Video Applying Technological Advances in CGM to Move Beyond HbA1c in Older Persons with T2D Play Pause Volume Quality 720P 720P 576P Fullscreen Captions Transcript Chapters Slides Applying Technological Advances in CGM to Move Beyond HbA1c in Older Persons with T2D Overview Continue to Test Back to Symposium That was an excellent presentation by my colleague and friend Lucia. So it is my privilege to now talk to you about flying technology advances in CD M to move beyond a one C into the older person with type two diabetes. I'm kind of wondering if I got the older one because Lucia is so much younger than me. Um But I'm just gonna take it and go with it. Ok. So, um the goals today are to show unique characteristics of older adults with type two diabetes, current evidence regarding the use of CGM in older adults with type two diabetes and to address unique barriers in utilizing technology in the aging adult. Um This is the standards of care for the medical care in diabetes, of older individuals, for the American Diabetes Association. I'm certainly not gonna read it to you. It's really put there to explain that we recognize that the older adult needs different kinds of support. They're more prone to hypoglycemia. Um They may have balance issues, they may have other comorbid and maybe we're gonna have to rethink um their treatment goals, uh depending on their age and everything else that's going on maybe we don't want their A one C to be less than 7%. Perhaps it's gonna be 7.5. I've been, as I said, in practice, more than 40 years. I have people in their eighties and nineties that are using technology, they're using CGM, they're using insulin pumps and we don't want them to have an A one C of less than 7% and we don't want their time and range to necessarily be greater than 70%. Um, I don't want them to have hyper hypoglycemia either. So it's a fine balance. But keeping in mind that we might relax the goals based on the needs of the person sitting in front of you. Now, I, I think this is really interesting too because, um, we have taught patients for so long people with diabetes, independence, own your own diabetes, understand your data, um, understand the technology we're giving you and they have done that and now they're in their seventies, eighties, nineties and they haven't shared their technology or the knowledge of how to use that with other people. And so what I'm seeing in my practice and I think that's what this is telling you is. Well, is that we want people to have all the technologies across the span of ages, but we might have to rethink the support system and sometimes you have to wrestle with the patient who might not recognize they now need support. I think of my 94 year old patient on an insulin pump with CGM, just moved in to live with a family member thinking is phenomenal but her death, austerity is not the same. And she finally is letting her granddaughter help with insertion with her fusion that's placing her sensor. So we have to rethink that and why do we have to rethink that? But guess what? There is 30% of all people in the United States over 65 have diabetes. That's 16.5 million people and 1.2 million people every year are diagnosed with diabetes. So if you're in practice, whether it be primary care or family, it doesn't matter, you will be managing diabetes and especially type two diabetes because I'm a specialist and I'm happy to see all comers, but it's hard for us to get them in. We're sharing and so we want you to know this data as well. So the technologies there, they absolutely should all be wearing CGM. Um, and then older adults, um, we have to figure out what's the best way to support them, um, as we move forward with the use of technology. So how do we define, um, an older adult? Well, uh, you know, in the clear cut way we speak, we think of it is greater than 65 but I am here to tell you that I don't think of myself as older adults and I'm over 65. Um, and so we have to think about the person sitting in front of us, many people are working longer, are capable of working longer and then there are other people that are living longer, which is a, you know, is a testament to what we have been doing in care. So looking again at the person sitting in front of you, what their age is and how that's reflected in what their personal needs are. So you need to ask these questions. Um What do you need help with? Um Are you having cognitive dysfunction? And the patient may not recognize it. A family member may be the one that has to tell you, gee, they don't remember everything the way they did. And a lot of us as older individuals aren't remembering everything the way we did when we were younger. But how is it affecting their diabetes? Um Depression, which we understand is related to as we grow older, it's more prevalent as well. And then physical disabilities, by the time you're 65 you will have dexterity issues. And so the person who has to open the container of CGM, even though it is drastically changed from the person who was using maybe a G five to a G7 or any of the sensors that are available. So maybe we have to work with the patient on who's gonna open it and help you put it on. But again, ask the questions, what are your needs? So today, if you have to put a sensor on. Can you do it? Do you need help? Do you have help? How can we make those arrangements so that you can get help? Um And how would that affect your diabetes um with aging? And this just to remind you that the goals of care are prevent complications um helping the patient live every day to their fullest. And again, from my perspective, everybody deserves a censor. It is a right, not a privilege and you should be offering it to everybody in your practice, which will help them with these goals. And also they are