Welcome everybody that's joining we're waiting for a few more participants before we start the formal program. I'm Dr. Joe Aloi at Atrium Health Wake Forest Baptist in North Carolina where it's hot in the afternoon so good morning, good afternoon, good evening, depending on your geography. We'll start as I said in just a couple of minutes for a few more people to join us. We've got a reasonable number of people on the webinar today. Again, I'll be moderating today's webinar. I'm Dr. Joe Loy from Atrium Health Wake Forest Baptists in North Carolina. The technology interest group for the American Diabetes Association put this together. The framework is under empowering elderly patients using diabetes tech in particular for optimal management of the elderly patient. We've got two great speakers, Chanae Uso, who is in my division of endocrinology at Wake Forest and Kate Callahan, who's an associate professor in the division of geriatrics. We've been partnering together to try and optimize the health for elderly patients with diabetes. The next slide. I wanna remind people, although it's summer, October is around the corner and we'll be getting the ADA sponsored, exclusive to ADA members, hands-on webinars, tips to improve diabetes care. They rotate on the second Tuesday of every month at 3 p.m. Eastern time. And bookmark the page, it'll be in the chat if you wanna link to it now. And I'll remind you that there's one CE credit available. I'd like to highlight also that this has been a great resource from providers across the spectrum, from educators to physicians to APPs, and really encourage you to try and catch as many of these as you can. With that, I'll be monitoring the Q&A for questions during the presentation. I think we've left enough time to answer them at the end. We're gonna begin our presentation with Kate Callahan, who's gonna open it up and I turn it over to Kate. Thank you. All right, so hopefully you all can hear and see me. So very glad to be joining you today. I'd like to say what an honor it is to join you. It's been a pleasure and a privilege to work with Dr. Uso as I've learned more about diabetes and technology and with Dr. Aloi about the same. So I am a geriatrician as Dr. Aloi said, and the bulk of my work is as a researcher focusing particularly on frailty in older adults and how we can frame healthcare pathways to optimize care for frail older adults. But in my day job, I am a primary care physician for older adults across the spectrum of a function. And a question that often comes up among primary care is how do we operationalize that chapter 13 of the American Diabetes Association guidelines on caring for older adults? And specifically, thinking about how we can personalize or individualize our glycemic targets. Heterogeneity of aging is the name of the game when it comes to the care of older adults. And if you think about this, two big themes come to mind. The first is if you've met one 80-year-old, you've met one 80-year-old, right? Older adults are so varied in terms of those who are still quite robust. I have a 91-year-old who is still running her own business. And I have patients who are in their late 60s who are really very vulnerable and frail. So I think it's a great gift that the ADA gives us to say it's appropriate for us to individualize. But one of the major challenges that I think we face is when we get down to brass tacks, exactly how do we do that? It's challenging in a typical primary care office visit to determine the degree of say functional status, cognitive impairment, et cetera, to be able to say in which of these categories should the older adult in front of me fall? And so I'd like to introduce the concept of how physiologic changes of aging and common diseases of aging really influence how older adults experience diabetes and experience management of diabetes. Highlighting just a few here, cognitive changes are common. Dementia is not normal in aging, but age-associated changes do often mean that there's slower reflexes and it does take often more contacts with a concept in order for learning to occur. Cognitive impairment is subtle and many older adults don't really show it until further on in a cognitive impairment journey. But those elements that are first affected, insight, judgment, executive function, these are critically important when it comes to making decisions, particularly around higher risk diabetes medications. The next several here, including a reduction in GFR, a decreased inotropic response to catecholamines, including intrinsic ones, skin atrophy, all of this comes down to challenges when it comes to an older adult's delivery of medications, absorption of medications, regulation of those medications, and particularly relevant to today's presentation, hypoglycemic unawareness. So the majority of older adults do not experience the adrenergic symptoms of hypoglycemia. Instead, these shift to predominantly a neuroglycopenic phase. So that can be subtle and hard for people to pick up on, especially caregivers who may interpret confusion, slowness, fatigue as being part of other chronic conditions, et cetera. So all of this has led international geriatrics and diabetes collaborators to argue that frailty should actually be the primary organizing principle when it comes to personalizing and individualizing diabetes care for older adults. So what is frailty? We use this term in the lay world quite freely, but in my world, it's a technical term, and it refers to a biological syndrome where there's a loss of reserve, both physiological reserve, those physiologic changes I was mentioning before, and function, those day-to-day functions like planning a meal, the ability to move independently through a large space, et cetera. This also means that those who have frailty have