Hello, everybody. Welcome to today's hands-on tips to improve diabetes care webinar. Today our panel will share their expertise on empowering older adults in navigating diabetes technology. And we're all excited that you're joining us. I'm Dr. Joseph Aloi. I'll be moderating today's webinar. To share a little bit about myself, I'm currently Section Chief of Endocrinology, Diabetes and Metabolism at Wake Forest School of Medicine in hot and humid Winston-Salem, North Carolina. I just completed my term on an ADA interest group in diabetes tech, and hence my interest in technology in general, but specifically this area. Today's agenda, a few announcements about some upcoming webinars, the presentation, and some case studies to work through this whole topic. We'll conclude with time for Q&A. You'll see in your chat box links to the next hands-on webinar. We're going to be using Kahoot! If you've added the pin, there's a little question and answer that's going to pop up after each presenter's title slide. So there'll be quiz questions that we go through. We'll be using the Zoom Q&A section, which is at the bottom of your toolbar, for you to type in some questions during the presentations, and I'll be moderating the Q&A after the presentations are complete. If you put it in the chat box, we'll try and get to it as well, but the Q&A makes it a little bit easier for me to manage one section. So this is how you join Kahoot! The game pin was in the very beginning. And at least on my screen, it pops down at the bottom of 4627661, and we can put that in the chat box for folks. There you go. So I want to announce our next hands-on webinar, In Motion Through Ages, Tracing the Legacy and Application of Exercise in Diabetes Care, Tuesday, August 13th, 3 to 4 p.m. The registration link's in the chat box if you want to register now for it. We've assembled a great panel to walk you through this very important topic. So today's panelists, we have both Kate Callahan and Dr. Maeda Munshi. I want to introduce Kate. She's a geriatrician and health systems researcher whose work focuses on scalable, sustainable solutions so that every older adult can access high-quality geriatrics-informed care. With the support from a K76 Career Development Award in Aging, she led the adaptation and implementation of an electronic health record-based frailty index. She put this into the Wake Forest and now Atrium Health EHR. Dr. Callahan's collaborations with primary care, population health, and specialists to test care pathways to improve health outcomes for older adults with frailty has been supported by both the NIH and by the Duke Endowment Foundation. Dr. Maeda Munshi is a professor of medicine at the Harvard Medical School. She is both board-certified in geriatric medicine and endocrinology, diabetes, and metabolism. Dr. Munshi practices geriatric medicine at the Beth Israel Deaconess Medical Center, and she's developed and directs the Geriatrics Diabetes Program at the Joslin Diabetes Center. This unique clinical program considers clinical, functional, and psychosocial barriers faced by older adults with diabetes before formulating individualized treatment strategies. Dr. Munshi has published extensively in the field of geriatric diabetes. She's participated writing national and international guidelines for managing diabetes in older populations and have co-authored textbooks on this subject. She is also the founding president of the International Geriatric Diabetes Society. At this time, I'll let our panelists introduce themselves and state their disclosures. I'll be back for the Q&A. Thanks so much for the introduction. So as Dr. Loy said, I'm Kate Callahan, and just to update my disclosures, I do receive a small amount of research support from Abbott as well. So, okay, I'm going to come up here and see if I can get started. All right. Up here you're seeing our gentleman Bowman Gray, who stands outside our School of Medicine. Which of the following perceptions by older adults have been described in the literature? All right, wrapping up, and yes, indeed, it's the perception that longer duration of diabetes means more intensive treatment. So we'll talk about this a little bit more during the presentation, but one of the challenges in caring for older adults around diabetes treatment is that, you know, older adults have heard a lot of things over the years that they've been living with diabetes about what their targets should be. And so sometimes their preferences, goals, don't entirely align with current recommendations, and that is a stumbling block when it comes to thinking about how to partner with folks and move forward. Okay. All right, our scoreboard here. So I wanted to start talking a little bit today, as Dr. Loy said, I'm a geriatrician, and so I'm not an expert in diabetes, but I am an expert in older adults and how things change over time. And in my clinical world, I spend time as a primary care physician, particularly for frail older adults, and I wanted to start by orienting us to some of the physiologic changes that occur as we all age. Cognitive changes are typical. Cognitive change is not normal. That's still a disease state, but older adults are predisposed to mild cognitive impairment and subsequent dementia. And some of the areas that are first affected are people's insight and judgment, their executive function and ability to plan. And these are critically important if you're talking about a complex medical plan for diabetes. It may become more difficult for people to put two and two together if they're recognizing symptoms and seeking to act or if they're juggling