Video Applying Technological Advances in CGM to Move Beyond HbA1c in Older Persons with T2D Play Pause Volume Quality 900P 654P 524P 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 Well, thank you so much Gene. And now I get the opportunity to advance our CGM Expert board. Moving beyond A ONE C to apply technology based advances across the full spectrum of diabetes care. Uh Thanks for coming virtually or in person to the A AP A, I'm going to be talking about how to apply technological advances in CGM for those with older persons with type two diabetes. I'm Doctor Eden Miller, primary care provider by training. I am a diplomat of the American College of Diabetary and a diplomat of the American Board of Obesity Medicine. So today, our objectives are to show the unique characteristics of older adults with type two diabetes. I think they do have a special approach and individual needs and outcomes that we have for them and how to integrate technology with them because there's quite a bit of evidence regarding the aging or older adult with type two diabetes and use of CGM. And then I wanna make sure top of line that we address and identify those unique barriers in utilizing CGM technology and aging adult. It is not by any means a disqualifier because I do think that sometimes we kind of overlook the aging adult thinking they won't be able to understand how to implement technology. And so we're gonna top of line discuss that and help us to identify and overcome them. I think we start with how do we define the older adult as you see here. Uh Aging has quite a scope of activity levels, secondary comorbid conditions, technology, understanding and cognition. And I think that should be what plays into how we specifically choose CGM technology. There are certain systems that may be better suited for individuals based on their life. And so sometimes I make sure and ask some of the questions. Do they have dexterity issues? Uh How active are they in terms of types of CGM and on body uh type of interaction? Are, are they gonna have a caregiver, try and help manage them with that? And so I think looking at a person who is older, looking at all of those different socioeconomical personal chronic disease is gonna help you match the CGM technology to the person rather than trying to match that person to that technology, right? We, we wanna keep the patient or the person at the center of this particular decision. You know, we know that there are a lot of comorbidities for individuals with diabetes. As we age, we tend to see more issues uh regarding um macro and microvascular complications. And it's in the center of both the aging diabetes person because we both have small vessels, large, large vessels, slowing of cognition. And in some case cognitive decline, we can get secondary depression as the individual ages as they're dealing with uh comorbidities and chronic diseases. We can have actual beyond mental disabilities, we can have physical disabilities, coordinations, disabilities. And then one thing we're always trying to avoid uh is polypharmacy. But one of the things I try to do is to lessen the burden of diabetes in the aging adult, to keep pace with their physical and mental changes, to try and ease diabetes distress, which helps with their overall um mood and to try and prevent both hypo and hyperglycemia which prevents complications and prevents hospitalization. We're not necessarily using CGM to see how low of an A one C we can get. But rather we're using CGM to improve variability, improve the extremes or the acute related hospital events related to CGM and to try and limit the contribution of why glycemic excursions has on macro and microvascular disease. So you have a different objective when we talk about CGM. And by no means does the aging adult get disqualified from it because of their age? We have to be very mindful of the different environments they live in, whether they're fully independent, whether they're in a care home, whether they're in uh uh a multifamily generational home, what are some of their challenges? But you don't just say, well, you know, somebody's in a wheelchair. So let's not give them AC GM that might be the best person of all because they may have other physical and mental limitations that allow them to protect themselves or identify by glycemic episodes. And I know even for those individuals in, you know, adult foster care or in extended care facilities, using CGM is something that will actually lessen the burden of the health care team. I have to tell you a crazy story that just happened yesterday. I was giving a talk about continuous glucose monitoring at a large restaurant and it was in a private room and this older gentleman, I'm not kidding. 