increased vulnerability to stressor events. So while a robust older adult might get a urinary tract infection or the flu or a hypoglycemic episode and be fine on the other side of it, someone with frailty will have an outsize, a disproportionate drop in their health status, and that is followed by a much lengthier recovery process. And in some individuals, they never quite get back to their status previously. Frail older adults can look like this beautiful origami boat. You know, the boat can float on the water for a long time, looking very beautiful and proud until there's chop on the wave or until there is a big wind that comes along, and then it's very hard to recover. And the principle of frailty is also helpful because of its prognostication. Independent of age and comorbidities, frailty itself predicts adverse outcomes, whether that's increased acute care utilization, complications of care, the development of dementia, institutionalization, disability, and mortality. So I hope you'll agree with me that it's important for us to be able to recognize frailty. And the challenge is that we don't know it when we see it, right? It would be easy for any of us to take a look at the woman here on the left and say, well, clearly this is an older adult who's frail. But what if I told you that the woman on the right is also frail? It's simply that she is not exhibiting it externally in the same way as the woman on the left. But faced with a stressor event, she is also likely to experience that outsized negative response, which can be really disruptive to her quality of life. So why aren't we all using frailty all the time? Well, implementation of frailty has been held back. And a lot of that has to do with the fact that most frailty tools are time-consuming. They rely upon expertise like geriatricians to do them. But there's only about 6,000 geriatricians in the country. So while I would love to assign a geriatrician for each of your older adults with diabetes, that's unlikely to happen. What we have done at Wake Forest is built upon the genius of others in establishing a frailty index. And we have automated this within our electronic health record. So our electronic frailty index runs in the background using existing information that's routinely gathered as a part of care to produce a single number that can give you a sense of where your patient falls and the spectrum of the heterogeneity of aging. So what are those elements that make up the frailty index? Well, medical diagnoses are a critical part of this. We also use laboratory tests that are common not only in diseases common in aging, but also in the inflammation process that is strongly hypothesized to accelerate aging. We use weight, blood pressure, smoking status, medications, and where possible, we pull in actual functional data about say muscle strength, cognition from the Medicare annual wellness visit. And this produces a single score between zero and one where the higher the score is, the more likely someone is to be frail. Okay? And we have gone through and validated this in the populations throughout Atrium Health Wake Forest where we've shown that the higher a frailty score is, the higher they all cause one year mortality. This also shows that frailty status is strongly associated with increased healthcare use in the acute setting and the ambulatory setting, and particularly with adverse outcomes. There's a lot going on in this slide. So I really want you to zero in on the following. What we're looking here is a mean cumulative count, which means that if we were to take 100 individuals in each of the following categories and follow them for a year, how many events per 100 individuals would happen? So looking specifically over here at emergency department visits, if we looked at 100 people who are frail, that's in the purple here, and 100 people who were fit here in the gold, then those who are in the frailty category would have about 42 emergency department visits in that year. Ooh, that one jumped ahead on me. That also means, you know, when we look at the multiplicative effect, we're looking at about eight times as many emergency department visits and about six times as many injurious falls. But this is with all comers. I'm not specific to the population of those with diabetes. When we zero in and say, you know, what is happening for glycemic control with older adults and is there variability by frailty? You know, are clinicians already intuiting that their older adults who are more vulnerable should not be driven as low for the glycemic goals? We explored this in 16,000 older adults with type two diabetes who were affiliated with Wake Forest Accountable Care Organizations. And what we did is we looked at those 65 and older with a type two diabetes diagnosis, and we defined intensive glycemic control as less than 7.5% or very intensive, less than 6.5%. And we defined higher risk medication regimens as insulin, sulfonylureas, or combination meds. And what we found is that despite ADA guidelines, over a third older adults classified as frail with type two diabetes were prescribed one of these higher risk medications to achieve a potentially inappropriately low target A1C. And what I find fascinating about this slide in particular is that, you know, this is the degree of A1C control by frailty category. And you'll notice that if clinicians were automatically loosening their glycemic control targets on the basis of frailty, I would expect there to be a drop of the percentage who had these tight glycemic control. And you'll see that there's no association. There's no relaxation of the A1C target with increasing frailty. And this holds true with literature across the country. Our region is not alone. So then the question is, what about the medication choice? And we