coordinates the integrated drugs and diseases and phenology course. Dr. Devine has practiced in ambulatory care for over 20 years and currently provides collaborative care focused on diabetes management at Bluegrass Community Health Center in Lexington, Kentucky. Previously, she was the founder of the Pharmacist Care Program, a nationally recognized innovative employer-based patient care service which provides medication therapy management for patients with diabetes, as well as the program coordinator for the UK Healthcare's Accredited Diabetes Self-Management Education and Support Program. We are looking forward to her talk enlightening us on medication management in the older population of diabetes best practices. Without further ado, Dr. Devine. Thank you, Dr. Rizvi, for that introduction. I am honored to be here. I really appreciate you inviting me to come and to be a part of this session today. I'm going to share my presentation with you. Can you see that presentation slide okay, everyone? Yes. Okay, great, thank you so much. So we're gonna jump right in and talk about diabetes and aging best practices in medication management. The objectives for our presentation today are to understand medication use concerns in older adults, to identify safety considerations for medication use in older adults, and then select an appropriate treatment plan for the management of diabetes in older adults. I always like to start here. This is a question that I love to answer. Where did my love for older adults begin? This is a collage of photos of me and my grandparents. I am a professor at the University of Kentucky College of Pharmacy, as Dr. Rizvi mentioned earlier, that's in Lexington, Kentucky. Lexington and Louisville are really more of our urban areas, but most of our state is quite rural. So I grew up in a very rural part of far Western Kentucky called Dawson Springs, Kentucky. My parents, my grandparents, great-grandparents all are from that same area of the state. So a very small community, very close knit. I had the opportunity to really spend a lot of time with my grandparents. I grew up in a very faith-based community as well, a multi-generational church. My Sunday school teacher when I was seven years old was in her eighties. So I've always just been surrounded by people who are multi-generational and just having sort of that collaborative family environment. And so I have certainly developed a passion for older adults just because of my life experience. Then I always share as I do some presentation like this, if you've heard me talk on medication management and older adults at all, you've probably heard me tell this story. I will tell it every opportunity and every single chance that I get to share it. This gentleman right here is the reason why I'm passionate about appropriate medication use in older adults. This is William Faye Bunton. He is my maternal grandfather. Again, very close to all four of my grandparents, paternal and maternal grandparents. Spent a lot of time with them in and out of their homes growing up. A lot of time with granddad or granddaddy as I called him. He was the reason I'm actually in pharmacy. One of the main reasons I'm in pharmacy. My grandparents, again, spending a lot of time with them. I went through all their bedtime routines and morning routines with them when I would have sleepovers at their house. They always had a system for keeping track of their medications and how they took their medicines. They had very elaborate records of recording their adherence to their medications and when they took things and when they were missing doses and they had a very elaborate system. Wouldn't run errands with them, would go to the pharmacy. My grandfather was a businessman. So an entrepreneur. And when I was probably in elementary school, he took me to the pharmacy one day and as we were leaving, he said, you know what, Holly, I'm spending a lot of money at the pharmacy. I'm thinking that pharmacy might be a profession that you might wanna go into. Again, thinking about sort of that business perspective, not realizing that all of that money is not going to the pharmacist, of course. But just again, the wheels turning and got me thinking about it. I loved healthcare. I loved science. I was sort of an entrepreneurial family. All of my family owned small businesses. I really thought that that was the direction I would take when I graduated pharmacy school. So again, spent a lot of time with them. Why I'm passionate about the medication use in older adults is when I was in later elementary school, my grandfather was taking my grandmother to a doctor's appointment. So they were in a medical appointment. He was in the waiting room waiting for her. She was in the back with her primary care provider and he went into cardiac arrest in the waiting room. And thankfully he was in a healthcare facility. They were able to bring him back and he survived that major event. The cause of that event was my grandfather was on beta blockers. And just like they taught you in whatever healthcare program that you had, certainly they ingrained this to us in pharmacy school is if you have a patient who's on beta blockers, one of the counseling advice that you always give them is you never stop those medications abruptly. You always need to taper those medications. So he had an overstimulated beta adrenergic response and he went into cardiac arrest. So he had stopped taking that medication, his beta blocker, because he didn't feel well. So sometimes it makes people feel sluggish and slow and he stopped taking that medication and had a major adverse event. Thankfully he survived that event. But when I was a freshman in college, I'd just finished my freshman year at the University of Kentucky. My grandfather had another event that cost him his life. He had had an orthopedic procedure and was on the anticoagulant Warfarin. And he had confided in a relative a few days earlier that he just didn't really like how much he was bleeding when he was shaving his face. And so unfortunately he had a blood clot that he did not survive because he had stopped taking that medication. We knew he had stopped taking the medication, putting the pieces together because of those elaborate records that he kept. So we looked at his medication records and we saw the date and when she stopped taking that anticoagulation medication. So even though my grandfather was older, he was young old, if you will, he was only 71 when he had that event that cost him his life. And so I'm passionate about that because I think about in healthcare how much influence we could have over our patients. My grandfather was an intelligent man, a business owner, made very astute business decisions, really had faith in the healthcare system. He just didn't have the health education. He didn't have the information that he needed to make good decisions. If someone had just told him these are medications that you need to take long-term, here are some of the side effects that you may have from these medications. Let's talk about if you're having