complex insulin regimens or other complicated medication approaches. Certainly there's several cardiovascular changes, one of them being a decreased inotropic response to catecholamines, which means that people may not have that, you know, fluttering of the chest effect or some of the symptoms that can come on in lower blood sugars. There's a reduction in GFR, which certainly affects the how long medications sustain in the system and a decline in lean body mass, which can make management of sugars more difficult. Your dietary changes come up because many older adults will lose both their taste sensors and the last to go is actually how we taste things that are sweet. So people may lose their ability to discern a lot of flavors, but that drive for something sweet is one of the things that is the last to go. So you may note that many older adults seem to develop a sweet tooth in older age. And part of that is because they're not necessarily picking up on the more subtle notes of either bitter, umami, or salty flavors. Decrease in absorption also means that there may be variable absorption of food, of calories, and therefore of sugar levels. Skin atrophy, loss of visual acuity can make it more difficult for just the simple finger prick that they may have been used to. But one of the things that's most challenging when caring for older adults is that hypoglycemic response shifts from more of an adrenergic surge, you know, that shaky, sweaty feeling when blood sugars go low, to neuroglycopenic symptoms. So people are less likely to notice that their sugars have gotten low until they're already woozy and about to fall over. So that leads to a good bit of hypoglycemic unawareness. And not only does that occur through longer duration of having diabetes, but also it occurs through physiologic changes of aging alone. Therefore, someone doesn't necessarily have to have had diabetes for a very long time to have hypoglycemic unawareness. So a few other features of, you know, reviewing what we know specific about type 2 diabetes in older adults. The ACCORD trial and others in recent years have shown that tight glycemic control in older adults with type 2 diabetes may carry risks specifically related to hypoglycemia without cardiovascular or mortality benefit. And subsequently, guidelines, whether that's from the American Diabetes Association or from other national and international communities, have suggested individualizing hemoglobin A1c goals in older adults. Despite all of this and that it's been over a decade since these studies have come out and adjustments and guidelines have been produced, over a third of adults aged over 75 use insulin, even in those with poor health who are more likely to have adverse effects. And ironically, deprescribing or the reduction in dose of medication or, you know, cessation of medications is more likely to occur in healthy older adults, meaning that those folks who have the highest risk of complications are also the most likely to be tightly controlled. We'll talk a little bit about why that is likely to be the case. One issue that comes up, in addition, and this slide is courtesy of our colleague, Chinenye Uso, who is an endocrinologist here at Wake Forest. But there are limitations to hemoglobin A1c, as many of you know. First, they may not accurately reflect short-term glycemic control. So if someone has had a pretty big change, it may not even show up in the A1c. There's several conditions, many more common in older adults, such as anemia or uremia, that can affect the A1c level. And, you know, a challenge to making changes in real time is that you're kind of in a lag state, right? And there's a lot that can be said for the technological shifts to be more active and responsive. So going in specifically, what are some of the things that have come up, speaking specifically to the advice of the ADA with regards to type 2 diabetes management in older adults? The first is that it's important to consider several areas that you might not think of when you're assessing diabetes. So moving away from a disease state and looking holistically at an individual's medical, psychological, and functional status, you know, to provide a framework for how you can communicate around goals and approaches. And that that needs to include some geriatric syndromes that many of you may not have thought about since medical school relate to folks' cognitive impairment, depression, etc. That when you're thinking about the holistic person, these may come up as barriers to traditional or the person's historic management of their diabetes. And I really like the approach in the standards of medical care and diabetes and have made just some slight adaptations to this so that you can think about what your targets might be in managing older adults. And so bringing this together, you know, if you're thinking about someone who's healthy, you know, while many of those older adults who are healthy are actually the ones getting deprescribed, those healthiest older adults may in fact still benefit from a tighter control because they have longer remaining life expectancy. And if they don't have a lot of those comorbidities, then they may actually not need to adjust their strategy just yet. However, as people accumulate more multiple chronic illnesses, may begin to have more challenges with their day-to-day activities, it's important to consider not only life expectancy, but also is someone frail, meaning are they more vulnerable to stressors in their day-to-day life? Do they have early cognitive changes? And what might be the risk-benefit ratio of medications? A1c goal may be