85 year old kind of came up to the front and the server who was helping us said, I'm, I'm sorry, this, this gentleman wants to come because he heard what you were talking about this particular CGM and he's wearing it and literally not even stage this older adult, you know, mid eighties comes in saying I'm wearing this sensor and, and pulls up his phone and shows us and I said, let me ask you how has this changed your life? He said, I'm less fearful, I'm letting the CGM monitor my condition. It's easy for me to do. My loved ones can follow through with it and it's changed my life. And I thought, wow, it's never too old to change somebody's life. So please really consider that individual, their environment that needs what the CGM can bring for them. So there are a lot of secondary challenges we have with the elderly that affect A ONE C uh as we age, we have those unknown changes, metabolically, behaviorally, we see quite a bit of changes in uh uh dietary and, and blood levels and they can have an impact on that A one C level. And really what we're talking about is where if you ever seen a discordance between uh an A ONE C and the um the SMBG or the CGM type of material. Here's what I mean by that, an A one C is a particular type of hemoglobin where the A one C terminal has a glucose attached to it. There are a lot of things that can affect the reliability of an A one C because as you age and as you have change in kidney function, we get change in red blood cell turnover and lifespan. So an A one C may not accurately capture what the glycemia is. If we have somebody on uh you know, hemodialysis, the, the R BC gets lost. And so we tend to see a lower A one C if we have uh um uh R BC turnover from iron division C anemia, we tend to see the effects related to A one C as a rise. And so you can see on the right hand side, depending on whether you have race or t types of anemia or infection. Recent transfusion. Imagine you get a new transfusion and you have a higher blood count but your A one C drops, uh you have other kind of hemoglobinopathy. You can have these changes that you're gonna get an A one C and it just doesn't quite make sense. So one of the things I always try to do is, you know, you can know time and range from CGM, but you won't necessarily know your A one C. But if you know what a person's time and range is, you will automatically know what that A one C is, but you're not gonna know the opposite by just knowing an A one C. So I really wanna validate the A one C by time and range because maybe you get an A one C like I did the other day, I had a person at a one C of 6.3 and you might say, oh, that's amazing. Uh But 9% of the time they had a blood sugar less than 70. So we gotta validate the time and range when we look at just an A one C. OK? And so we gotta make sure that those two things are concordant. And so please go beyond just A one C. As you can see, it's a metric that's not as reliable in the aging adult. And so understanding that when you get time and range with the CGM, you're getting an interstitial glucose value, not getting a blood glucose value. So A G PC GM, that interstitial glucose number is not going to be affected by these conditions that we commonly see in older adults. And so it's gonna be more of a reliable test. So, are there studies for utilizing CGM in older patients? Absolutely. I'd I'd say the number one thing to do is to mitigate hypoglycemic risk and acute related hospitalizations. Now, let's pause for a second because many of our older adults are gonna be on Medicare. And as you know Medicare criteria, which we have gone through is, you know, one shot of insulin or more multiple daily injections. But it also says if there's any acute related events due to hyperglycemia or hypoglycemia, so you need to make sure that you understand that tho these are actually an indication to get it covered. And so there are a lot of studies that identify that, that the use of CGM prevents hypoglycemia both through an an additional alert for the user to be aware, especially if they're hypoglycemic unaware and be able to mitigate that. But also this translates into change in acute related hospitalization. We can also improve glycemic outcomes by looking at the uh report and knowing where to change. I often say you get an A one C, you don't know where to adjust or fix the meds. And in fact, I had another client come in the other day on base linsin an elderly individual with an A one C of 7.3 you might think Oh, I need to intensify their treatment. No, but rather they were going pretty near low at the, in the morning time. So their, their basal in was titrated to the appropriate level. But I needed to add a peranio agent or shift some of the glycemic interventions to a different time of the glycemia. So a lot of you as clinicians are kinda prescribing blind because you really don't know what is the problem? Glucose and we can improve glycemic management. Even though again, I told you to the line is hypo and hyperglycemia variability and overall quality of life. But while you're doing those things, you are going to get improved glycemic outcomes and targeted uh medication management. So to quality of life, uh I told you that, that an older guy comes into my program and tells me how, uh it's just lifted a burden off of him. Not only that, ask the family, ask the caregivers, ask the staff that might be caring for this individual. They equally love it. They're like, oh my gosh, I love the CGM. It's so awesome. It, it's, you know, I've heard it being called their little guard dog, their accountability partner. I've heard people say uh that machine remembers they have diabetes when they don't want to. And so, you know, this is a way to have multiple impacts on the aging individual where risk and quality of life and that mind, body and spirit really come into top of line and then when you improve the quality of life, you lessen diabetes distress, that's what we're looking for. We're looking, uh, to help this individual kind of have a, a new, you know, outlook on life. I, I mean, we don't kind of think of it this way but when you're older, you know, small things mean a lot. And as I was seeing this older man's face beam, you know, it was like, whoa, you know, how do you change somebody's life when they're older? It's