to the center of the caregivers and how we look at this, the center of care and the goals is to prevent complication and to optimize their quality of life. So the other thing we're working with now too is that older adults are living in different environments and each person in those environments may have good care or support um or not any support. And so you hear people going to different living arrangements and oh, nobody can manage my pump. So I have to come off my pump or they don't understand CGM. And I think CGM is a must, those individuals must stay on it. And we to work through ways to help patients, whatever environment they are by teaching the, the caregivers um what needs to be done wherever they are. And then of course not forgetting the burdens for the caregivers because that may be a change to their life if they've never helped manage the diabetes because in a younger day, the person didn't need it. All of these things need to be asked and a plan of action needs to be in place. So going back to our concerns about A one C, there are conditions that are commonly seen in the elderly that may affect A ONE C levels. Of course age, it's unknown, um, insulin resistance, but the A One CS do change and increase. We know that race, um especially our African American patients and Hispanics have a higher A one C and that's a clinical research. We didn't published iron deficiency in the anytime there's a change in the red blood cell and then a recent infection transfusions, anything that affects the red blood cell hemodialysis, you know, a lot of our patients are having um hemodialysis. They have CKD and even stage three CKD will affect A one C and finger sticks. Um So different things that affect individuals as they get older will affect the validity of the A one C. I had someone call me and say a patient of mine is on dialysis and they said I'm, I'm following the A One CS and I don't understand them. And I said that's because you can't understand a patients on dialysis. You need to stop following that. And I'm putting the patients CGM data in the chart. I'll give you access through the cloud so that you can see what I'm seeing as well if you want or look at the patient's handheld device, but you gotta stop following the A one C. So um current studies that um help us understand the older individual um help to mitigate hypoglycemic risk because they're at greater risk um and acute related hospitalizations to improve glycemic outcomes by targeting medication management and to improve quality of life. And um focus I start watching for uh more studies on acute related hospitalizations because more and more CGM is being used, not only for the patient who owns it and comes into the hospital, but placed on the patient when they come to the hospital to help manage that patient's diabetes and then lessen the diabetes related distress um and preventing hypoglycemia and all of these issues is not just for the patient, it's for the whole family support system and that could be the friends, the neighbors, whoever is supporting that patient. So this is um another one of the studies that I was participated in uh for patients that were older. And what we were looking at was randomizing the patients to see if they would accept CGM. It's called wisdom uh accept CGM. We CGM. And was there a benefit? And of course, the study is older study. And so we were really focusing on hypoglycemia. And then the other thing we were focusing on was the patient's acceptance and being able to manage the CGM. So what you're looking at right here is that it was a 52 week study and um, after 26 weeks, the patients were flipped so that if you didn't get randomized, the CGM, you've got to use it. So look at the 1st 26 weeks. The lighter bar is the patient that was on CGM and stayed on CGM. The darker bar was the patients that were on blood glucose monitoring for the 1st 26 weeks and then got CGM without a doubt within the 1st 818 weeks. Look at the decrease in time, spent less than 70 by visit. Ok. And then the entire study hypoglycemia, how much less it was for the individuals who were on CGM. Now look at the 39 to 52 weeks, how the hypoglycemia went away when we gave those individuals who were doing finger sticks the CGM, the transfer over. So we know it works. We know people will accept it. They, these patients did it for the 12 months and we're not willing to give back the CGM. That's what we wanted to see too. So here's um, other studies and I, I briefly went over these in the beginning, but this is the portions that related to the inclusion of those individuals who were greater than 60 or greater than 65 years old. The first study um is the, um, is done by Doctor Pratley's group in type one diabetes and that was a small but statistically significant improvement in for those individuals who were given CGM, the middle group I presented already to you the type two information for um the diamond study. But we're now talking about all comers with that have um are over 65. And for those individuals that were looked at in the diamond studies, type one and type two, we saw better A one CS, we saw less um uh CV values, lower CV values and decreased time and severe hypoglycemia. And then finally, the mobile study, this is the portion for individuals greater than 65 years old. Um comparing uh CGM and blood glucose, greater time and range less hyperglycemia, less hypoglycemia. And that's pulling up the data for those individuals over 60 years, 65 years old. This was a study done by Dr Polanski and company and he looked at an online survey measuring um history of hypoglycemia experiences and quality of life with two groups in both type one and type two diabetes greater than 65 years currently on CGM users. And um those that were hopeful to CGM, the