this is Grady Meneely presenting the 2018 clinical practice guidelines for diabetes and older people I'd like to acknowledge my co-authors on this work Eileen nip david miller diana sheriff oli daniel teshe and half chenza heeding the key changes are outlined below there will be new information on screening with fasting plasma glucose than anyone see and the role of deep prescribing medications and older people with diabetes this is the diabetes in the elderly checklist first assess per level of functional dependency on frailty we'll talk a bit more about that later second individualized glycemic targets based on the above a 1 C less than eight point five percent for frail elderly but if otherwise healthy use the same targets as younger people avoid hypoglycemia and cognitive impairment as these patients tolerated it very badly select an T hyperglycemic therapy carefully caution should be used with a phone in areas are thiazolidinediones dpp-4 inhibitors should be used over Sohan areas basal analogues instead of NPH or human 3070 should be used and you should give regular diets instead of diabetic diets or nutritional formulas in nursing homes frailty is a widely used term associated with aging that denotes a multi-dimensional syndrome that gives rise to increased vulnerability this figure shows a clinical frailty scale which has been developed by Ken Rocklin and his colleagues in Halifax it's important to understand this scale because the frailty index will be used to determine how our glycemic targets are set in other words as you'll see later where a person falls on this scale will predicate the parameters that we use for controlling their blood sugar blood pressure and lipids as noted above the scale is from one to nine in essence people who are in the 4 to 5 category are moderately frail and have impairments in at least one of their instrumental activities of daily living which are cooking cleaning shopping driving paying the bills etc patients from 6 to 8 are more severely frail and these patients have impairments in their basic activities of daily living such as bathing dressing toileting feeding that sort of thing and patients who are ready to 9 are essentially terminally ill the a1c targets that we're currently going to use or as follows less than 7 percent for most adults with type 1 or type 2 diabetes less than 6 point 5 percent for adults with type 2 diabetes to reduce the risk of CKD in retinopathy if at low risk of hypoglycemia 7 point 1 to 8% for functionally independent individuals those patients who have the impairment of more than one instrumental activity of daily living seven point one to eight point five percent for patients with recurrent severe hypoglycemia and/or hypoglycemic unawareness limited life expectancy and frail elderly and/or those with significant dementia we should avoid higher a1cs to minimize the risk of symptomatic hyperglycemia and acute and chronic complications and finally at the end of life Avon C measurements are not recommended we should avoid symptomatic hyperglycemia and any hypoglycemia this slide shows to the glycemic targets and older patients with diabetes if patients have a clinical frailty index of one to three in other words they're functionally independent the a1c target is less than seven percent the pre Pandya sugar target is four to seven and postprandial five to ten four functionally dependent patients grade four to five on the Rockwood scale patients with impairments of at least one instrumental of activity of daily living the a1c target is less than eight percent unless there is a higher risk of hypoglycemia in which case the target should be seven point one to eight percent pre prandial 58 postprandial less than 12 for frail patients or patients with moderately advanced dementia these would be category six to eight on the Rockwood scale patients who have impairments of their basic activities of daily living the a1c target would be less than eight point five percent if there's a low risk of hypoglycemia and seven point one to eight point five percent if the risk of hypoglycemia is higher pre prandial six to nine millimoles per liter postprandial less than 14 finally at the end of life anyone sees measurement is not recommended you should avoid symptomatic hyperglycemia or any hypoglycemia this slide compares the guideline recommendations from diabetes Canon and the American Diabetes Association and the International Diabetes Federation the glycemic targets are very similar except for the fact that diabetes Canada recommends the hemoglobin a1c target for functionally independent patients of less than seven percent the a1c target for the ATA in the IDF is less than seven point five percent the blood pressure targets are also somewhat different diabetes Canada recommends the systolic blood pressure target of less than 130 for patients who are functionally independent and with a life expectancy of greater than 10 years for functionally dependent patients patients who work the stasis for limited life expectancy blood pressure pirates are individualized and the lipid targets are very similar between the three groups this slide shows the characteristics of the patients enrolled in the goal-oriented controlled diabetes in the elderly program a study which was recently conducted to gain contemporary insights into the status and