OK. Uh Thank you, Doctor Sheer for this brilliant presentation. And now we are going to go to the other end of the age spectrum, applying technological advances in uh care of older adults uh to uh uh advances in CGM to move beyond A one C in older adults with type two diabetes. These are my disclosures and in this brief presentation, I wanted to show you some unique characteristics of older adults with type two diabetes and why we should think a little differently when we are talking about CGM using them and then show some current evidence regarding the use of CGM in older adults with type two diabetes that we have at current time. So before we start, you know, the question most people have is that who is an older adult, how do we define an older adult? And if I ask you to think about 80 year old person in your practice with diabetes, some of you might be thinking about someone who looks like that and someone might be thinking about someone who looks like this. And as you can imagine, these two types of older adults require completely different goal setting and different approach to the diabetes management. Another important difference between younger adult and older adult is that there are more comorbidities in older persons with diabetes. And we know that with aging and diabetes, there is higher risk of macro and microvascular diseases. We understand that for the all the all the people with diabetes, but there is so called geriatric syndrome that includes conditions such as cognitive dysfunction, depression, physical disability, polypharmacy. These conditions also occur in older adults with diabetes and not only they interfere with their ability to take care of themselves and self care about regarding diabetes, but they also impact the glycemic control. The next difference between the younger and older adults is where they live. The older adults live in different environments. And the reason to understand that is that there is a variable support for the diabetes care. Some people age in place in communities, some people are in assisted living facility, so they could be in hospital in rehab in a completely uh um completely dependent and in a nursing home settings. And again, depending on where they are. Uh not only how much supportive care they re they get for their diabetes, but also access to their food and type of food and timing of food changes. So this is again important to, to remember or understand before we start considering different therapy as well as technologies for diabetes. And as we are thinking about A one C and and how uh how the uh CGM can add to the A one C. There is also this issue about uh A one C having uh frequently not being a reliable marker of glycemia, older adults. And this is because of the conditions that either change the RBC turnover or RBC lifespan and thus they change the normative value of the. So things such as race and deficiency, recent infection, recent transfusions, hemodialysis erythropoietin therapy, all those things can affect the A one C value and they could be in a different direction. So it's sometimes really hard to interpret the data in person who has multiple of these conditions at the same time. So with that, what are the current studies for CGM using in older adults? And primarily you can think about studies that show mitigation of hypoglycemia risk. Those who show that show improvement in glycemic outcomes and those who show which show improvement in quality of life. So, here are some of the studies uh that showed uh the I uh the impact of CGM on the glycemic parameters. And this is a study on type one diabetes showing significant improvement in hypoglycemia. Uh This is the diamond trial in type one as well as type two. older adults with diabetes. Again, showing improvement in A one C decrease in variability and decrease in time in severe hyperglycemia and the mobile subset. Uh sh uh in type two older adults with diabetes, uh again showing increased time in range and decreased time in hyperglycemia. This is important. Uh Another interesting study looking at the health and quality of life benefits of real time CGM. And this was done right before the Medicare approved CGM for use in older adults. And the authors here did online survey measuring history of hypoglycemia experiences and quality of life in two groups of older adults with type one and type two. those who are currently using real time CGM and those who were actually wanting to do it but were not qualified to do that. And what they found was that people who were using real time CGM reported fewer moderate to severe hypoglycemia, fewer ear visits and paramedic visits at home because of hypoglycemia better, well being less hypoglycemia, fear and less diabetes related distress. Another study here showed association of freestyle libre and treatment satisfaction among elderly patients with diabetes. And this was a post approval prospective multi center non randomized study in older adults. Uh 267 of them who used BGM for six months at baseline and then for follow up, they used Freestyle Libre and then they showed the uh improvement in diabetes uh treatment satisfaction in several of the uh sort of uh uh and several of the aspects of that including the satisfaction with treatment, treatment, convenience, convenience treatment, uh flexibility and so forth. And they also showed that daily frequency of scan were actually correlated with the improvement in glycemic control as seen by A one C. So how do you put this together the heterogeneity of older adults? And then the what data we have on different types of older adults and how CGM helps them? Well, the important thing to remember is that we need to choose the right patient for the right technology. How do we do that? Let's think about the framework, same way we think about the framework for glycemic control. So healthy adults, older adults are those with fewer commodities that do not interfere with their self care. They have intact cognition and they have no caregiver need in those individuals. Perhaps any type of CGM is OK, depending on their preference. With the time in range goal, probably a little broader at 90 to 180. And the goal is to avoid all hypoglycemia. Now, I want to make it clear that when I say time in range goal, that doesn't mean that