hard to do that because they kind of experienced a lot. And so, you know, this is a great opportunity to bring um additional insight to them. So let's look at some of the studies on CGM in older adults. Of course, it is always standard of care for type one diabetes. Uh There was a small but statistical improvement in hypoglycemia, uh the older adult over 60. And I would say that all persons with type one must must, must have CGM. And especially if you're an older individual, as we often lose the ability to see hypoglycemia. There was an additional study in diabetes, science and technology about 100 and 16, you know, a third at type 12 3rd at type two and they looked at improved A one C cardiovascular uh and time and severe hypoglycemia. Those are the ones that really get you. And so we have less cardiovascular issues because remember, hypoglycemia can trigger cardiovascular events. And that's why they can be in fact lethal uh to uh older individuals. And then there was a great trial looking at self monitoring, blood glucose and cesium and those greater than are equal to 65. And we saw an increased uh time and range, decreased hyper hyperglycemia. And so, you know, I know that a lot of the standards say, well, you just raise the A one C in older adults because of safety. That doesn't keep them safe because it's not the destination A one C that keeps you safe. That's how you get there. And in fact, the A one C with the highest rate of hypoglycemia is 8.2. So I'm gonna try to bust that myth that if you're gonna raise your A ONE C and your older adults, you're gonna keep them safe. No, you're gonna give him CGM in order to keep him safe because you're going to improve the outliers, both the hypo and the hyperglycemic episodes. So when we look at health and quality of life benefits for real time CGM, uh we're measuring the history of hypoglycemia experiences as well as quality of life. There were two older adult groups, type one and type two, within some great eight or greater than 65. Remember, I know this sounds silly but type ones do get older. Uh They're currently on real time CGM users about 210 and hopeful uh users of real time. And what they did is they asked them, their experience, they all reported fewer, moderate to severe hypoglycemia, less, er, paramedic visits at home. I wanna just, uh, jump in with a statistic for our area in my, uh, area here in the county next to us. Uh, my friend is the head of the chief dispatcher for, uh, EMS and she said the number one EMS call, you know, pick up the call for paramedics to come was for hypoglycemia. I said you gotta be kidding me. I said I would thought it was chest pain or falls. Nope hypoglycemia. And so as a result of that, uh that information, that safety, we get of increased feeling of well being less hypoglycemic fear and all of this translates into improved diabetes distress scores. So when we look at specifically the association of the freestyle libre usage and treatment satisfaction among elderly participants with type two diabetes. Remember, standard of care for type one, they got a lot of variability. They must be on it. But when we look at those individuals with type two diabetes, we looked at a post approval, prospective, multi center randomized trial uh for six months, baseline SMBG. And then we looked at six months follow up of freestyle libre for those uh 65. Uh And above what we saw is we had the before and after, you know, the, the teal is the blood glucose, the, the salmon color is the FSL and look at the satisfaction of treatment. These were all the, the top five were statistically significant and oh, actually, the top six were statistically significant. Looking at satisfaction with treatment, convenience, flexibility, uh improved understanding with their diabetes. Uh They would recommend it to friends, they would continue treatment. Uh They had a better understanding of their hyperglycemia and they had less hypoglycemia which really, ultimately all of this convenes at treatment satisfaction. And what we saw is the more they scan. So this was the earlier iteration of the freestyle Libre which was scanned. Now we have all real time or, or streaming that as they engage with their disease, we saw a direct correlation uh with the A one C drop. This is a lot of improvement, you know, because you can drop a one C and do it in a burden burdensome way. But what we're doing is we're dropping a one C empowering the person along the way to have a better understanding of their disease and a better engagement. So, you know, it's a win, win for everybody. Like I said, your job is to match the technology, to the person, not the person to the technology. You need to identify those comorbidities and you know how they interfere, do they interfere? Do they not with their self care? What's their lever of uh intact cognition? Are, are they need a caregiver or not? So this is what you do. That's that assessment you do, you know, is it, are they independent gonna do this or are they going to do it in tandem with a family member? Are they gonna have a caregiver do that? And, and that's who should be in the room? Um I also see um uh um impaired individual cognition wise where we're doing this for somebody else to help impact their overall care. So you can use an intermittently scan CGM or a real time based on that preference. Again, our, our goal is a little higher because if you remember that time and range for them is 90 to 180 we're gonna avoid hypoglycemia at all cost rights. Because