thought, well, maybe most of it is driven by GFR. People are being pushed to use higher risk medications because of GFR. But even those who do not have, you know, the lower kidney function, there's still a preference for the use of sulfonylureas and insulin in this population with increasing frailty. Okay. So we then also were curious. There is a pervasive feeling that, you know, tighter control of diabetes by A1C is significantly important in terms of mortality or in terms of acute care utilization. And what we found here is that while that is true for this population of folks who are pre-frail, you know, older folks who have a couple of conditions but are not frail, these folks are less likely to experience death if they have tighter glycemic control. But that relationship goes out the window for those who are frail. And it really is frailty that is dominating their risk of mortality. So you see here the two shades of pink and red. These are those who have frailty and an A1C either above or below seven and a half. And there's really no difference between the two. Whereas there's some space between the black line here and the gold line here where for these pre-frail folks, you know, it appears that a tighter glycemic control is protective for this group of older adults. And the same pattern holds true for acute care utilization where it's really interwoven and there's not a distinct difference for those who are frail. But again, tighter glycemic control does seem to be protective for those who are pre-frail. Now, major caveat, all of this is observational data, okay? So there's limits to what we can intuit from these, but it certainly is suggestive that frailty is significant. Then we also took a look at mortality in terms of choice of medications. Now, what I find interesting here is that the highest mortality is in older adults with frailty who are not on any medications. So their naturally occurring A1C is below seven and a half. These folks are likely nearing death. We have found that to be the case in other studies that those whose blood pressure starts to decline, their A1C starts to decline, their LDL starts to decline on their own without medications. These are older adults who are really reaching the end of life. So that's not as surprising, but the next highest mortality is those who are on sulfonylureas and insulin. This may well be confounding by indication, right? Those in whom we feel they have the highest disease burden or the hardest to treat diabetes or the longest duration of diabetes may certainly be most likely to be on these medications. So again, these are observational data, but I think this drives a need for some further exploration by randomized control clinical trials to think about what's optimal for managing diabetes in this population. So in collaboration with Dr. Uso and the endocrine team and the pharmacy team here at Wake Forest, we've done a couple of pilot studies where we're starting to look into what happens if we shift and attempt to align diabetes management for frail older adults with ADA guidelines. In our first, this was a relatively simple QI study where pharmacists contacted PCPs to say, hey, here's a list of your patients who meet criteria for frailty, they're on a higher risk med and their A1C is below seven. Do you think that maybe we could lighten up on their medications? And about 50% of the time, the primary care physician agreed and made a modification. We also conducted a pragmatic pilot that had a little bit more involvement of the pharmacists. Pharmacists actually in North Carolina, there is a role called the clinical prescribing pharmacist where these individuals function more like an advanced practice provider and within a relationship with a PCP can adjust medications for specific conditions including diabetes. Our pharmacists are brilliant. I learned so much from them and they take excellent care of folks with diabetes every day, typically attempting to bring them below certain targets. In this case, we tested whether they could help loosen, you know, and lessen the intensity of glycemic control. Now, 80% of the people who visited with a pharmacist underwent at least one medication change, but the stickiness wasn't there. You know, by about six months out, most of these individuals were, you know, back under their usual A1C targets. I think this speaks to some concerns both by older adults and by clinicians of out-of-control highs, fears of lows, frustration with monitoring. You know, what's been good enough is good enough. And, you know, there was a lot of interest expressed about the possibility of using technology to help older adults face these concerns about their diabetes getting out of control in the face of loosening the intensity of glycemic control. And, you know, we really think that technology can provide a pathway forward in two ways. In one way, you know, in the rising presence of population health teams to work with older adults, automated digital markers such as our frailty index, or there's a tool out of Hopkins called the e-radar, which can identify those who are likely to have cognitive impairment. This population-level information about subgroups of older adults at higher risk of complications could lead to a significant help both to endocrinologists and primary care providers in terms of managing this vulnerable group of older adults. And then also knowing that intermittent monitoring and a lot of the, you know, challenges of multi-dose insulin can be very challenging for older adults, whether it's due to cognitive impairment, difficulty with manual dexterity, just the overall burden of intervention. And then in particular, I want to emphasize the skilled nursing facility and long-term care population where when older adults are dependent on a caregiver, that