a problem with them, come to me first instead of discontinuing them abruptly. So that really motivates me and how I talk to my patients and how I counsel them and how I make those decisions with them and on behalf of them in their healthcare. So without further ado, let's jump in to understanding medication use concerns in older adults. So around 1900, the population of America's older adults was around 4% and it's projected to be over 20% by the year 2040. So we certainly have an increasing population of older adults, generally defined as age 65 and older. Other things that I think are important to share in terms of the statistics with medication use and aging is that 90% of older adults take one prescription drug regularly. Over a third of older adults use five or more medications and that tripled from 1988 into 2010. There are one in 10 elderly patients who will experience an adverse drug reaction or an adverse drug event that leads to hospitalization or that occurs during their hospitalization. So let that one sink in just a little bit. You know, one in 10 have an ADR that takes them to the hospital, sends them to the hospital or will actually have an event while they're having a hospital stay. That's not what drove them there, but they have an event actually after they arrive at the hospital while we're trying to provide care for them. Two thirds of hospitalizations are due to unintentional overdose. And then this one is one that I think is really important for us talking to providers who take care of patients with diabetes is that there are four medications or classes of medications that are implicated in the majority of hospitalizations when it comes to an adverse drug event that drives them there. So if you break down the number of, you know, how those hospitalizations occur due to an adverse drug event, then what are the cause of those? The four big things that contribute to most of them are warfarin and coagulation, insulins, oral antiplatelet agents or oral hypoglycemic agents. So two of the four major classes or medications that drive patients to the hospital because of an adverse drug event are medications that we use to manage patients who have diabetes. This slide here is just to talk a little bit about, there's nothing really magical that happens when someone turns 65. You know, it's not that all of a sudden there's this whole new set of rules that have to be applied when it comes to medication use. And so it's not, okay, this person's 65, everything changes. We start all these new roles, we think about all these new things, but there are some general changes that happen to us physiologically when we age that do affect medication use and outcomes that we'll talk about here in just a few minutes. But to understand that all adults do age differently. So I always use my grandfather as an example. My paternal grandparents are still living. My papa is 96 years old. He still tills plants and harvests his own garden. He cooks meals for his family. And if he can slip away long enough from my memo, he'll get on his four-wheeler and ride around the bottoms of his property. He actually talked my brother-in-law into taking him to a big excavating auction. He was a retired coal miner and run an excavating business after he retired from the coal mines for a number of years. And he said he needed to buy a new backhoe because he had to clear out a road on his property of several acres of property. So this is a 96-year-old man. And then we also are probably already thinking about those patients right now who are 70 years old and they have chronic multiple medical conditions and they have poor health status and they're really struggling or the 70-year-old who's working full-time and has no chronic health problems at all. So the point is we can't really make it a one-size-fits-all but we do have to have some acknowledgement that as we age, our bodies are changing and we need to at least have on the radar that internally there are physiologic changes that happen as we age at different times but throughout the course of our aging process that do require some oversight for prescribing and monitoring drug therapy and understanding there is some potential impact there. So I bet you all didn't think that you would go back to medical, pharmacy, nursing, PA school again and ever have to revisit pharmacokinetics. So I will keep this as brief and painless as I possibly can but it's important to give just a brief pharmacokinetic refresher on what's happening. This is pharmacokinetics are really what does the body do to the drug? So how do we process drugs? And as we age, our body changes and the way that it changes then will affect the drugs differently. So it could cause the drug to behave differently and as we age than it did when we were younger. So there are certain drugs and drug classes we have to keep on our radar for sure. So the processes, as you may recall of how a drug goes through our system are absorption, distribution, metabolism, and excretion. So we'll just kind of hit the first one really quickly and probably the easiest one to talk about is absorption. So what happens when we age is you have a decreased surface area and you have a decreased blood flow to the GI tract and that could lead to decreased absorption. So the absorption relies on good blood flow but at the same time, as we age we typically have a slowing of GI motility. So there's decreased GI motility and that could lead to an increased absorption. So the drug stays around in the GI tract longer and so it could increase the absorption of that drug. So what's the net result? Well, generally it's, they kind of cancel each other out. So even though we have decreased blood flow we have also decreased GI motility. So a lot of times there's really minimal impact on drug absorption as we age. The exception to that is that we do tend to have a more basic environment in our GI tract. So we have an increased pH, a less acidic environment. So the result of that is that there could be some decreased absorption of drugs that for those drugs that rely on an acidic environment for absorption. One of the classic ones we think about in geriatric medicine is calcium carbonate. So a lot of older adults will take calcium supplements. Calcium carbonate does rely on an acidic environment for absorption. So a common recommendation is to use calcium citrate or another salt form that's more easily absorbed because that may not be as well absorbed in our bodies because it does require a more acidic environment. Iron supplements are another one, some antifungals. So that's kind of a general way in which we age that we have to think about how the drug might behave or respond differently. So the next one is distribution. So we've got absorption, second one distribution. A couple of things happen as we age. So older adults who are institutionalized, those that might be in skilled nursing facilities, older adults who are malnourished, thinking more about your really sick older adults, they could have really a decrease in the protein albumin. And