more appropriate to be closer to eight with concomitant changes in targets for fasting and bedtime glucose. Finally, in those who are most advanced, you know, these are individuals where their limited remaining life expectancy and complications like more advanced cognitive impairment or mobility challenges really moves us into a comfort-focused, lower burden environment. We're really looking at what I often say to my trainees is we're trying not to break them, right? You know, you're trying to just help people have high quality of life for whatever time they may have left, and that may not mean multiple daily doses of medications for their diabetes. Certainly want to avoid the scourge of hyperglycemia and the negative symptoms that follow, but you're really trying to avoid the extremes here. And here's another way of looking at it. The recommendations are over here on the right, but I wanted to highlight just a couple. One is that both sulfonylureas and insulin in older individuals, particularly those who are more complex, may not be appropriate. And increasingly, there's other medications on the market that are getting tested more frequently in older adults that may be better options as we learn more about those. Thinking about the risk of falls, the risk of medication errors, both with mobility problems and cognitive problems are important, and that particularly for those who are on high risk medications, and sometimes you GFR and other features really limit access only to those medications. There are ways to make that safer for our older adult population that may include the use of technology. Now, one challenge is that many older adults are not interested in changing their strategies. They may be afraid or disappointed or be concerned about what could be driving a clinician's interest in shifting their focus. And so, you know, there's been some interesting studies that have shown that in general, endocrinologists and geriatricians are more comfortable with the idea of either deprescribing or reducing certain regimens in diabetes for older adults, whereas many primary care clinicians who have so hard fought to get patients to certain specific targets, and many of the older adults themselves may be less comfortable with these changes in targets. Some of that is the gaps in the research base that we still have. There's still some challenges to how do we select patients for deintensification. You know, I can sit here as a geriatrician and say, you should be doing a comprehensive geriatric assessment, but I also, with my primary care hat on, know that takes a huge amount of time, and it's sometimes hard, often hard to fit that in into a primary, a busy primary care practice. And so how can we select patients for deintensification using easier tools, quicker tools? And many of the studies that focus on deprescribing are not using hard outcomes. They may say, okay, our goal is to reduce high-risk medications, and hey, look, presto, we reduced medications that are high-risk. Many people want to know more about whether this is safe, what might the long-term effects be? So there's certainly a lot of research needs that are still out there. Further, older adults themselves have pretty strong differences in their perception of the risks and benefits associated with intensive glycemic control, and these often don't align with the guidelines that have been put forth by the ADA and other organizations. One perception is that worse diabetes should merit more intensive treatment, that basically if someone has more complications, then you should be going harder, not lightening up, whereas many of the guidelines recommend and recognize that if someone has already developed some of the complications related to diabetes, that the purpose in that type control may be obviated. Another is that the longer someone has had diabetes, the more closely controlled they should be, not really recognizing, again, that the type control may be harder with longer duration. Something that's very interesting to me as a geriatrician is that some older adults question whether function prognostication should drive decision-making around care, and voice discomfort, and even fears of ageism when these issues are raised. But what's great is that folks are receptive to the idea of assessing individualized risk. This is a little bit more detail from one specific study that I thought was particularly well done, and there have been several great papers looking at these perspectives, but this disconnect really showed how people would make decisions when it comes to adding a medication versus stopping a medication. You'll notice that many of the things that are important with adding a medication is that wanting to focus on diabetes duration, treatment effort, people are okay with adding a medication in that instance. But stopping a medication, there's some difficulties. The one that seems to be most important, by and large, is the risk of adverse effects. And so, speaking to folks around the area of adverse effects is important, and this also is going to be a really important area for future research so that we can explain to patients, what are the treatment strategies that are likely to reduce adverse effects? How can we keep you as safe as possible? And with newer emerging therapies, are some of those going to fill in the gap for potential safety? And are there tools that can be used, such as the technologies available, to think about safety as well? Okay. So again, here are some areas for future study, and specifically would want to talk about what needs to be done for patients and caregivers, particularly