remember, hypoglycemia in this group can actually have an adverse cardiovascular event. And we, you know, we hate to say and it's dramatic but it can kill people. So we want to avoid hypoglycemia in the aging individual 100%. In order to do that, you gotta monitor, you're not gonna do that by raising your A one C. You know, those are those healthy individuals that they're able to engage in an intermittently scanned or you do, you know, streaming a real uh or a real time, let's say if it's somebody who has several comorbidities, heart failure, renal failure, obesity, hypertension, a little bit impairment in cognition and they have some ability to do their independent uh daily um living, but they got some dependency on some of them. You can, you know, do an intermittently scanned is a preferred. But I, I personally think you could do either uh you can have the health care provider be in charge of that or the caregiver, not health care provider, the caregiver family members, that kind of thing. Um You're already using a real time with those individuals, you're gonna continue it. Why do we say that? Because we want somebody to be in charge of the CGM And so the ISCGM can be used, but the real times can be used just as easy. As long as the caregiver under stands it. Uh We're gonna probably raise the basement a little bit and allow the ceiling to go up, maybe uh 100 to 200 mg per deciliter. But again, we're not saying if you have somebody that's in a lower time in range and they absolutely have no hypoglycemia, then you're good. But if you do have hypoglycemia, you're going to try and raise that um that basement a little bit more for protection, end stage chronic disease, renal failure, severe cognition, delay, no uh uh no ability to do their own independent activities of daily living, but they're fully dependent on individuals. You know, we're gonna avoid finger sticking in, in these people. You know, you can do the intermit scan one because then the staff or the caregiver or the uh trained health care uh assistant can, can be in charge of that. Um We can also do a proc GM for them to do risk assessment. So this is kind of your low hanging fruit. You're gonna put a proc GM, you can download it later and see if we're having any, any events that would qualify for this individual to get, uh, their personal CGM. We're gonna absolutely avoid the hypoglycemia. We allow for a higher time and range, I'm sorry, higher, uh, range of time and range. Uh, but again, I'm gonna tell you if you, if you have, you know, a high percentage of time and range without cost of hypoglycemia, you're good. Um I do think uh a uh a real time would be fine but that individual needs to be in more direct care uh with their caregiver if you're in an extended care facility and there's limited interaction between the patient and the responsible CGM uh interpreter, uh having alarms go off and such. Uh, we, you need to be mindful of that but it wouldn't be disqualified for a real time or streaming one as well. So let's talk about a case. Uh study number one. We have a 77 year old male, uh again, living situation at, at home with the spouse. So they're, they're cohabit. Uh the latest, uh A one C was 58. And you say, hey, uh are you having any hypoglycemic symptoms? The wife or the partner and, uh, or the um, person says, no, I'm not, I'm not having any hypoglycemic symptoms and maybe their fingers sticking in the morning and, you know, I got a few, uh, in the seventies. So you decide, you know, looking at those comorbidities. Uh, we got a lot here. Right. We are definitely more than five. you know, ch fa FB aneurysm chronic kidney disease, COPD gout prostate cancer. This is, this is somebody who's been around the block a bit hypertension hyperlipidemia. You know what I mean? Uh, medically they've got a lot of these comorbidities. They've lived a good life but they had a recent fall with the right hip injury. Was that hypoglycemia? A lot of falls are associated with that and here's their medication, they're on Metformin, uh, er, in the morning because if you give them too much they all G I issues and, uh, they're using glimepiride at 5 mg, uh, in the morning and here is their A GP. So you've decided, you know, I, I got comorbid, he's got an elderly individual. I got a, a partner that's gonna be able to look at it. I've got a medication at risk. Uh, this person would, uh, qualify for CGM based on Medicare criteria because of the sulfa rhea. You see the A GP there and I like a GPS because you should be able to read it from across the room. And what do you see? Uh, this person's going low in the middle of the night and the low in the evening time and what are their stats. Their time below range is 19% for low, for less than 77% less than 54. Now, I wanna orient you to something to the right those hours. Do you see those hours? 