can be really highly variable in terms of the strictness with which we would ideally see testing and delivery. So I give you over to Dr. Uso, who's going to speak more about these amazing technologies, and thank you for your attention. All right. Thank you so much, Kate. That was a wonderful introduction of frailty and the frailty index and how we can use it to identify older patients who are at risk for poor outcomes and would benefit from some of these advancements in diabetes technology. And I want to thank everyone who's on the webinar watching for your interest in taking care of this specific patient population. As we all know, people are living longer, and so older individuals with diabetes is becoming a larger part of our patient panel. So it's really important to be aware of the unique and specific challenges that can come with that population and how we might leverage diabetes technologies to help overcome some of those challenges. And so first I wanted to touch upon mobile apps. So we know smartphones are becoming more widely available and more widely accessible. The prices tend to be coming down, so more and more individuals are using smartphones. But it's not just younger individuals. There's also a large portion of our older population who are utilizing smartphones. The AARP put out a study showing that over 70 percent of adults greater than 70 years old were utilizing smartphones. And so with the growing use of smartphones, we also have had this rapid increase in the development of mobile apps, specifically mobile apps that are utilized to help manage health conditions, including diabetes. And so there are several different mobile apps and different types, including nutrition apps, physical activity apps, glucose monitoring apps, also apps to even help titrate insulin and make treatment decisions. However, the safety, the evidence for safety and effectiveness of these apps is limited. And so the ADA and the European Association for the Study of Diabetes came together and put out a review which ultimately concluded that many of these apps are largely unregulated. So they really call on health care providers to be knowledgeable about these different digital apps and be able to educate and support patients who use them and answer questions. And then in addition, whatever health data is collected, being able to use that to improve the quality of care and health outcomes for the patient. See, OK, great. So next, I wanted to talk about the continuous glucose monitors, which I think we can all agree has been somewhat of a game changer in the last five years in terms of all the data that you can get and how you can make more precise and informed decisions about medication changes in our patients. But I think it's really important to have a discussion with the patient prior to starting CGM about what it is actually measuring and what it is not. I've had several patients come to me and say, after a month I stopped using the CGM because I felt it was inaccurate and it was 30, 40 points off from my finger stick glucose. And so it's really important to tell the patient ahead of time what to expect. And that can further improve long term adherence to the CGM. And so the CGM measures the interstitial fluid glucose, which typically approximates the blood glucose unless there are wide changes or rapid changes in blood sugar levels, such as when you consume a high carb meal or maybe taking a large dose of insulin, you can see that the interstitial fluid glucose may lag behind the blood glucose by 15 minutes or so. Like I mentioned before, CGMs can take measurements every five minutes. And so they can provide a lot of data. Most of the CGMs are factory calibrated, so you no longer have to do finger sticks. And all of them reduce the number of finger sticks needed to monitor the blood sugar. And many of the CGMs available have automatic alerts and alarms that can detect and warn the patient of hypoglycemia or hyperglycemia. So that's really important for our patients who have hypoglycemic unawareness. And so they can catch it very quickly. And so the different types, different categories I wanted to talk about. First, real time versus intermittently scanned. So real time CGM automatically transmits a continuous stream of glucose and provides that not only to the patient, but you can also share that data with your provider or a loved one. And I think I saw in the chat what may be some resources on how to share that data. Most of the large, the most common CGM companies have instructions online on how to share the data. I know with Dexcom, you can even have the patient give you a sharing code, and then you put that into your own portal, clinic portal, and then you can have access to their data. And so there are a lot of instructions and resources online. I'm happy to further talk about that more at the end of the presentation. But real time CGMs are my preference for older adults just because one, they have the alerts and it's much easier to share data without the patient having to physically come into the clinic. The intermittently scanned requires the user to scan the sensor to obtain glucose information. So for someone who might be forgetful, who may not always be able to scan and remember, that's not an ideal type of CGM to have. And it also does not include the automatic alerts and alarms, which are really key for managing diabetes specifically in an older population. The next category I wanted to talk about are professional versus personal. So the professional is typically owned by the clinic. It can be worn for anywhere from actually 7 to 14 days and returned to the clinic for analysis and interpretation. It can be blinded or unblinded to the patient. And I've been able to use the professional CGM in some cases where I may be with