there are some drugs that are very highly protein bound. So when that drug then binds to that protein, it's not really in its active form, but you take that protein away and you've got all this free drug that's floating around. So that may have a higher therapeutic effect than it had before at the same dose. So some examples of drugs that are impacted by that would be phenytoin and warfarin, for example. The other thing that happens is volume of distribution changes. I had this pediatric specialist pharmacy professor who I remember vividly saying in pharmacy school, babies are basically just bags of water. And really what he meant by that is babies and children have higher water contents and less fat content. And as we age, we have less total body water and unfortunately higher fat content. So as from ages like 20 to 80 years old, our total body water decreases by about 15%. So kind of remember a little bit about pharmacology and some of the basics of that. You have some drugs that are water loving or hydrophilic drugs, and then you have some drugs that are fat loving or lipophilic drugs. So those hydrophilic drugs might have a higher concentration in older adults. As you have the same amount of solute, you take some of that solution away and that's gonna increase that concentration of drug. I mean, glycosides are some of those, digoxin is another one. Lipophilic drugs could also have a longer elimination half-life because they're kind of set up in there, almost have a depot effect at times. And they just kind of build up in the fat and then are excreted at higher concentrations. And phenytoin and diazepam are a couple of examples of that. We move on to metabolism. You guys hanging there with me, we're over halfway through the pharmacokinetic refresher. And without getting too far into the weeds, I mean, there are some drugs whose metabolism is just highly dependent on hepatic blood flow. And hepatic blood flow is reduced generally with aging. So you have decreased hepatic blood flow, you have decreased amount of drug that's extracted by the liver for metabolism during first pass. You might have an increased bioavailability of that drug. So some of those drugs like calcium channel blockers and beta blockers and tricyclic antidepressants work into that category. There's also a reduction in hepatic mass and number of functioning hepatocytes. So there's a decline in phase one metabolism that phase two is not affected. So some of those drugs that go through phase one would also be affected with aging. And last, but certainly not least, I know that in the world of diabetes, we hear a lot about renal function, but mostly in the terms of diabetic kidney disease. However, there are changes to the kidney that occur that are just simply related to aging. So our renal function generally just decreases as we age. About 10% per decade, the creatinine clearance will decrease after age 40 and about two thirds of the population. So obviously not gonna list all the medications, but there's a whole host of medications that are renewally eliminated that could be impacted by this pharmacokinetic change. So as we go through the second objective and really understanding safety considerations for medication use in older adults, the reason we kind of laid that foundational background is that it might make sense as we talk about some drug specifics as to, oh yeah, that makes sense now why that drug is on that list or maybe in that category of not appropriate for use in older adults because of its pharmacokinetic profile and how the body reacts differently to that particular drug. So one area that I would be remiss without talking about in a talk about medications and aging are the BEERS criteria. So the BEERS criteria were first developed in 1991 by Dr. Mark Beers, and it was an effort to decrease inappropriate prescribing and adverse drug reactions events and to identify medications or classes of medications that should be avoided in older adults in skilled nursing facilities. And in 2011, after Dr. Beers' death, the American Geriatric Society then began to oversee the revisions and the update to the criteria and the AGS has provided updates every three years starting in 2012. These, that I'll just kind of point out a few things for the 2019 criteria, the 2022 were out last year in for comment and I'm expecting those to be published at any time. So they should be coming soon, but we'll have the 2019 ones right now that we're working on but again, they're published every three years and they contain a list of PIMS or Potentially Inappropriate Medications. What that means is that this is a list, this is a table of medications within this Beers' criteria that these medications are best avoided by older adults in most circumstances and under specific conditions. So there's three categories in Beers' criteria, Potentially Inappropriate Medications, Potentially Inappropriate Meds that are due to a disease. So these might be okay unless you have the specific disease or diagnosis and then they probably shouldn't be used. And then also a use with caution which is a little lighter recommendation, but still something to be on your radar. I just put this up here as an example. Certainly don't expect you to read this in the small print, but just so that you can see this little excerpt of what the potentially inappropriate medication list looks like. Hopefully everyone has seen this before, but this gives the organ system or therapeutic category and drug in the left-hand column, the rationale for why it's considered potentially inappropriate, what that recommendation is. So you can see clearly in here at some of it's avoid, some of it might be avoid under certain conditions like renal function, the quality of the evidence that's there and how strong that recommendation is. So just to, since we're talking about medication use in diabetes, I want to make sure that we pull out a couple of diabetes-related medications that are on the Bayer's criteria. So the two that are here are insulin sliding scale and sulfonylureas long-acting. So the sliding scale insulin, there's some clarification that came out in 2019 about this as well, talks about avoiding the use of only short or rapid-acting insulin without having a basal or long-acting insulin on board. Their rationale is that there's a higher risk of hypoglycemia without improvement in hyperglycemia management. And then the sulfonylureas glomiferide is actually added in the 2019 table of potentially inappropriate medications because there's a higher risk of severe prolonged hypoglycemia in older adults. So again, we're kind of talking about some of the safety considerations for older adults. So I'll kind of hit things like adverse drug events, adherence and other things that we have to be thinking about when we're talking about our older adult population. I know we specifically manage things with diabetes and we'll certainly get to some of that at the end but there's just a lot of big picture things we have to be thinking about. So when I look at this table right here that