management of diabetes in an older patient population in a primary care setting in Canada the study involved 833 patients 64 physicians and 36 primary care clinics in Ontario you can see from the slide that the hemoglobin a1c values LDL cholesterol values and blood pressure values in these patients were quite reasonable there were several insights that were gained from this study first exercise and dietary plans were prescribed in a minority of the patients in this study this suggests that we need to do better in terms of implementing appropriate lifestyle modifications in these patients less than 20% had assessments of cognitive functional frailty again if we are going to use functional status and frailty scales as a way to assess glycemic and other risk factor parameters in these patients we need to do a better job of assessing these patients so we can appropriately apply these criteria most patients were on multiple medications in fact 20% of the patients were on more than 10 drugs per day many patients treated with so far only reason insulin had a hemoglobin a1c of less than 7 and this was true even in patients with high complexity and multiple comorbidity we conclude from this study that there are a subset of older patients with high complexity and frailty or being over treated for diabetes in a primary care setting in Canada and we also concluded that we should consider using agents which are associated with a lower frequency of hypoglycemia in a patient population that is suffering from complex comorbidity and high complexity this slide illustrates why older people are more susceptible to hypoglycemia during hypoglycemia older people are almost completely unaware of the autonomic and Nurik like a Phoenix warning symptoms of hypoglycemia this is shown on this slide where middle-aged patients have clear symptom awareness for these symptoms during hypoglycemia but the elderly do not at the diagnosis of type 2 diabetes start healthy behavior interventions including nutritional therapy weight management physical activity plus - metformin if the a1c is less than 1.5% above target if not a glycemic target within three months you start our increased metformin if it's greater than 1.5% above target you start metformin immediately and consider a second concurrent anti hyperglycemic agent if patients have clinical cardiovascular disease you start an anti hyperglycemic agent with demonstrated CB benefit including fo callosum the Regla tide and cannibalism if the answer is no we'll move on to the next page and if not a cleisthenic target the same thing will occur if a patient has no clinical cardiovascular disease you should add an additional anti-fur glycemic agent best suited to the individual based on the following considerations avoidance of hypoglycemia and/or weight gain with adequate glycemic efficacy the choice of agent would include a DP for inhibitor a GOP one receptor agonist or an escheat lt2 inhibitor other considerations to think about include the reduction in GFR the degree of hyperglycemia other comorbidities etc if patients have renal impairment the subsequent table will show how to adjust medications appropriately the following slide shows various additional anti hypoglycemic agents that can be used I'd like to make a couple of editorial comments first of all sglt2 inhibitors seem to be effective in older people but the risk of dehydration Falls and fractures appears to be increased therefore patients who are started on these medications must be carefully selected dp4 inhibitors have been used in thousands of elderly patients and have been found to be safe and effective caution should be exercised in regard to saxagliptin in heart failure insulin glargine insulin Degla deck and insulin dead aamir are associated with the lower frequency of hypoglycemic events than n ph or premix insulin in this patient population in general size Olding Dione's should be avoided in the elderly because of an increased risk of fluid retention osteoporosis and fractures this slide nearly reproduces the previous slide if a patient is not a glycemic target after the use of one of the agents shown above you should add another anti hyperglycemic agent from a different class and or at or intensify insulin therapy it's important to make timely adjustments to attain target a1c values within three to six months this slide shows the adjustments that need to be made in regard to a heady hypoglycemic agents and renal function the table is self-explanatory but should be reviewed prior to beginning any anti hyperglycemic agent in an older person if you decide to use insulin you need to be certain that the patient is capable of administering the insulin independently one way to determine if a patient may have problems with insulin therapy is to perform a clock drawing test if a patient cannot draw a clock correctly the either won't be able to give the insulin independently or will need extra time to be taught to use the insulin so that they can deliver it effectively diabetes in long-term care under nutrition is a problem in people with diabetes living in long-term care regular diets may be used in long-term care instead of diabetic diets or diabetic nutritional formulas because the latter have not been shown to improve glycemic control so the recommendations are as follows first of all and functionally