4.4 hours and 34 minutes, one hour and four minutes? That is how much time they spend in hypoglycemia per day. That's not good. That's not good. And if you looked at the A one C and if you look at the finger stick, you would miss this and this is an individual with comorbidities and risks and events and a medication that needs to be addressed and changed. You know, one would say, well, I don't use uh, sofas and the other while they're still being used because of economic reasons. So, what are you gonna do as a result of this newfound information? Because now you can manage what the appropriate glycemia is. So, first of all, you're gonna stop the glimepiride, you're gonna continue the Metformin er, in the morning right down with the sulf, you know, do you need to target a one C of that type with this individual? Remember you're gonna avoid hypoglycemia. Don't be. So a one C centric avoid hypoglycemia and this is what she saw. So we see a significant improvement. Uh We see a, a barely dip under 70 again, I in this individual maybe we want to increase or decrease even more. But some, you know, would you stop the Metformin altogether? No, that's not your goal. Your goal is to do better, to do some medications and do better. Uh, you know, here we have less than 1% 14 minutes. Uh, less than 70 we have none. At 54 you've raised the A one C to 63, you know. Yeah, you're seeing the low, significantly better. You see stuff a little bit of high, kind of at that breakfast. And so what would you possibly do? They're way less fatigued, better balance on, on waking. We got better quality of life. What are our options? Now? I know some are like, well, stop the me Metformin altogether. Well, really, uh, you can do good, you know, maybe that low is when they're going for a walk. Maybe they delayed a meal. You know, you can have a discussion about avoidance of hypoglycemia. Was it a real severe symptomatic hypoglycemic event? You know, they had heart failure, maybe we wanna move to a different medication, you know, besides Metformin that deals with some of that heart failure. We know, you know, SGLT two options. Um, you know, they are taking, uh, the Metformin in the morning, uh, talking about dietary changes, why we get that little spike. Uh, maybe even saying, well, if you're taking a walk in the afternoon causing low blood sugars, maybe you want to take it after breakfast. So these are all your different ways to customize to that individual. So let's talk about another case. We have a 76 year old, uh, female. I actually just had, uh, a case like this a couple of days ago. A one c was actually 11 but this individual is 10.1. Um, lives alone and checks. Uh, uh, the fasting blood sugar occasionally is between 9150. Uh, but says I'm not having any hypoglycemic symptoms and you're like, yeah, everyone sees really high. And so I'm sure they're fine. But do you know the appropriate glycemia uh of where to intervene? And what are the secondary comorbidities that can impact glycemic control? Yeah, you might say, oh, let's just leave her there. You know, she's 76. She's got mild cognitive impairment. Parkinson's disease. She's exceedingly afraid of falling. I think that's common uh hypertension hyperlipidemia and sleep apnea. And y you can illuminate a lot of the glycemic issues and probably improve some of the cognitive impairment by have less, less hyperglycemia as well. And so she's on immediate release, Metformin 1000 mg twice a day. She's on NPH 20 units twice a day and HumaLOG 20 units is a correction dose for meals after meals if the blood sugar goes beyond a certain thing. So we call that reactive uh glucose management right now, you might say, oh, you know, I wouldn't put them on this kind of insulins, but a lot of individuals for economic reasons, even though recently we've seen a better, uh, uh, coverage of the analog insulins. And so you might say, you know, what am I gonna learn from the CGM on this individual? Well, here's what we see by, uh, looking at the report and we only have 32% in range. And yes, we do not have hypoglycemia, but we have quite a bit of variation at 40 you know, highs to lows. The, the, the roller coaster, the amusement park glucoses are what kept people sick. Uh They feel really bad by the way, uh really, really high, really, really low. And here's where they're at, which is interesting because even though they don't have hypoglycemia, do you see the night to morning glucose variability? Right. You see that midnight, close to 3:56 a.m. tanking you, she, you, this is an excess insulin scenario, but rather let's be more specific. This is the wrong amount of insulin at the wrong time, right. This is all about timing and that's one of the things I've really been aware of is it's really not so much the amount of insulin. It's about the timing of insulin and incorporating CGM will illuminate to the individual. And you can now start adjusting the insulin based on a time intervention more and, and maybe a type of insulin as well. So we have less variability because we've got variable insulin on board NPH is a variable insulin and it kind of doesn't know what it is it's not an intermediate, it's not a long. And so you got a clean house because you can do better uh with that overall glycemic uh intervention because you can do the right insulin. So what kind of changes were made? We got away from the MP H which is highly variable B ID insulin that shows up at odd times. And we moved them to uh 40 units of an analog basil in the morning to make it easy. And then we did a fixed dose of 20 units before meals. And I talked to them about doing it either right when they sit down, don't do it at the end of the meal. Try to do it a little earlier if they know they're gonna eat. And so then the next question is, you know, can you use GOP ones and elderly? Absolutely. In fact, you might be able to reduce the, the HumaLOG dose or the rapid acting insulin in some cases, you can eliminate it all together. Uh, I, I urge you to explore that, but that might be kind of phase two in this individual. And what do we see? Wow. Now we, we had some lows at 1% and, but we didn't have any severe hypoglycemia. And so with this, I, I would talk