talks about adverse drug reaction or adverse drug event risk factors, those risk factors are advanced age, female, lower socioeconomic status, lives alone, dementia, polypharmacy. You can read that list that's there. So, okay, great, Holly, you've given me this list. What does this mean? How do I use this information? Well, let me tell you how you would use that. If you're working up or reviewing your patients for the day and you have an 87 year old female who weighs a hundred pounds, she lives by herself, she takes 12 chronic medications, sees four different specialists and has mild dementia, you need to plan to spend a little more time with her in your visit today because she is at a very high risk of having an adverse drug event. Don't let her be that one intense statistic that we talked about on the intro slides where they were admitted to the hospital or had an event once they were in the hospital. So don't end up like my grandfather with one of those events. She needs some more attention in reviewing her medications for appropriateness. We need to make sure she's appropriately counseled on appropriate medication use and on adverse effects. So that's how you would use that. I think just take this information to heart. If you take anything away from this talk today, I would say, as I would tell my students in class, put a little star by this one. This is gonna be on the test. I want you to know this. If you forget everything else I say today, there's a couple of things I want you to put a star by. And this is one of them. As you think about that patient right there that has multiple of those risk factors, they're gonna be high on your list for having a major adverse drug event. So please spend a little more time with that patient. The second thing that I always really wanna make sure that I get across whenever I'm providing a presentation on medication use in older adults is this one right here. This is another one that I would say. You just put a little star beside it because I would want you to remember this. Again, takeaways at the end of the day, a week from now, a month from now, five years from now, this is something that I would really want you to take to heart. And I always say that one of the things that we do is healthcare providers, as pharmacists especially, really put this onus on our pharmacy students is that if there's any ADR or adverse drug event, it's a lot of detective work. So I say to them and teach my students that if you have a patient who presents with any one of these things right here on this slide, that you should first say what drug on their medication profile caused that to happen. So before we jump to, oh, the patient has depression or the patient has anxiety and we add another medication to treat that, we need to stop and say what medications on this profile might be contributing to that symptom that the patient is having. So falls are a great example to use for that. I worked in consultant pharmacy in skilled nursing facilities for a while early in my career. And so we went and did, as a consultant pharmacist, we were required to go in every 30 days, review all of the residents' medications. So do comprehensive medication reviews on every resident in the facility every single month. And so when I would be reviewing those charts and I would take a look at patient Jane Doe, she had a fall a couple of weeks ago. My first thought was, I'm gonna look on this drug list and I'm gonna find the drug that made her fall. So I wouldn't stop until I could rule out that that drug was not a cause of her fall. So these are things to really take into mind, falls, GI distress, incontinence, constipation, depression, anxiety, confusion, insomnia. These were all things that could be caused by drugs. So instead of piling on more drugs and adding to the polypharmacy problem, we need to take a pause and just make sure that we aren't causing this by a drug that's already on their medication profile. So adherence is also something else to really take into consideration in older adults. So why would older adults have the issues with adherence? What are some things to really think about? Lack of perceived need, right? So I think about granddad and I think about a smart man, great businessman, really astute entrepreneur. He just didn't, nobody took the time to tell him why he needed to take those medications. Nobody said, this is a beta blocker. We're using it for that time. I think he was using it for blood pressure, but you can't just stop this medicine. That could cause more harm. You've got to taper that drug off. So give us a chance to talk about it before you do that. Same thing with his boyfriend, right? So thinking about like, you need this to keep your blood from clotting. Like you could die from this. And so if you're bleeding too much, then let's talk about ways that we can work on that adverse effect versus stopping the medication altogether. So again, adverse effects, inconvenient scheduling, barriers to communication, digital lack of understanding. The lack of understanding could be related to some age-related changes in hearing that the patient has. They didn't hear everything well. Cost is a problem for older adults. It's gotten better, I think, with Medicare Part D. Years ago, we didn't have that. Medications were outlandish, and now we have a little more access, but still challenges for a lot of our older adults. So those are all reasons that an older adult might have issues with adherence. I always love to share this quote as well, just about the prescribing cascade. We talked about this a little bit, that we have to be careful not to use medications to treat the side effects of other medications. So as older patients move through time, often from physician to physician, they are at increasing risk of accumulating layer upon layer of drug therapy as a wreath accumulates layer upon layer of coral. So polypharmacy certainly is a concern and an issue in older adults. So just making sure that we are spending time with older adults and not adding to the problem of polypharmacy, creating more problems and making sure that we are really prescribing targeted appropriate medication therapy, really good patient-centered care. So as we're moving right along in our discussion today, we're gonna talk about objection number three. So selecting appropriate treatment plan for the management of diabetes in older adults. So lots of background before we get to this part. There are lots of you that are on this webinar today that are probably much more astute than me at managing diabetes care in older adults, but hopefully taking the principles that we just talked about and really learning something new and applying those things to your older adult patients. So we'll just hit a few stats and highlights here as we talk through managing those patients about 29% of patients ages 65 and older have diabetes and about half of older adults have pre-diabetes. We use a couple of things and resources that will round out today's presentation and webinar on is we use the Diabetes and Older