independent older people with diabetes who have a life expectancy of greater than 10 years they should be treated to achieve the same glycemic blood pressure and let the targets as younger people with diabetes blood pressure targets should be individualized for older adults who are functionally dependent or have or the stasis who have a limited life expectancy in older persons with diabetes and multiple comorbidities or frailty strategy should be used to strictly prevent hypoglycemia which include the choice of hitting hypoglycemic therapy and less stringent a1c targets anti hyperglycemic ages that increase the risk of hypoglycemia have other side effects should be discontinued in these people a higher a 1 C target may be considered an older people with diabetes taking an T hypoglycemic agents with the risk of hypoglycemia with any of the following functionally dependent patients 7.1% frail and or dementia 7.1 28.5% and of life anyone see measurements not recommended avoid symptomatic hyperglycemia in any hypoglycemia the clock drawing test is indicated above may be used to predict which older individuals will have difficulty learning to inject insulin older people who are able should receive diabetes education with an emphasis on tailored care and psychological support if not contraindicated older people type-2 diabetes should perform aerobic exercise and/or resistance training to improve glycemic control as well as maintained functional status and reduce the risk of frailty in older people type 2 diabetes so far areas should be used with caution because the risk of hypoglycemia increases substantially with age dp4 inhibitors should be used over our cell phone there is a second-line therapy to metformin because of a lower risk of hypoglycemia in general initial doses of so fonder is in the older person should be half of those used for younger people and dosha should be increased more slowly glucose identical aside mr and the mappy ride should be used instead of glyburide as they are associated with a reduced frequency of hypoglycemic events finally Midland IDEs may be used instead of glyburide to reduce the risk of hypoglycemia particularly individuals with irregular eating habits yet older people with type 2 diabetes with no other complex comorbidities but with clinical cardiovascular disease and in whom glycemic targets are not achieved with existing anti hyperglycemic medicine who have a GFR greater than 30 on an T hyperglycemic agent with demonstrated see the outcome benefit could be added to reduce the risk of major cardiovascular events and this would include epical Folsom la regla tied in Kanaka foe dead Amir largely new 100 and u 300 and deadly deck may be used instead of NPH or human 37 the insulin to lower the frequency of hypoglycemic events in older people pre-mixed insulins and prefilled insulin Prinze should be used to reduce dosing errors into it potentially improve glycemic control in older long-term care residents regular diets may be used instead of diabetic diets or nutritional formulas sliding-scale reactive and correction supplemental insulin protocols should be avoided in elderly long-term care residents with diabetes to prevent worsening glycemic control and reduce the risk of hypoglycemia the key messages from the chapter are as follows first diabetes and older people is distinct from diabetes and younger people and the approach to therapy should be different this is especially true in those who have functional dependence frailty dementia or who an end-of-life this chapter focuses on these individuals personalized strategies are needed to avoid over treatment of the frail elderly second in the older person with diabetes and multiple comorbidities or and/or frailty strategies should be used to strictly prevent hypoglycemia which include the choice of candy hyperglycemic therapy and a less stringent a1c target so foggy areas should be used with caution because the risk of hypoglycemia increases significantly with age dpp-4 inhibitors should be used over so fond areas because of a lower risk of hypoglycemia finally long-acting basal analogues are associated with a lower frequency of hypoglycemia than intermediate acting or pre-mixed insulin in this age group the key messages for older people with diabetes are as follows first no two older people are alike and every older person with diabetes needs a customized diabetes care plan what works for one individual may not be the best course of treatment for another some older people are healthy and can manage their diabetes on their own while others may have one or more diabetes complications others may be frail at memory loss and/or have several chronic diseases in addition to diabetes based on the factors mentioned above your diabetes healthcare team will work with you and your caregivers to select target blood glucose and a1c levels created glucose lowering medications and a program for screening and management of diabetes related complications if you want to learn more about the guidelines the various chapters and recommendations please visit guidelines diabetes CA or you can download the app from the App Store or the Android app on Google Play finally more information regarding the guidelines can be obtained at guidelines diabetes C if you're a healthcare provider or diabetes dot CA if you're a person with diabetes