an older patient and they're just not 100% sold on using a CGM. They don't know, they're not sure if they're going to like how it's going to feel and if they're going to be restricted in movements. And so I feel like the professional is great because it almost gives them a chance to test drive it and you still get a lot of good data when they wear it. And then you have the personal CGM, which is owned and routinely used by the patient. And the patient can actually see the blood sugar data and act upon it in real time. And so here are some of the most recent models or forms of CGMs from the varying companies. And CGMs, they're just advancing so rapidly. They're getting smaller, they're getting more accurate. I know they're also getting simpler to insert. The Dexcom G7 and the Libre 3 are some of the smallest sensors that have ever come out and relatively simple. And so this is again, great for our older patients who may have challenges with following kind of complex steps. Again, many of these are now factory calibrated. So you don't have to calibrate it with finger sticks twice a day, such as some of the older models. And then Eversense is actually still one that you do need to calibrate it with finger sticks twice a day, but it's the only implantable CGM that's out there on the market. I would still, in our older patients, go for the ones that don't have to be calibrated via finger sticks. Again, some older patients may have dexterity issues or may forget to actually calibrate the CGM. So I really would go for the ones that don't require the finger sticks to calibrate. So who can get a CGM? And so this is a slide, all this information is straight from CMS website on what are the criteria for individuals to get a CGM covered through Medicare. So they must meet all of the five criteria. So have diabetes, the treating provider must conclude that the beneficiary or the caregiver has sufficient training to use the CGM prescribed. And then the CGM must be used in accordance with its FDA indications. And then the patient must have at least one of the criteria below. So that can be insulin treated or history of problematic hypoglycemia. And so that can be a level two hypoglycemic event, meaning a blood sugar less than 54, or sorry, recurrent level two hypoglycemia that persists despite adjustments in medications or a history of just one level three hypoglycemic event, which is blood sugar less than 54, but characterized by altered mental status or a physical state requiring third-party assistance for the treatment. And then fifth, they need to have seen a provider within the six months prior to ordering the CGM. However, this visit can be in-person or telehealth, which is really great. The telehealth option for our patients or older patients who may have difficulty leaving the house and making it to appointments. So that's a nice characteristic or a nice part of the CGM criteria that they have now included. And so next I wanted to talk about the automated insulin delivery systems. And I will say that just in general, these insulin pumps have just really kind of helped our patients so much. I've had many patients tell me that before these automated insulin delivery systems came out, it was such a mental burden to manage their diabetes, just constantly having to think about, what's my blood sugar? How many carbs are in this? Did I bolus before? And so it just took up a lot of mental energy. And with these new automated insulin delivery systems, they're able to adjust insulin delivery and at least ease some of that mental burden that a lot of our patients talk about. And so specifically in the older population, I think another benefit from the automated insulin delivery systems are the suspend before low. So if the CGM is predicting that you're about to drop low, then the pump based on a specific algorithm can suspend insulin delivery. And so this again helps reduce hypoglycemic events in our older population. I think it's also important when you're picking a specific insulin pump to be aware of maybe some of the physical or visual impairments for the patient who's sitting in front of you. So for instance, if you have an older patient who may have macular degeneration or cataracts, you wanna make sure you pick an insulin pump with a bright, large screen, such as the Omnipod. And then one who may have arthritic changes and have maybe some hand deformities may have trouble with doing a touchscreen. So preemptively encouraging them to get a stylet so that they can navigate the touchscreen for these insulin pumps is very, very helpful in that population. I do wanna talk about smart pins as well, as this has also been helpful in increasing adherence to regimen. And so the smart pins are able to transmit data from the pin to the cloud and provide digital memory. And so it can track the amounts of insulin that have been given. So this is really great for our patients who sometimes remark, I couldn't remember if I took my fast-acting and so I didn't wanna take a double dose, so I just didn't take any more. So with the smart pins in conjunction with the phone app, they can actually look and see if they've delivered the insulin. And also this is great for the provider in that you can download it and actually track the amounts of insulin in correlation with the blood sugar as well, because these can be connected with a CGM as well. So some of the benefits, like I said, it keeps that record, keeps that data. So it provides a lot of information to not only the patient, but the provider. And then it's also a good alternative for maybe those individuals who want the benefits of an insulin pump with specific dosing based off of an insulin carb ratio, a sensitivity and a target blood sugar, but they don't necessarily want to be attached to a machine