Adults Consensus Report from the Journal of the American Geriatric Society. And we'll also use the ADA Standards of Care and in the 2023 standards, it's chapter 13 that talks about older adults in the standards of care and talks about some specific guidelines for them. I wanna spend a few minutes today talking about diabetes and geriatric syndromes. So I think that this is really interesting. And again, when we think about, we've spent the first part of our presentation today really talking about generalities in older adults and big picture things that we need to consider. This is your patient with diabetes. This is your older adult with diabetes we're talking about right here. So diabetes is actually associated with an increased risk of multiple coexisting medical conditions in older adults. So in addition to the things that you might think about is coexisting medical conditions like cardiovascular disease or microvascular disease, there's a group of conditions that are termed geriatric syndromes that occur at a higher frequency in older adults with diabetes. So these include things like polypharmacy, cognitive impairment, depression, urinary incontinence, injurious falls, vision and hearing impairment, and frailty. So compared to your older adult patient who does not have diabetes, all of these things right here are more common in your older adult with diabetes. So if they're commonly associated with diabetes, let's view these through the lens of medication management. This is a mid-management talk in older adults. So how do these geriatric syndromes affect medication management? So if my older adult with diabetes is more likely to have one of these, how does that impact medication management in that older adult? So geriatric syndromes, diabetes, and medication. So we'll just pick a few here to kind of give some examples. So vision. So if you're one of the geriatric syndromes is vision and hearing impairment. And we know that that's a higher likelihood of occurring in your older adults. But again, this is the geriatric syndrome associated with diabetes. Your patient with diabetes, your older adult patient with diabetes is more likely to have even more vision and hearing impairment. So difficulty seeing the prescription labels or the markers for the insulin injectables. So again, spending more time with that patient to just really assess what their vision might be and how they're going to be able to read and accurately prepare their medications. Hearing. So if hearing is a geriatric syndrome that we were talking about, misunderstanding medication directions from the prescriber, the pharmacist, or the educator. I mean, that has huge implications. We talk a lot in pharmacy, and hopefully you do in your other disciplines too, about the teach FAP method. So anytime I share information that I know that my patient needs to really be able to grasp when they get home, in addition to writing it down, if they have literacy skills that they can utilize from writing things down, I do teach back. Tell me what I just said. Can you repeat for me just so that I didn't miss anything? I want to make sure that I told you everything. Can you share with me a little bit about how you're going to take this medication or what some of the side effects are that you're going to be looking for, or what happens when you have an adverse effect? What are you going to do? So teach back is a really important communication tool to use and even more important for our patients who may have geriatric syndromes related to hearing. Polypharmacy, and I'll talk a little more about this in the next slide. We've sort of talked all around it throughout this presentation. Polypharmacy is basically just multiple medications, and there's a high risk of non-adherence, errors, drug interactions, and adverse drug effects that happen with any patient who's on multiple medications. Falls, again, we've talked a lot about falls. There are a lot of medications that can cause or contribute to falls in older adults. So if you have an older adult who has diabetes, then those medications should even be given more close attention because it's a higher likelihood that your older adult with diabetes will experience a fall over your older adult that doesn't have diabetes. Urinary incontinence, again, thinking about medications that contribute to incontinence and their quality of life, and then cognitive impairment. So medications that might cause confusion or sedation or may worsen existing cognitive impairment need to be given some extra consideration in your older adult who has diabetes because it could have a more profound impact on them. So just to kind of delve in a little more about polypharmacy, because again, we're talking about medication use in older adults, and I'd be remiss without talking about this a little more. So polypharmacy is generally, it's loosely defined in the literature. So someone's tried to really kind of have a more like central definition, generally five or more medications is what might be considered polypharmacy when they look at different research studies, but a lot of medications, basically, multiple medications. So polypharmacy increases the risk of drug interactions and adverse drug events. That's just common sense, right? But how much does it increase them? If you have a patient on two medications, there's a 13% risk of a drug interaction. If you have a patient that's on seven or more medications, there's an 82% chance of having a drug interaction. 82% chance, that means you're pretty likely you're gonna have a drug interaction if you're on seven or more medications. More chronic medical conditions, equal more medications. So a lot of times that's why, your patients that are really sick or have chronic multiple conditions are gonna end up with more medications. Why else would you have polypharmacy? Sometimes a patient or prescribers need to do something. I think we've gotten a lot better with antimicrobial stewardship, for example, about really having good appropriate use of antibiotics, but that's just one area. There's lots of drug classes and there's lots of areas where we sometimes may over prescribe medications that are not necessary. Multiple providers and specialists and having no common electronic medical record, that's also getting better, but it's not great. It's not perfect yet. I have my father-in-law is 88. He just finished a 24-day stint in the hospital for a major health event. It was a lot to manage. All the multiple providers, all the specialists that were consulted, a lot of things that were going on. So it transferring, he was air flighted to a different facility. So getting records from the home facility to the facility he was air flighted to. And then now he's got yet another facility that he's been transferred to. And so transitions of care is a huge deal of trying to get all that information and then the pharmacy information there. And I went and visited with him last weekend when he was transferred to some acute care facility. I was like, he's really sedated. Can I just see the MAR to