around the perceived benefits and risks building on this. You're thinking about how providers both think about guidelines, discuss guidelines, what are the resources that we can build upon as a care community to get to our fellow clinicians? How do patients and providers interact around decision making? And then ultimately, are there things that our health system can do as well? Okay. And then, wrapping up, just wanted to say that technology may provide a path forward. So there's some areas both on the patient side, so how can we think of an individual in terms of their personalized risk-benefit analysis? There are some great tools that have been developed that are automated digital markers, whether that's for cognitive impairment, a tool like eRADAR, which was developed at Hopkins and has been used in a couple of other places. Our own eFrailty Index is at Wake Forest, but there are other folks who've developed frailty indices in the VA, or some of Dr. Munshi's colleagues at Harvard over at Brigham have worked on a frailty index as well. Population-level information about identifying groups of older adults that may be at higher risk from more intensive control, or may be ideally suited for increased monitoring. And as I mentioned, both for physiological reasons, for cognitive reasons, and for just day-to-day, you know, the difficulties of day-to-day life, intermittent monitoring may be more difficult for older adults, and so are there ways to build in? And so there's a nice article that was done, you know, looking at here, by Battolino. By Battolino and colleagues looking at targets for CGM interpretation in older adults specifically. And so if we're thinking about shifting, including more of this CGM data, you know, what can we do for engaging with these specific targets? So this overview is to help set up for Dr. Munshi's more in-depth discussion, and thank you so much. So do older adults value intensive treatment of diabetes? All right. Yes. Generally speaking, yes. You know, there are those who are less so, but the surveys done so far and interviews so far suggest that yes, older adults do value intensive treatment. And some of that is on us, that we as clinicians have fought for a very long time, that the lower the better, and that can be difficult to let go of over time. But then a lot of it too is a discordance with understanding the source of data and why guidelines may be shifting over time. Thank you. And Dr. Munshi is next. Well, hello. Sorry about that. Yeah, hi. I'm Medha Munshi, and after this very comprehensive sort of phenotyping of this older population, we'll be talking about the next step of empowering older adults in navigating diabetes technology. So let's start with the question. All diabetes technologies can be effectively used in all older adults in clinical practice, just like in the younger adults. What do you think? Is that true? Okay, well, this is perfect. So we are not sure, we are half and half. So I'm just going to start sharing my screen here and see if, yeah, I hope you can see that. So here you go. Okay, so the question is, why are not all older adults with diabetes prescribed technology, right? And I know there are more than one aspect of this area where some of our colleagues would say there are many different reasons why this is not happening, but let's look at the clinician's point of view. And as you heard, I am a geriatrician as well as diabetologist, and I have privilege to work with some of the amazing colleagues on both sides, on endocrinologist side as well as geriatrician. And I see them look at and treat their patients with passion, and they have some of the, some sort of a different approaches to the same issue. For example, in a healthy person, an endocrinologist would say that the patient is older but healthy, why not provide tools for better glycemic control? And my geriatrician colleague would think that patient is healthy, but has other barriers and priorities. Why add this burden with limited data on benefits of this complex technology? For somebody who has more complication, the endocrinologist would consider that there is enough time to develop complications. For this patient with reasonable life expectancy, perhaps they do need more technology. A geriatrician or a primary care provider point of view might be that patient has other medical problems and caregiver burden and can become too much. What about the cost of all this stuff? On somebody who is in a poor health, the endocrinologist would look at them and say there is a lot of data that shows older adults can use technology successfully. And the other side would think that I don't know where to start with this technology. Who will help and provide support to this patient? And how do you continue the use of technology? So the point is that there are very different point of view when you are thinking of an older patient and how do you use technology. So the trick is, or the basic of this is that to choose the right technology for the right patient. And the question is, how do we do that? Then let's go back to what Dr. Callahan just showed about the goal setting framework that is actually recommended by the American Diabetes Association where we don't look at the age of the patient, but rather the overall health status. So if you are thinking about a healthy person, that means that comorbidities do not interfere with the self-care. They have intact cognition and they do not require caregivers for their day-to-day activity, then consider complex technology use. Even the automated insulin delivery, they probably can handle that. However, it's