permanently. And so this allows for the freedom, but also allows for getting precise treatment recommendations. And it also helps support adherence to treatment plans because that memory is kept and the patient can easily see if they've taken their medication or not. And it also helps support appropriate dose decisions and barriers, as usual, the potential costs and the potential technology inertia with the patient and sometimes even the provider. So I won't go too much in depth in glycemic goals, but I do want us all to be aware that there are different A1C goals in older adults, as Kate had mentioned at the beginning of the presentation. So depending on the number of chronic illnesses, these older adults will have a less stringent glycemic or A1C goal just because you're trying to avoid or prevent hypoglycemia. And so we should be screening older adults for hypoglycemia at every visit. And if someone is having significant frequent hypoglycemia, we really don't focus on the A1C goal at all. It's really about trying to prevent recurrent hypoglycemia as it can have negative effects, just like Kate had mentioned with individuals who are frail and not having that reserve, that ability to bounce back from a severe hypoglycemic episode. So if we can avoid that in the older patient, that really can improve their quality of life for pretty significantly. Again, also wanting to avoid those high-risk medications that may be associated with hypoglycemia. So the sulfonylureas and insulin, if possible. Sometimes you're not able to avoid use of insulin, but if you do have to, then trying to go with a simplified regimen, even though it may not be able to get the precise glucose values that you want, but making it more simple can help avoid medication errors and thus potential negative sequelae from a hypoglycemic event, such as a fall. And then for these individuals who are on high-risk individuals, really thinking about using a CGM with low alerts, especially, again, if they're on a high risk medication. And so we've kind of talked about these different A1C goals based off of the number of, you know, comorbidities the patient has, but even the location or the health status individuals may have a different glycemic goal. So for those individuals who are community dwelling or live in a SNF or, you know, for short-term rehab, really you're not focusing on the A1C so much, but mostly focusing on the glucose target. And then those who have very complex or poor health or maybe have an end-stage chronic illness, again, avoiding reliance on the A1C and avoiding hypoglycemia and symptomatic hyperglycemia. And so, you know, much of our guidelines and much of our research has been based off of A1C, but I think with the increasing use of CGM, we've seen how limited the A1C really is and that it doesn't always accurately reflect short-term glycemic control. And it can also be affected by several clinical conditions such as anemia and uremia and also HIV and some of the medications used to treat HIV as well. And, you know, the fact that it's typically obtained every three months and if a patient is waiting to just see what their A1C is, I think they missed the opportunity to make changes sooner in regards to achieving better glucose control. And so, again, that's where personal CGM has really stepped up to overcome some of those limitations of A1C and that it can, one, provide a lot of sensor glucose measurements and a lot of data to the patient and also the provider taking care of them. And it also helps because it's providing glucose data during sleep, where a lot of times, you know, the patient is sleeping, so they can't really be checking at that time. So, the personal CGM allows for those levels to be monitored and it also permits real-time feedback to the patient about things they can change. And so, the figure to the right is just an example. Each column, vertical column, is supposed to represent a patient. All these patients, all three, have A1Cs of seven with a mean blood sugar of about 154, but the time in a specific range is color-coded. So, green being time in target range and then purple being time spent below target range and then the yellow time spent above target range. And so, the third patient, the one farthest to the right, I think we would all agree that this person has excellent control, A1C of seven, 100% time in target range, but then if you look at the two other patients, they both have pretty significant time below range. So, 8% in the middle patient and 24% in the first patient. And so, if you just looked at the A1C, you wouldn't see just the sheer number of hypoglycemic events in these patients and you may not make any adjustments that really need to be made. And so, that's, again, some of the benefits of the personal CGM. And so, because of, you know, the CGM becoming more and more popular, we do have different clinical targets for CGM data in our older adults, just like we have different A1C targets. And so, this is a figure from diabetes care, just kind of talking about the different clinical targets for CGM in older adults. And so, you can see in the older adult group, our goal target range is greater than 50%, which is much less than the greater than 70% in maybe a younger patient. And then the goal time spent below target range is less than 1%, which is much more than the typical less than 4% to 5% in a younger population. And because of that, we allow for higher blood sugars as well. So, it's really important when you are interpreting CGM data to be aware of that when you're managing that in an older patient, that you do have different targets. And so, as you can imagine, we keep saying you get a lot of data from these CGMs, and it can be overwhelming, especially for maybe a provider who's not used to looking at them routinely. And