we cannot go better than that. Of course, we can try to do less or tighter than this. However, when we talk about goal for the entire population, it is reasonable to put a little broader goal and avoid all hypoglycemia. Those older adults who are considered intermediate health, that means they have more than five comorbidities, mild to moderate cognitive dysfunction and more than two IDL dependency. These are the activities of daily living such as medications, management, cooking, traveling and so forth. They probably may benefit from intermittent CGM, which can also be helpful to their caregivers. Now, if they are already using real time CGM, then they can absolutely continue to use that as long as they are not making errors and they are not being burdened by them. Again, timing range goal can be a little bit uh broaden, not that you cannot do better, but for the entire population make it a little broad to avoid all hypoglycemia. And then those in poor health, such as those with end stage chronic diseases, moderate to severe cognitive dysfunction or more than two activities of daily living such as bathing, eating. Uh Those are the ones where we the the intermittent CGM can still be used to avoid multiple finger sticks while pro CGM can be used by the clinicians to assess the risk of hypoglycemia. And pattern management goal can be broader for the whole population and again, to avoid over all hypoglycemia. So with that, let's show you some of the clinical cases that makes the point that I was making in the uh prior discussion. So this is a 77 year old man who lives at home with his spouse. Uh A one C currently is 5.8% and he does not really report any hypoglycemia and reports that few fasting glucoses are in their seventies and he doesn't really check anything else other than fasting glucose, multitude of uh comorbidities. But more importantly, to look at the severe CHF with biventricular I CD and recent history of fall. And he is on a very uh sort of simple regimen of Metformin 500 mg in the morning and Lamper due to due to his uh chronic kidney insufficiency. So this is a man which probably may not uh have much identified except for the for uh because of the A one C being so low and being on Gliperide, he agreed to undergo professional CGM and here is the data. So he was actually going hypoglycemic significant amount of time overnight, 26% of the time spending below range. And then, you know, he was waking up uh sort of in a normal range. So what we did was to uh to stop his glimepiride and continue Metformin. And then his CGM shows much better uh improvement with uh still 95% time in range, but uh very little uh load that, that he was having. And importantly, when he, when he did do that, he realized that, you know, I'm feeling much less fatigued and I have better balance when in the first thing in the morning. So he was actually feeling hypoglycemia which is in many a times is hypoglycemic unawareness. Second case here is about the 76 year old uh man who was living alone. Uh The A ONE C was very high and he did not report any hypoglycemia uh symptoms again, only checking fasting glucose somewhere between 90 to 150. This man had Parkinson's disease. So a real gait and balance problem and mild cognitive impairment. His medications included Metformin 1000 mg twice a day and ph 20 mg twice a day and HumaLOG 20 units as a correction for high glucose levels. And here is his uh uh continuous glucose monitoring data. He was 32% time in range, not spending a whole lot of in hypoglycemia but very high variability. And here is what you see commonly, especially in older adults that they tend to have very high bedtime glucose numbers that, that precipitously drops overnight. And so the uh the more the overnight or just before waking, they might go low if we get this data, if this get, uh we increase their, um NPH at night again, you see that they wake up in the morning in a very good range and, and thus, they don't realize where they are going high. So change in medications included uh 40 units of basal insulin, 1000 mg of Metformin. And then we were just giving him fixed dose of uh uh HumaLOG before meals. And you can see his uh timing range improved significantly, little bit of low glucose that we still need to work on. But you can see that his, his uh uh CGM shows much better control with the variability that was much, much more improved uh with this uh this uh uh changes. Uh and again, primarily because he was not getting so much NPH at night. This is another case, 67 year old man who lived alone and the C was elevated at 9.2% no hypoglycemic symptoms. The problem here was that the man has moderate to severe cognitive impairment and when they are living alone, it becomes very difficult to understand all the barriers. He was on le made 40 units in the morning and ya, 10 units with meals with Metformin 1000 mg B ID. And when he started using his TGM, we we again show, you know, very low time in range uh with a very, you know, um insignificant hypoglycemia. Uh and then uh CV was 31%. But uh again, he was spending a lot of time in hyperglycemia. Uh This is uh this is the problem when he was actually not taking his uh multiple mealtime insulin doses because of the cognitive impairment. Um The uh change here we made was to give him a mixed dose of uh a long acting insulin and G LP one receptor agonist, which can decrease the number of injections he needs. And then he needed to take Metformin, which he still forgot uh frequently. So one could then um you know, the next step was to change the dose of Metformin also to the morning. But again, trying to, you know, uh decrease the and simplify regimen which will increase the timing range without actually increasing hypoglycemia and decrease the glycemic variability. So I hope that we are discussed in older adults that they can they have unique characteristics that need consideration before technology is prescribed. Any technology especially CGM can be used successfully in older persons. If the need and complexity of the regimen is matched with persons, coping abilities and CGM use should be tailored to each individual's need and overall health status. With that. I thank you for your time and um happy to take questions.
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