important to keep an eye on the red flags that sort of shows you that the person is struggling, such as sudden deterioration of glycemia or increased stress in using the technology. And as always, people do get older. So you have to continue with periodical reassessment. If somebody is in their intermediate health, that means they have more comorbidities, mild to moderate cognitive dysfunction, and more than two instrumental activities of daily living dependency. And these are higher levels, such as managing their medications or transportation or finance management. These are the people where probably you don't want to start a new, very complex technology. However, we see that many times if people are already using a certain technology and they are used to doing that, then they may be able to continue their use. However, CGM can be very useful in this population to avoid hypoglycemia or extreme hyperglycemia. And again, putting the plug for periodic reassessment whenever you are starting someone on the technology. Even those in poor health, that means having end-stage chronic diseases, moderate to severe cognitive dysfunction, or more than two ADL dependency. These are the basic day-to-day activities such as bathing, toileting, and so forth. For this population, you really do not want to use technology to improve glycemic control. However, the CGM has used to decrease the burden of monitoring and mitigating risk of hypoglycemia and severe hyperglycemia. And that still can be a good technology for this population. Mind you, even for a very simple technology in this population, you want to make sure that there is some caregiver support is available. So how do we put this in a practical term? So as we approach the patient, you want to see who the patient is. Pick the right patient. Does the patient need self-care education or improvement in their self-care behaviors? And these are the young old, so to say. And for this population, real-time continuous glucose monitoring can be very useful to improve their dietary habits, to help them understand how the glycemic excursions happen. Does the caregiver need more data to help? The patient may not be able to help themselves, but the caregiver may, son or daughter, wants to know what happens to the glucose level, and they can perhaps reach out from farther away, and you can use the share feature on a lot of this CGM. Or it's us who need help. I, as a clinician, need to understand the pattern so I can make the changes to the medication. And in this case, probably just a professional CGM might be adequate for the need. Where is the patient living? Are they in independent living facility? Are they in assisted living facility? Are they in long-term care? We know that availability, caregiver support, and the need for the technology, and primarily we are talking about continuous glucose monitoring here as a technology, as a lot of other technologies do not have a whole lot of data yet. But even in continuous glucose monitoring, we know that in certain living situations, they are not quite covered yet. And again, we thought without caregiver is an important area to watch. And based on this, we would then decide what type of technology the person might be able to use, whether they need professional CGM versus personal CGM, whether smart pen can be used for that purpose, or even insulin pump and automated insulin delivery one could consider based on who and where, and thus we get to the right patient and right technology. However, even that overarching question is, why are we doing it for the patient? So there are two things. It is, what are we trying to achieve for the patient, and what is important to the patient? And Dr. Callahan made this point very well, in geriatric medicine, it's not just what is important that we think is for the patient, but also what patient thinks about what we are trying to do to them. And in my mind, there are really three primary reasons why a person would want to have a technology. Most importantly, mitigating the risk of hypoglycemia, achieving the better glycemic control, and this is almost like a precision medicine where we can choose what needs to be prescribed, and also what needs to be de-prescribed. And I do have a, you know, we have a sort of a big discussion going on about how we can probably call it realignment rather than de-prescribing, because it's not about taking the medicine off it, but rather changing the strategy so that the patients are safer with the medications that they are using. And then finally, some use of technology to improve the quality of life. And I have put some cases so I can actually show you what I mean in a very practical way. So here is the first case where the idea is to mitigate the risk of hypoglycemia using professional CGM. So here is a 77-year-old man with type 2 diabetes. He's at home with spouse, no hypoglycemia, but the A1c was 5.8%. And like Dr. Callahan mentioned, many a times A1c may not reflect the glycemia, but I was worried about him because he was on a small dose of metformin when he came to me, and a small dose of glomepiride, but had a recent fall with a right hip injury. And then he had a pretty significant heart failure with a defibrillator that was implanted. So professional CGM was there to make sure that he is not having hypoglycemia. And good thing that we did that, because look at this, he was spending 26% of the time in hypoglycemia, where? Overnight. So he is not really going to identify that, and majority of them have hypoglycemic unawareness. So I stopped the glomepiride, and then metformin was continued, but I was still uncertain