see what you're giving him? They weren't giving him anything. No sedatives, nothing like that. But something that did happen was that he was reinitiated on the medication he had at home that caused sedation that he hadn't been on in the acute care facility. And it's a medication that needs to be escalated slowly. Start low, go slow. But they put him right back on the high dose that he was on before when he was at home and he was taking it continuously and had already been titrated to that dose. So they were able to reduce that back down. And so again, lots of reasons why those things happen. My grandmother was great at saving or borrowing medications. So she had her own little pharmacy in her closet. What they borrowed from a neighbor, what they had. You got a cough, I got something for you. You got this, I got something for you. So I think that comes a lot from particularly your advanced age patients who lived through the depression and they just sort of saved and hoarded things. I have a pharmacist colleague in my clinic who told me a few weeks ago that she's had one of the most complicated medication review med recs that she's ever done. We had in our clinic that she was on 12 medications. That was what was listed in our chart. We're her primary care clinic. And she was seeing six other specialists, endocrine, pain management, cardiology, nephrology. Well, we asked her to bring all of her medications in. And I kid you not, she brought a duffel bag full of medications in. And to complicate things even further, someone else filled up her weekly pill boxes for her. And she didn't even know what was in those. She had no idea what pills were in those boxes. So it took my colleague like three weeks to work on reconciling all those medications, calling providers, going through records just to figure out what she was taking. And it just was a really complex thing to figure out. So polypharmacy is a big problem in America. So as I talk really more specifically about our older adults and work toward inclusion and some time for questions at the end, just some big picture things for us to think about and with our older adults, considerations for medication management in older adults, three things to take home with you today. Individualizing their goals of therapy, which I'm sure most people in this audience know and are very, very familiar with. Avoiding hypoglycemia. Again, you should all be familiar with that, but you can never emphasize that enough. And then patient-centered pharmacotherapy. So what does your patient really need? As they get older, do they need that intensive of a control? You know, my 96-year-old grandfather who has type 2 diabetes, does he need the type level of A1C control that he needed 30 years ago? Does he need, you know, the insulin dose that he needed back then? So just thinking about those patient-centered care things. Individualizing goals. Again, these are, this shouldn't be new information to anyone here. This comes straight from our ADA standards of care, but targeting a goal of less than 7 to 7.5 percent, and maybe in older adults who are otherwise healthy, they have fewer coexisting chronic conditions, they have more intact cognitive function and functional status, so we're not super worried about falls. Dementia and hypoglycemia that we'll talk about in a few minutes is a real concern, so making sure that all the cognitive function is at the level of being not compromised. A1Cs of less than 8 percent, we might consider those for older adults that have multiple coexisting medical conditions, those who have some cognitive impairment and functional dependence. When we think about hyperglycemia, you know, glycemic goals for some older adults, we may just want to relax those a little bit. Again, it's very patient-centered, but really individualizing those to what that patient needs. We want to avoid hyperglycemia with symptoms or acute hyperglycemia complications, so even if we do relax those goals, we don't want them to be symptomatic. We don't want polyuria, polydipsia. We don't want all the things, you know, that go along with that miserable hyperglycemia, but we also know I still don't want to go into DKA or HHS, so we don't want to have a hyperglycemic crisis take place, so balancing what the patient needs and long-term outcomes and goals, but also making sure that we're taking the hyperglycemia into consideration. At all costs and above all things, we should avoid hypoglycemia, so, you know, those that are 75 years old and older than 75 years old, they have double the rate of emergency department visits for hypoglycemia than the general population does with diabetes, so we think about, you know, those are your highest risk folks, and we talked about earlier what drove people to the ED, you know, it drove them to hospitalizations where the drugs are called hypoglycemia. There's an impaired awareness of hypoglycemia, the warning symptoms, so there's kind of a loss of that ability to recognize hypoglycemia, and there's also this sort of bi-directional link between hypoglycemia and cognitive dysfunction. It's so interesting to read and learn about that. There's a lot about it in the standards of care, more research articles that are out there about that, but, you know, hypoglycemia is linked to cognitive dysfunction, and, you know, so cognitive impairment increases the risk of hypoglycemia, and the history of severe hypoglycemia is linked to increased incidence of dementia, so a very interesting correlation there, so avoiding hypoglycemia is so very important, and if you've got a patient who has cognitive impairment, it's even more important that you really think about relaxing those goals for your patient because we want to, and avoiding, you know, making sure that we have the right medications that are not contributing to hypoglycemia because it is a real concern. So, you know, just some tips is, you know, at every visit, ask about hypoglycemia, assess the hypoglycemia risk, advise patients of signs and symptoms of hypoglycemia, and address hypoglycemia, so don't just ask about it, you know, if they've had it, then we need to do something about it and make sure that it's really a focus. I think you guys know probably one of my styles of presentation is storytelling, and as I mentioned, I was super close to my grandparents and my in-laws, and so I have a lot of stories. This story I always share, this was my husband's grandmother, 79-year-old female with type 2 diabetes. She woke one morning with numbness, slurred speech, and confusion. Her husband had visual impairment, he was legally blind, he couldn't see, couldn't find the phone, he couldn't dial 9-1-1, so they didn't drive, he couldn't see, they just were kind of stuck there. The patient felt like she was paralyzed, she lay there in bed until the daughter came to check on them a little later that morning when they were unable to get a hold of him. They transported her to the emergency department for assessment of stroke. She was on metformin, a thousand milligrams twice daily, and glabiride, 10 milligrams