current users reported fewer moderate severe hypoglycemic events, er visits, uh a paramedic visits at home better, well, being less hypoglycemia fear, which is huge for the patient and the family and less diabetic related distress. So overall for all of them, uh a much better outcome by just giving them CGM. Ok. Here's your benefits and your challenges. And I really think since this was published, there's less and less challenges. And every year as we get to utilize it and get reimbursement and we see more and more people using it, there's less challenges but the benefits and I think we both outlined them is reduction in hypoglycemia, less glucose variability, improved glucose, controlled no more finger sticks because the devices we're talking about do not require calibration. Um We have downloadable reports for the patient as well as the healthcare provider. So we're both seeing the same thing. They have alarms and alerts and that we can adjust those alarms alerts. So the patient does not get fatigue but that the most important alarms do occur to help the patient and help the family members and then the share feature which um caregivers uh significant others can see the same data and so they can be in tune with the patient and say, wait a minute. Did you, did we need to treat this hypoglycemic event if the patient is not able to do so. And some of the challenges um changing for some patients, changing the sensor may be a challenge and that's something you're gonna have to ask, see touch, feel with that patient and see what they're capable of doing. Um Their dexterity, as I mentioned, over 65 may be a problem. Um high cost, I think we're getting such great coverage now that that's less and less of an issue. But it can be for some people and then, um, hearing impairment if they can't hear the alarms, but they vibrate as well. So that, that's um, a waiting for them to see the, to know that they're having alarms. Um, and then perception of data over load again, I think we can work through that and we can work through alarm fatigue. So here among the elderly with type two diabetes, it's a post approval prospective multi center non randomized study for individuals over 65 years. Um six months baseline of blood glucose monitoring use and then six months follow up using the libre. So diabetes, the goal was diabetes, improvement treatment satisfaction, daily frequency of scanning completed with a decrease of ac. So the patients got a better outcome. They were able to use. The device scanning was not a problem. And of course, we have newer devices now that scanning is not an issue because you don't have to scan. So the blue is your blood glucose monitoring. The pink is your chm in every parameter. Convenience, satisfaction, flexibility, satisfaction with understanding diabetes, able to do the recommended treatment. Continuing the treatment frequency of hyperglycemia and hypoglycemia in every category CGM outweighed blood glucose monitoring. There's a pattern here of what Lucia and I are sharing is that CGM works patients like it, they can use it, we can get reimbursement and the patients have a better outcome and they're able to change behavior. Follow their program have less hypoglycemia and more time in range. So how do you choose a device? I think quite honestly, it's all patients choice. Um comorbidities do not interfere with self care in a healthy person. Um And it's based on their choice for those individuals time and range might be 90 to 180 depending on the age we want to avoid hypoglycemia, intermediate health, maybe five comorbid or more, maybe having some cognitive dysfunction. Again, I think it's based on patient preferences because both all the devices are easy enough. Um, of the first two columns I showed you, you most likely pick for these individuals, either Libre or Dexcom and they're easy to use time and range depending on their age, might be 100 to 200 avoid hypoglycemia and those individuals with poorer health. Um, CGM, you do not want to be doing multiple things. You don't want to be doing finger sticks for any of these patients. Um, and then, um, what's, what works for the healthcare provider or the family member that's working with this patient or the place the patient is living. What's easiest for them to manage would be the choice. And maybe, um, the goal would be 100 to 250. And again, we want to avoid hypoglycemia. Ok. Let's move into a couple of cases for you. Um, this is a 77 year old male at home with a spouse. A one c was 5.8. That should be a trigger for you. A one C is 5.8 and the patient probably doesn't know they're having hypoglycemia or they're telling you they're not having glycemia. They're telling me, well, they have a few fasting blood sugars in the seventies. Um, these are medications and the comorbid you can see patients recent fall with hypergly had hip injury, maybe it was hypoglycemia, we're not sure CKD. Um, and the patients on Metformin, uh, er, and glimepiride 5 mg every morning. That's another red flag for you. Glimepiride causes hypoglycemia if you can avoid it, avoid it. I understand there might be some reasons to use it as a cost. However, it's just nasty, it causes weight gain, it causes hypoglycemia and there's really no other value to it. So this is the first, um, CG MA GP for this patient but watch, look at the midnight to about 4 a.m. but look what it is giving me. Um, 26% hypoglycemia and 19% less than 70. Um, but 7% less than 54 and the patient didn't feel it, the patient didn't know it. Now there's 73% time and range. But if I got, got rid of that hypoglycemia, I could make the time range high higher and I'm ok with having more time and range, even if we adjust the goal and it's not 70 to 180 maybe it's, you know, 80 to 200 or whatever it needs to be