whether that was needed or not. Did another professional CGM, and we could see that he was doing much better. So some of these patients, we just don't want to take everything off, but we want to do that more, you know, targeting the hypoglycemia without making hyperglycemia that common. And interestingly, the patient said, you know what, since we changed their medication, I don't wake up tired. And when I wake up, I am so much better balanced. So there was hypoglycemia, it was just not recognized by patient as the hypoglycemia symptoms. The next one is mitigating risk of hypoglycemia using the Bluetooth pen cap. And this is a study we did a long time ago, where before the smart pens were in the market. And here is a case of 71 year old woman with type 1 diabetes. A1c was really high, and even though she was not feeling hypoglycemia, her regimen, as you see, was basal insulin at bedtime, and sliding scale at mealtime. With a lot of time, she was giving herself a sliding scale mealtime bolus at bedtime. But she was really not checking that often. She is on real-time CGM now, so we are not worried about that. But this was an important time when it was not quite there yet. And here is our data that shows the blue line here is a continuous glucose monitoring. The light blue line is where she was getting herself long-acting insulin right around midnight. And then you can see that she was really not giving herself a bolus right before breakfast, but as her glucose level started rising, she gave bolus, and then she gave another bolus because she was worried about that. And that was followed by prolonged hypoglycemia. Again, she over-treated that, and as soon as it started going up, gave herself a bolus. When you show this to the patient themselves, that is a very powerful educational tool and to show them why not to chase high glucose and low glucose, and rather proactively give themselves the pre-meal boluses based on their carbohydrate content. This is a case, again, mitigating risk of hypoglycemia using real-time CGM. This is a 70-year-old woman who had a long duration of type 2 diabetes living alone. Even she was pretty good, but her MOCA score showed that she had a moderate cognitive impairment. She was taking basal insulin at bedtime and then fixed dose of insulin 15 units before each meal. And overall, her numbers looked very good. She was CGM-naive, no hypoglycemia symptoms, but because of her cognitive impairment, I was concerned about her ability to recognize and report hypoglycemia. And you can see that that worry was sort of justified here. She was spending about 4% of the time, again, overnight, because of the nighttime basal insulin. So we sort of chained the basal insulin to the morning and asked her not to take same amount at each meal, but rather, you know, five units for small meals and 10 units for large meal. Again, this is making a point that the technology allows us to look at what is happening and provide a very specific targeted therapy changes. And again, as you see, she did much better, a little bit higher, but you know, still 77% time in range without hypoglycemia. Another case of now improving glycemic control using the real-time CGM. This is a patient, you know, a relatively younger patient for a stereotrician who really was living alone with involved kids, but she had a recent history of breast cancer, multiple DVT. So she was actually quite overwhelmed with a lot of medical comorbidities and was put on this basal bolus insulin, basal insulin in the morning, meal time sliding scale three times a day. And here you go, you know, we know that the A1C was not very well controlled, but you can see that she was sort of running quite high with 22% time in range, no hypoglycemia for sure. And here is the patient that then you can have a fixed dose mealtime insulin with a lower insulin, basal insulin. And then this helped her to get her self-care better, right? This is a younger patient who understand what she needs to do. And CGM really helped her to sort of get that, get her diet under control, exercise under control, and just to decrease the burden of changing too many times and sliding scale she could do with a fixed dose meal timing insulin. Another case to how to improve glycemic control using CGM. This is a 76 year old man with a very high hemoglobin A1c, but again, quite significant burden of comorbidities. And here is a person, well, relatively younger person with a lot of cardiovascular comorbidities. So you want a better control, but then the Parkinson's disease and fear of falls. So there is a really, you know, that getting too low is going to be a problem for that. And he was in this very complex regimen, twice a day NPH, UMA log 10 to 20 units before breakfast. And then if she eats a snack, he takes some at bedtime. And if you look at her CGM, you realize that really there is no good way to manage this regimen without looking at this pattern. So although no hypoglycemia, he was spending really less amount of time in timing range, and then lot of high glucose levels. And again, we changed the basal insulin in the morning, fixed dose before each meal to decrease the burden of how much calculation and executive function that he has to do and added some metformin. And you can see that the numbers were much better with 82% timing range and 1% low below, which we would be working on that. And lastly, you know, using the professional CGM to improve quality of life. This is one of my favorite patient, 87 year old patient with, you know, really the weight loss was a huge problem after multiple hospitalization, very high comorbidity