twice daily. So you all already probably can figure out what happened here, you know, she was diagnosed with hypoglycemia reaction due to her sulfonylurea. Just a little bit of history about Memo, so that you kind of get the picture here, is that she had had about a 50-pound weight loss over the decade prior to that. So she'd had diabetes, type 2 diabetes, for a number of years, and you know, she was managed fine on those medications, but she changed, right? She changed over time. Her body composition, her body weight changed, as well as her age. So she aged and advanced aged up into her late 70s. Nobody provided any recent education on signs and symptoms of the treatment of hypoglycemia, that wasn't even on her radar. She didn't even think about having a hypoglycemic reaction. She never had one. There was no evaluation, reevaluation of the need for her current diabetes medications, despite that major lifestyle change of weight loss. And she had regular primary care visits. She never missed a visit. So the results of that was that she actually ended up taking her off everything for her diabetes control. She wasn't on metformin, and she wasn't on glabiride, and she didn't need anything. The weight loss was enough to manage the diabetes goals in the reasonable range. But she ended up with a constant daily fear of hypoglycemia. She checked her blood glucose like 10 times a day, because she was so terrified of having that hypoglycemic reaction again. And granted, she wasn't on anything. She wasn't on any of these medications anymore, but she was terrified. So just a learning point from this is that, you know, a lot of the sulfonylureas are potentially inappropriate medications. They do have a prolonged hypoglycemic response in older adults. We do need to reinforce hypoglycemia signs and symptoms in management at every single visit and encounter, every single time without fail. Even if it's a patient that you see all the time, and you've seen them for decades, you know, they're going to get older. They're going to change. Things change. Make sure that they know what to do. And then reassess your older adults with diabetes regularly for their medication needs. They may not need that stuff anymore, right? So things might change what, you know, maybe you've relaxed their goals a little bit. Maybe they don't need that stringent control. So those are all important things to take away from that example. When we think about patient-centered pharmacotherapy, so this is the last point for our diabetes in older adults focused part of this presentation. So use medication classes with low risk of hypoglycemia, especially for those that are at increased risk. Avoid over-treatment of diabetes in older adults and simplify the complex regimens to reduce hypoglycemia and polypharmacy, if possible, to reach their A1C targets. So we all are, I think, probably pretty familiar with the new 2023 Pharmacotherapy Guidelines with Listering Meds, an algorithm that sort of came out. It looks a little bit different. So before there was this nice big section about, you know, hypoglycemia and a list of all the drugs. Now it is buried right here. I'm still trying to get familiar with the new guidelines in the way that they look a little different, but this is kind of where they are. So it talks about choosing approaches that provide efficacy to achieve goals, consider avoidance of hypoglycemia a priority in high-risk individuals. So if we look at, you know, specific drugs, you know, and before, just to kind of maybe go back to that previous slide, you know, when you think about what are those drugs, the old sort of chart had those really spelled out for you, but, you know, those things like, you know, DPP-4 inhibitors, GLP-1 receptor agonists, SGLT2 inhibitors, and TZDs will all be low risk of low to no inherent risk of hypoglycemia. You know, the sulfonylureas, of course, and insulins are going to be higher risk for that. So let's look at each sort of drug class. This is just kind of a snapshot. You know, these things are not, you know, any big revelation. It's just the things that I'll just say on a couple of slides here, let's just hit a couple of points to think about when we have diabetes medications in older adults. So metformin contraindicated in advanced renal insufficiency monitoring B12. Our TZDs, you have to be cautious with heart failure, osteoporosis, falls, or fractures. Sulfonylureas and insulin secretagogues, we have to think about hypoglycemia. I think we've talked about that enough. And DPP-4 inhibitors, there's really few side effects to think about when we think about older adults and the considerations there. The GLP-1 receptor agonists, you know, injectable, this requires visual and motor cognitive skills. Nausea, vomiting, diarrhea, think about a concern. If you have patients that have unexplained weight loss, adding something else that's going to contribute to weight loss, we have to be very cautious about that. SGLT2 inhibitors can cause some volume depletion, urinary tract infections, might worsen urinary incontinence. And again, this is already common in older adults and more common in your older adult patients with diabetes. And then insulin, I think it's pretty clear that the hypoglycemia and the injectable skill level that's required to administer an injection, as well as sometimes the complexity of the regimens that are there. So last slide before our summary and questions, and we think about the simplification of complex insulin therapy. I just pulled this right out. This is figure 13.1 from the ADA standards of care in that 13th chapter there. And they talk about, you know, if you can simplify the regimen, I don't expect you to be able to read this on this slide, but I just want to refer you to that and kind of show you what a screenshot of what that looks like. So, you know, just some things that you might change in the timing of the medication, thinking about, you know, dose reductions of pre-annual insulin, you know, what are some little things that you can do that might simplify a complex regimen for a patient who is on insulin therapy? And so it gives you several different things to consider and, you know, tips to kind of work through if you're trying to simplify a regimen, an insulin regimen for your patients. All right. In summary, not all older adults are equal, but we do have pharmacokinetic changes as we age. And so sometimes you have to think about universal precautions, if you will, and sort of applying and erring on the side of caution. So we think about, you know, the potentially inappropriate medications from the Beers criteria and so forth. Those are things that even though everybody ages a little differently, I would certainly err on the side of caution because of the changes that we have related to age in our bodies. Evaluate all the potential medication-related concerns, polypharmacy adherence, adverse drug events. Don't take any of those off the table. Individualize the goals and therapeutic plans for your older adults with diabetes and avoid hypoglycemia and