for that patient. What I don't wanna see is hypoglycemia and it's directly related to the glimepiride. Now, depending on the individual they may not be eating as well either. Um, this is a 77 year old. I don't think about that as being very old as a personal comment. Um, and we're gonna stop the Gide and we're gonna continue the Metformin and look how beautiful that is. Remember, we want everything between the green bars. Now there's a spike at nine o'clock um that goes up until noon and we can probably fix, but we're not given them glimepiride. So this patient by getting rid of the lows by getting rid of glimepiride 95% time and range and 1% low. Now, I think that will go away as well. But look how gorgeous that is. Do I need to do anything more? Yeah, I, I think maybe my personal feelings. Um the patient feels less fatigued, having better balance, you know, they're just on Metformin. They might do better on, they might do well with the G LP one, but it would depend or an SGLT two inhibitor, it would depend on their comorbid. And we saw some of them, we know there's a cardiovascular benefit to G LP one and, and probably heart failure uh benefit to SGLT two inhibitors. He also has kidney disease and we know both of those drugs will prevent uh for the kidney or help with the kidney disease. So, you might think that through. But look, we got rid of the hypoglycemia. 76 year old living by themselves A one C and um checks only fasting and it runs somewhere between 90 100 and 50 mild cognitive impairment. Parkinson's disease that tells you something about the ability to put a sensor on fear of falling hypertension, hyperlipidemia, sleep apnea, 1000 mg of Metformin max dose B ID NPHNPH. It has a strong onset, it's a cheap drug. You can get it um in Walmart uh over the counter, but it causes a lot of hypoglycemia. And in addition to that, they're on 20 mg of HumaLOG for correction um after meals. So this is what the CGM looks like. There's only um really no time, 32% time in range, not having low blood sugar, which is a bonus. But look at that craziness, look at the CV on that roller coaster. So the patient is gonna be feeling crappy just because of that. And if they are using the HumaLOG to correct some of that, they're risking hypoglycemia better to bring it down with something else and get rid of some of the um MP H and maybe even HumaLOG. OK. So the change of medication, we're gonna give them a basal insulin a longer acting. Get rid of that MBH with a flatter profile. Um uh basal insulin, 40 mg. You might even go a little bit lower. Metformin 1000. Now, HumaLOG fixed dose 20 units before meals. I probably would stop that for now. And do a G LP one titrate the G LP one, then go back and see if I needed the HumaLOG. And then I decrease the risk hypoglycemia in a person. And if I can give a once weekly G LP one rather than giving a fixed dose of HumaLOG three times a day who's having some dexterity issues. I think I'm all about that. 82% time in range with 1% low. Again, G LP one better than the HumaLOG. And then here finally is a 67 year old lives alone. That is definitely not old. Um 9.2% moderate cognitive impairment, uh hypertension, I elevated lipids. Um MOC a score of 13 Metformin 1000 Levemir, 40 HumaLOG 10 with meals and then 32% time and range and look at that mess as well because the Levemir is not doing it. Levemir really needs to be dosed twice a day. And just so, you know, it, this is an older case, Levemir not in the market anymore and we have plenty of options to replace that. So overnight kind of getting there and then all day long hypergly hyperglycemia. So what can we do? We're gonna change that G Levemir to Glargine and a smoother insulin that you can give once a day and add some magle 1 mg. We can go up to 2 mg if we need Metformin, um, we're gonna give an, er, maybe instead of the they're doing, but I checked to see if they're having any G I symptoms and sometimes when you add, uh, G LP one, the Metformin now has G I symptoms, even if they've never had it before. And I'm gonna get rid of your, um, HumaLOG and maybe after I titrate the seagle, I'm gonna add an STLT two inhibitor. But so far with what I've done, look how much better the roller coaster is gone. The hyperglycemia is gone. We're now gone from like 30% time in range to 61%. I still some work here, but I'm heading in the right direction for this patient and I couldn't do any of this without CGM. Every step of the way CGM has directed me and what these patients need and confirmed to the patient that what we're doing is right? And that causes adherence, behavior modification and adherence. OK. Just to remind you C MS uh Medicare is paying for CGM. If the patients on at least one injection of insulin, you don't have to prove blood glucose monitoring or if they're having two hypoglycemic events less than 54. And you've made some adjustments and that hypoglycemia continues despite the medication adjustments or they've had one assisted hypoglycemic. The, the key here, Medicare, you must get the CGM from a durable medical equipment, diabetes supply, not your pharmacy. All right. So older adults with diabetes have unique characteristics that need consideration before technology is prescribed and may change as they age because you don't want them to give up technology. Any technology can be used successful in an older person if need and complexity of technologies match with the person's coping abilities. CGM can use use can be tailored to each individual's need and overall health status, everyone deserves CGM. It's a right, not a privilege. Published Created by Related Presenters Davida Kruger, MSN, APN-BC, BC-ADM Certified Nurse PractitionerHenry Ford Health SystemDivision of Endocrinology, Diabetes, Bone and Mineral DiseaseDetroit, MI