burden, and not just her, but her husband was essentially doing everything for her. The problem was the patient had really needle phobia, and she would miss a lot of appointments because she just did not want to come to the hospital, did not want lab, and was on metformin 1,000 milligrams twice a day and dapagliflozin 5 milligrams in the morning. And the idea was to sort of leave her alone, but the professional CGM provides us with really good way of doing this pattern management, which showed that there was a significant amount of time. You would think that this is a pretty safe regimen, right? She was still spending a lot of time in hypoglycemia overnight. We sort of changed her regimen, so pushed the metformin in the morning and continued dapagliflozin, increased the dose in the morning and decreased the dose in the evening and sort of helped her get a little higher. And this we can live with, right? She had 57% timing range, no hypoglycemia, and she really didn't want to do much finger stick readings for us to do anything better. However, as you know, things change in older population, right? So she had other hospitalization, prolonged one, further weight loss, and now she was out again eating better, but she really needed to gain weight. We could not afford her to lose any more weight. Here is her most recent professional CGM, 68% timing range. And I wish I had a way to ask the audience, what would you do? Would you leave her alone at this point? Would you do something? Her GMI was 7.6%, no hypoglycemia. Well, we can talk about that in the question and answer if somebody has a question, but what I did was I did add a very small dose of sulfonylurea here against all the things that we are talking about. The reason why I did that was so that she doesn't look so much calories because with such a hyperglycemia after her really big brunch, so to say, she's going to lose a lot of calories in the urine if we don't control this. But I certainly did not do that to improve her glycemic control. So in summary, I would say that older adults with diabetes are a very heterogeneous population, as Dr. Callahan very elegantly showed you. And I believe that to empower older person in use of new technology, it is important to evaluate the need as well as ability to use it effectively and if we do so, they can use it effectively, you know, we can find use of technology in almost all older adults with diabetes. With that, I will stop the share and give it back to Dr. Alloy. Thank you very much. We're going to get a slide up with five key takeaways and tips to summarize the meeting. And then I'm going to, we've got one, two, three good questions to go through. And I'm just waiting for the five takeaways. There you go. So older adults, heterogeneous group, cognitive, functional and frailty status are better to characterize their risk profiles than just their chronologic age. Hypoglycemia and glycemic variability are common in older adults. Hypoglycemic unawareness increases in older adults. Cognitive frailty and functional assessments are important components of determining both diabetes care as well as engagement with technology and other tools. And lastly, to empower older adults in use of new technology, it's important to evaluate their need and ability to use the technology effectively. I'm going to give that a few more seconds and it really goes Q&A box, but we're getting some in the chat as well. But the first question that came through, I put a link to a journal article that addressed the question, but I'll open it up to both panelists and I'll start with you, Kate. And if you don't have a specific answer, you can pass it on. But the first question we got is about the question, does gluten sensitivity or celiac disease change with age? So I will say that this is one of the areas that's likely understudied. I also was doing some searching. I didn't have an answer straight off the top of my head. So if you do, Dr. Munshi, please jump in. But the initial reaction I would have is that first differentiating between celiac disease and gluten insensitivity. So celiac disease, one of the reasons that I think this has been rising in recognition is that as people are living longer and as appropriate measures can now be taken to do procedures like colonoscopies in older adults for a longer period of time, I think there's a lot more recognition that older adults are also living longer and more healthy lives. So that chasing down the anemia that a lot of people just kind of went, meh, for a long time, people are actually now chasing down the reasons for these. So I agree with the article that Dr. Loy posted about the increased recognition of celiac. I would say that along with many other things, that that's probably simply an increased recognition and not necessarily an increased incidence over time. With regards to gluten sensitivity, I'm not aware of any specific physiological reasons that that would increase. Maida, anything to add? No, I agree. I have, no, I'm all right, yeah. Well, there's a reference for people that are interested in this general review that talks about change in immune tolerance with aging and so forth. The second question, Jennifer's gonna put a link to a WebEx that directs this, but I'll read the question. Or she's already got it in there, doesn't she? Nope, coming up. But the question I'll summarize is, how do you assess the risk benefit ratio of newer agents, pharmacotherapies, such as GLP receptor agonists and SGLT2 inhibitors and people with comorbidities such as CKD or CVD? And I would just preface in that older population. And Maida, do you wanna? Yeah, I