overtreatment whenever possible. And with that, I think I'll turn it back over to Dr. Rizvi. Thank you, Dr. Devine, for the excellent overview. Very informative. We have a question and actually in the chat, which is meant as a question. It's mentioning a patient with type 2 diabetes, older individual with early dementia, and how they might be able to get off basal bolus insulin, currently using Trilicium at Hormone. The patient's daughter is managing the medications using the sensor, Freestyle Lidia. The patient has a sweet tooth and hardly sees blood glucose above or below 200. And also that's a segue to kind of my question about the utility or use of continuous glucose monitoring in older adults. It's proven to be very successful and widely accepted in younger patients, especially those on intensive regimens or pumps, for example. But in older individuals, there may be a little bit of a hesitancy in the acquisition of new technology and learning of new technologies. So if you could comment on that. Yeah, for sure. I think I heard all of the question. If I understood it correctly, one of the comments was about maybe a patient who had some dementia or cognitive impairment and they're on a complex insulin regimen. For the attendee who provided that question, I would certainly, and hopefully you have taken the time to do this. If you haven't, I would certainly look at that simplification of complex regimens chart. That's a great place to start in the ADA standards of care is just take a look at that. Are there some, can you kind of chip away at it a little bit? Can we start with some simplification? Can we loosen some of those goals? We think about, again, cognitive impairment and the high risk of hypoglycemia and that bi-directional concern there, avoiding hypoglycemia, relaxing those goals as much as you can, as well as looking at the simplification piece and trying to select alternative therapies that would not contribute to hypoglycemia, but not put them in a hypoglycemic crisis or symptomatically hyperglycemia. So those are all things to take into consideration that have any really hard and fast advice that certainly would start there and start chipping away at that as best I could. The other thing to think about, we didn't talk about this in the presentation, but you know, are there other people that are involved in their care? So, you know, I gave the example, right, of my father-in-law. My husband's sister-in-law is a nurse practitioner. I'm a Pharm D. You know, he has three sons who are not in the healthcare field, but very, very supportive, a wife who's very supportive, and we are all on the same team. We are all, you know, team, you know, dad. So, you know, having those people that you can talk to and rely on that are a part of that patient's caregiving team as well. So are there other people on, you know, the support, right? So we talk about diabetes support all the time, you know, who are the supporters in that family and, you know, how do we work together to make those decisions? You know, CGM, we could do a whole talk on CGM and older adults for sure. I don't do a lot of that in my practice. I do work in a federally qualified health center, and so I have a lot of medically underserved patients. Access to medications in general as well as CGMs is not as prolific as we would love for it to be, but we're getting there. But absolutely, those are all great things to consider for your older adult patients and how we might manage the highs and the lows and all of the and ups and downs that go along with that. I think, again, when you think about your team, you know, I don't know about you all, but again, I think about my family members and how much they rely on, you know, me and even my kids in the generation or two below me for the technology. So if you have someone who has a lot of support in their family, then I think a CGM is doable, right? So if they have people in their homes or people who care for them regularly or who are really involved in their care, you know, my grandfather just bought a new iPhone. My 96-year-old grandfather just bought a new iPhone last week. So I don't think that we need to make the assumption that they're technology averse because that's a terrible, probably age-biased decision or thought to make. So as healthcare providers, we have to really, we think about gender bias in healthcare, but, you know, age bias is a real thing too. There's a lot of really great research on that, and we don't need to make assumptions that a patient may not be ready or prepared for technology because, you know, my 96-year-old grandfather has Facebook and an iPhone, so he's doing just fine. Thank you. And I think one approach in that specific example could be to try to take the patient off bolus insulin since they're on a basal bolus therapy, and then optimize with the basal. They're already on a GOP-1 receptor agonist and metformin. I think that's pretty safe. The follow-up question is that, well, can we take the patient off insulin completely? That perhaps could be possible, but probably not necessary, and we could strike a balance between using a dose of long-acting insulin along with other agents. And what has been your experience, Dr. Devine, in using the newer medications that are now advocated, sometimes first-line, in patients with diabetes, like the GOP-1 receptor agonists and the SCMP2 receptor inhibitors in the older population, considering that they have cardiovascular and renal benefits, yet can also have some side effects which could impact the elderly in a negative manner? Yeah, I mean, we have such strong evidence for those compelling indications to use those, especially when we have those coexisting medical conditions. So we just work really hard at trying to get the right dose, work on tolerability, make sure there's appropriate education on the adverse effects, and really try to work toward that adherence piece. Is this something that we can really help a patient tolerate? I mean, there's a slower titration schedule for some of those patients, more observation, more education, and just spending more time. I think we're also rushed in healthcare. That's my heart. Obviously, I have the personal stories of granddad where I just wish somebody had spent a little more time. So that drives and motivates me, and I think if we all just have that lens of that compassion and empathy and thinking through the eyes of that older adult and making sure we're spending that time with them, I think that that patient-centered care is a home run. Thank you. We're right at the top of the hour, so we appreciate you giving this wonderful talk, and a recording of this webinar will be available on our interest group forum to access later, along with a link to the diabetes and the elderly subgroup of our interest group. Thank you again, everyone, and have a good evening. Thank you.

medication management

older individuals

diabetes

individualizing goals

risks and side effects

Beers criteria

medication needs

polypharmacy

continuous glucose monitoring

patient-centered care