so, I did want to touch upon a potential future glycemia metric and how it may be used to better manage diabetes in older adults. So, that's the glycemia risk index. And so, this is a composite metric for the quality of glycemia that is developed from CGM tracings. So, Dr. Klonoff's group came up with a model to predict expert clinician assessment of glycemia quality. And they based this and found that clinician assessments really typically depended on two main components. It was degree of hypoglycemia and the degree of hyperglycemia. And so, they took these two components and combined them into a single glycemia risk index, or the GRI. And here, again, is a figure from the paper that was published last year, just giving an example of the use of the GRI. So, it can be plotted on the GRI grid, and you can see that on the horizontal axis or the x-axis, you have the hypoglycemic component. And then, on the vertical or y-axis, you have the hyperglycemic component. And then, you have the grid that's split into five zones corresponding to the best quality of glycemia, which is in the green, to the worst quality of glycemia, which is in the kind of purplish color. And so, with this index, it allows the provider to have a quick assessment of glycemia risk and track changes also within an individual over time. So, the example given in the figure, you can see at time point one, which is kind of in that purplish zone, this patient is having significant amount of hypoglycemia and also a significant amount of hyperglycemia. And then, over time, they're able to get into the red zone by reducing the amount of hypoglycemia, and then eventually get into the green and minimize hypo and hyperglycemia. So, you know, I think this would be an interesting index to use specifically in our older population, when we know that maybe we may give more weight to avoiding hypoglycemia. And so, they can have a different goal GRI, which I think is an interesting way to use this index. And so, again, special considerations for our older patients and how do we choose the right technology. So, I think being aware of potential and experience with newer technologies and hesitancy, and that they may require more education and more instruction and more support. So, making sure that any caregivers or loved ones attends that appointment with the diabetes educator when they're getting trained on a new piece of technology. Also, being aware of vision or hearing or other physical limitations when you are picking a CGM or a specific insulin pump. So, being aware of those so that you can pick the right one for the patient. And then, also being aware of potential for some cognitive dysfunction or memory issues as well. Again, trying to pick a technology that is as, I guess, streamlined and makes it as easy as possible for the patient. And so, taking all those considerations into account, you really…recommendations must be individualized and consider the risk, the capabilities, and the limitations of each patient. And the table to the right just gives an example of, you know, how to potentially check or pick the right CGM. So, for maybe an older patient who lives alone, you want to make sure you have one that has remote data sharing with caregivers. For someone who may have some memory issues or cognitive dysfunction, I would go for the real-time CGM over the intermittent scan so they don't have to remember to actually scan the sensor. And then, potentially use of a phone as the receiver versus a separate device, just because I think we're more likely to keep our phones close by because in order to continue getting that data, you have to have the receiver and closer approximation to the sensor that's on the patient. And then, for those who may have hypoglycemic unawareness, again, picking the ones with the automatic high and low glucose alerts and alarms. And then, for those who may have dexterity or vision limitations, trying to pick maybe a CGM that has a combined sensor and transmitter for easier insertion. Okay. So, take-home points. Hopefully, you've seen that there are special considerations when managing diabetes in older adults and that one size does not fit all because everyone ages differently. Hopefully, you've seen that frailty and cognitive impairment key constructs to operationalize ADA guidelines. And then, hopefully, you've also seen that advancements in technology or potential are helping to overcome the barriers when it comes to managing diabetes in older patients and that A1C and CGM targets are varied for older adults and that the GRI may be a useful tool in using an individualized approach to diabetes management in older adults. So, thank you. Thank both of you. There's a couple questions in the chat, but before I get to that, Kate, did you want to add anything to the take-home points? I think the doctor summarized it beautifully, you know, the real take-home around, you know, the heterogeneity of aging. Individualization is an admirable goal. I think as we were thinking about the operationalization of that, I think we've got two different pathways of technology that can help us to optimize safety and optimize outcomes in a way where older adults continue to feel highly cared for and invested in. You know, it isn't just A1C alone that can be our guide for helping older adults have the best experience and outcomes with their care. So, thank you for letting me join you. Kate, before you unmute yourself again, but one of the questions I think is directed to you, Dr. Shah was asking, you know, how do I incorporate that frailty index in my AMR? I believe he's Epic-based, and we've talked about this before, but for the group, if you can share. Sure. So, the electronic frailty index is, full disclosure, we have taken some movements to commercialize, not