mean, I think I would follow the same format that we talked about for the goal setting framework. I think if, so there is no question that GLP1 receptor agonist and SGLT2 inhibitors have shown benefits in older adults as well as younger adults. So the question about benefit is not necessarily what we need to consider. Then the question about safety, right? So that's where we go with. So people who have cardiovascular disease and can tolerate GLP1 receptor agonist should be on GLP receptor agonist. No question about it. If you start seeing many, I didn't start using it very quickly after they were out in the market, but now that the safety seems to be fairly well established and people tolerate that well. And if I see that they are losing weight too rapidly, I back off. So you can still use a small dose on that. People who are not able to tolerate that, it doesn't matter what kind of other comorbidities they have, they can't and they shouldn't because it's a lifelong medication. For the SGLT2 inhibitors, again, the people who get benefit, those with the progressive chronic kidney disease or those who have high risk of congestive heart failure or hospitalizations, they are older. However, there is a distinct side effect of the euglacemic ketoacidosis and hospitalizations that we do see actually, not infrequently. And we talk about this all the time. There is not a whole lot of data on how do you recognize people who will get that versus you don't want to not give it to anyone. And I would say that the easiest practical way of thinking about it is that if the person cannot reach to the fluids, in the sense that the family says that, I keep telling mom to drink and she gets dehydrated, don't give it to them. The nursing home population where if somebody doesn't give them fluids, they don't get it, don't give it to them. UTI, genital, those are minor. We can deal with that. I would be more worried about that, the acidosis. No, good points. Kate, anything to add before I go to the next? Very briefly, I completely agree with everything that Dr. Munshi said. I would just add that, remember that particularly in those who are frail, we often think of those as yes, being more subject to the side effects. In many populations though, these folks are also more likely to have the outcomes of interest. So you may get the biggest bang for your buck, sort of metaphorically speaking for these agents, right? So the people who are most likely to have the cardiovascular outcomes and many folks who are frail still have good quality of life. It doesn't mean necessarily disability. It doesn't necessarily mean cognitive impairment. So, I would consider that many of these folks who appear more complex and sicker may still have the greatest benefit. The question really does come to safety and another physiologic change being the loss of the thirst drive, right? So that's a really big consideration that I've seen at least in terms of the GLP. Myself as well. And I would just add one comment for everybody but it was within the last two to three weeks that the FLOW trial was published with GLP showing benefit in CKD patients. Probably the last question, which kind of dovetails into this, but it's sort of a global question maybe for the older patient with changes in body composition, renal function, diet, everything that you were talking about. How does that factor in with how you prescribe insulin? And if there's any general comments, I think we've got another 90 seconds or two minutes. Yeah, no, so I think there is a longer, the pharmacokinetics and pharmacodynamics as you know, or as it is in the books may not work in your patient, right? The simplest, the most practical way I can tell you is look at the pattern once you start insulin. So always start low, start low and go slow, every geriatricians mantra. And then you look at the pattern and see where you are in that, where the, how long the insulin is hanging around. And same thing is true for sulfonylurea or metformin, look at the pattern. But it is true that we do need to consider, and it's not just the, you know, it is about the how much the fat content, how much the water content and exercise and kidney function, so many parameters that affect the aging population that it's certainly worth keeping an eye on that it's not eight hours and four hours as the book says. Good points. I really wanna thank both of you for an excellent presentation. I'm sure everybody learned something. Before we complete today's session, I want to let everybody know what to expect moving on. Later today, you should receive a link for a post-test by email. Please complete it to get your CE credit. Be on the lookout for today's webinar recordings on the ADA's Institute of Learning page few weeks before it's posted. So any fellow members, anybody you wanna direct us to that missed this, they can watch the webinar and get a CE credit eligible until July next year. I wanna thank everybody for their expertise. We didn't get to every question, but I think the discussions helped tie together some of the points you're making. And I hope to see everyone at another ADA webinar in the future. This concludes our session with 27 seconds to go. So I wanna wish everybody a happy afternoon. And I would also like to thank again the panelists. I learned something. I hope everybody else did as well. Well, thank you. This was a privilege. Thank you for having us. Thank you.

diabetes care

older adults

technology

Dr. Joseph Aloi

cognitive assessment

GLP receptor agonists

SGLT2 inhibitors

insulin prescribing

continuous glucose monitoring

individualized approach