about, you know, dinner, uh, what kind of food is being eaten when you're taking the insulin, whether you're gonna take it at the beginning of the meal that kinda affect that glycemic excursion. But she really just cleaned house. You got rid of that variable insulin. You put them on a long acting insulin, you, you fix their dose, you put it at the beginning of the meal. You're really avoiding hypoglycemia. I might say, oh, they're kind of close. Well, remember they've got something to protect, protect themselves. And the next step might be, you add a G LP one and you're gonna have to do two things. If you add a G LP one with this individual, you're gonna have to reverse titrate the basal. So you have them target a glucose in the morning and every morning they're less than a target. She's kind of a, you know, around 100 every time they're less than 100 you're gonna take away a unit of basal insulin, right? So you're gonna go down to 3938 we call that reverse patient driven reverse titration and then you might change the fixed dose to 15 and then see them at short end of follow ups, tele visits to try and reverse titrate that rapid. But this is how you navigate this. We wanna make it simple and, and look, you did not, you improve this without the expense of hypoglycemia. Like, come on, you got a one C of 65, right? You know, you don't have to necessarily get an A one C higher and de intensify. You're doing great. And this little CGM is helping you achieve that great glycemic control in this uh advanced aging person. So now let's look at a 67 year old also lives alone in, with C of 92, no symptoms of hypoglycemia but has severe uh cognitive impairment, uh hypertension and hyperlipidemia. Uh They're on Metformin in the morning, they're on Levemir, uh, once in the morning and they're on HumaLOG fixed dose of 10 units per meal that caregiver is giving it to them. And fortunately, they do not have a significant amount of hypoglycemia. Uh Their glucose management indicator actually comes back a little bit better just after that two week of use. It's not uncommon, we see it uh because the caregiver now is it has a visual informed information that all sorts of things can happen. Maybe they stop giving them a particular food because their blood sugars go up so high. Uh We don't have a lot of time and range in this individual. But what we're glad is we don't have a lot of severe hypoglycemia. Uh but we still have that risk for it and, and some of that at risk is happening when you could see it. It's with lunch. So what you might need to do is reduce that lunchtime dose, right? And maybe deposit it with breakfast. Do you get what I mean by that? I mean, look at lunch, you have at risk for lows, you got y glycemic variability there, right? Peak to trough, but you need a little bit more insulin with breakfast. And so you might need to borrow maybe you borrow two units from lunch dose and you put it into breakfast dose. This is how you do that. So in this particular case, there was a medication change, they added lixisenatide, which I think is great. It's a fixed dose, rapid, I'm sorry, long acting insulin with a rapid acting incretin. And what they did is they dosed it related to a target, fasting glucose in the morning of 35 units. And we added the G LP one component, right? And they really pulled back on their HumaLOG. In this case, they kind of reverse titrated to no HumaLOG because this is an advanced cognitive delight in a visual. We want to make it simple, simple, simple for them. Uh You can also um switch to extended release Metformin. I see you have an IR at 1000. You could do 250 I'm sorry, two of the seven fifties in the morning and it might be able to mitigate those night time or the, the evening highs. What about SGLT two? Now, why would we do SGLT two? You might say, ah, this is good enough. They're a one C A 75. They're good enough. But what about SGLT two? Remember when you add medications in the elderly, you're trying to keep them out of the hospital and if this individual had heart failure or had different things, you might add that SGLT two. If they add in continence or that kind of thing, maybe you wouldn't add the SGLT two. So this is how you individually advance the treatment based on the glycemia based on treating the appropriate and all those comorbidities at the same time. So in summary, older adults with diabetes have unique characteristics that need consideration before technology is prescribed, do not count them out, rather count them in and figure out how CGM can help lessen the burden, increase their engagement, increase their quality of life and help you as a prescriber to know which glycemia to treat how to impact poly pharmacy and how to be very determined with your medication intervention. Any technology can be used successful in an older person. You need to match that individual, that tech to that person with complexity, that a person's coping abilities. But remember it's a marathon with them, go slow with them, walk them through the components and again, it should be tailored to their individual needs. Keep those other caregivers family and participants in mind and how this is going to impact their overall health status. So, thank you so much. I hope this has been informative for you in helping illuminate the benefit of CGM and the unique opportunities and challenges in those patients with advancing age. Published Created by Related Presenters Eden Miller, DO FounderDiabetes and Obesity Care LLCSt. Charles Hospital Bend, OR