because we're ever going to get rich off of it, but because our team works really hard to extract data from the EHR. So, we have a very modest fee, which is even more modest if one wants to use it for research or education purposes. The short answer is, drop me an email and I can talk with you about it, but we have moved the EFI so that it is in a cloud-based EHR agnostic format and can talk with you about how we could work with you to get the EFI in your system. Perfect. And then, Chenan Yeh, I think you touched on this in your talk, but I think one of the questions came up that's something that I also struggle with is a provider who is independent, just does telehealth remote patient monitoring. So, any options to connect that elderly patient who's maybe homebound largely, how do we connect their clarity or any follow-up without integrating it into a physical visit to the doctor's office? Yeah, no, that's a great question. And, you know, I feel like, you know, we're blessed here at our institution to have a lot of support of diabetes educators, nursing staff, who actually helped me before some of my telehealth visits and getting people connected. But I would say, you know, if you don't have that type of support, potentially I've been able to walk a patient through how to share their data with me. Like I mentioned in the talk with Dexcom, you can actually get the patient to give you a sharing code. And then when you put that into your Dexcom clinic portal, you will have access for whatever amount of time you've, or the patient has designated. So, that's been a really powerful, you know, resource to have. There are, you know, I think each of these companies also have detailed instructions on their website. There are YouTube videos as well. So, those are kind of the resources that I've personally used. Myself as well, another question coming up, which is actually something that concerns me about the future of healthcare. And Viral is also saying, unfortunately, most nursing or home healthcare are not tech-friendly. And I myself have a patient that's one of the VA rehab centers, and they routinely take a sensor off, which he's had severe hypoglycemia, three-yard missions, has hypoglycemia unawareness. And so, I guess the question is, is, you know, this is the audience, how can we make a change to this situation? And Kate, as the senior geriatrician on the webinar, probably let's you see if you have any comments, and I'd open up to Chinenye too. So, I mean, I think the thing that's critical here is that it's important to separate out in our minds the difference between nursing home long-term care, which is highly regulated, and there would certainly be, I think, a very clear path to working with CMS in this space. You know, the fact that CMS is now willing to support continuous glucose monitoring for so many of our patients, and CMS is also the major payer for most long-term care and for rehabilitation, I think that seems like a natural pathway. You know, I think, you know, when you're a hammer, everything looks like a nail, so I'm a researcher. I think we need to have some research in this space to show the value of continuous glucose monitoring, even in those who don't necessarily have obvious histories of hypoglycemia, because it's much more common than we likely know. I think the other question is aligning with those who are the administrators of nursing facilities. They want to do right by their patients. The question is, how can this technology be used to streamline care, as opposed to duplicate care, right? And so that's, you know, I think a lot of the messaging, so often there's not the type of implementation and process measures in these studies to show things like, how long does it take to do a traditional finger stick versus scan a CGM? How, you know, how difficult is that to upload into the electronic health record of the long-term care? We recall that assisted living and memory facilities are not regulated in the same way. And so, again, you know, one assisted living facility will be very different from another assisted living facility. The progress in that space will be, you know, therefore more scattershot, because it doesn't have the same regulatory structure. So, I guess, not very helpful, but I would start with the nursing home CMS overlap with the regulations in one space and the management recommendations in the other. Yeah, there's a few others coming in. We only have about a minute left. Ellen Oswalt, who we work with quite a lot, says, have you done work in understanding technology or diabetes literacy, numeracy? What tools and resources are you using to assess, evaluate, or understand those barriers? And Holly Samples also recommends adding Bigfoot, their smart pen cap to your toolbox, Chenenye. But in the 30 seconds left, any other, because we're going to get logged off regardless of whether we're talking in a minute. Any words on numeracy, diabetes literacy? I don't have any specific resources for that, that I've used. Okay, well, let me just wrap it up, because I don't think they're, these are excellent questions. It makes me feel like we picked a good topic, since there's a lot of interest people stayed on. Ellen, I would say it's interesting, one of our educators is working, and we eventually will publish data in our indigent care clinic, where these have not been barriers once we educate the patient and educate, basically, it's having an embedded educator in our indigent care clinic. Thanks, everyone. And I think we've been logged off. Oh, wow. We'll be wrapping it up, I think. Yep. All right, more to come.

diabetes technology

elderly patients

frailty

personalized care

continuous glucose monitors

insulin pumps

automated insulin delivery systems

glycemic goals

glycemic risk index

improve outcomes