This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Carol H. Wysham, MD: I’m Dr Carol Wysham. Welcome to season 3 of the Medscape InDiscussion Type 2 Diabetes Podcast series. Today, we’ll be discussing managing diabetes in older adults, understanding geriatric syndromes and how they impact care, and how and when to de-escalate medical treatment.
First, let me introduce my guest, Dr Medha Munshi. Dr Munshi is a professor of medicine at the Harvard Medical School. She is a geriatrician and an endocrinologist. She practices primary care geriatrics at the Beth Israel Deaconess Medical Center and directs the Geriatric Diabetes Program at the Joslin Diabetes Center. Dr Munshi, welcome to the Medscape InDiscussion type 2 diabetes podcast.
Medha Munshi, MD: Thank you, Dr Wysham. It’s always a pleasure to come and talk to you.
Wysham: I feel the same way. Thank you. First of all, I know that you’ve been focused on research and education on the topic of the management of diabetes in older adults for probably two decades. Please share with us how you first became interested in this area.
Munshi: First, I did my endocrine fellowship. So, I knew about diabetes well, and then, as life happened, I ended up doing a geriatric fellowship. As I started working in this area, I absolutely loved it. As I was working in geriatrics, people began sending their patients with diabetes to me because they knew I was a diabetologist, and I started realizing that there was a difference in how the patients presented, what their background was, and how I was managing their diabetes. So I started studying them, and then my clinic became my laboratory. I moved from Little Rock, Arkansas, to Boston, and the Joslin Diabetes Clinic did not have a program. Actually, geriatric diabetes was not really a thing at the time. I was given the opportunity to start the program. So that’s how I ended up there.
Wysham: As you know, I share your interest, and in a similar vein, just having experience in diabetes and having patients age through. It is clearly different to manage this population. So, give us a perspective. How many people in the US and the world with diabetes are over the age of 65?
Munshi: If you look at diabetes in general, about 830 million people in the world, or 38 million of them in the US, have diabetes. But aging is different in different parts of the world, and with the Baby Boomers aging in the US, we now have an increasing number of older adults. The popular number was 10,000 people turning 65 every day for about 2-3 years. And the prevalence of diabetes is higher in aging individuals. We have about 29% of the population over the age of 65 who have a diagnosis of diabetes. That makes about over 11 million people, and that’s increasing. So, we are seeing a real shift. The idea is that in any specialty of medicine you practice, you are going to see more and more older adults and those with diabetes.
Wysham: There are what’s called geriatric syndromes, as you well know, and it would be interesting to have a quick overview of what those are and how they impact the care of the older person with diabetes.
Munshi: Geriatric syndrome is basically some of the conditions that seem to occur with aging and with higher prevalence with diabetes. These include conditions such as cognitive dysfunction, depression, functional or physical impairment or dependency, polypharmacy (which is taking multiple medications daily), chronic pain, incontinence, and so forth.
It is important to identify these conditions because, as diabetologists, we intuitively don’t think about them. They are not part of our macrovascular or microvascular complication cohort. These conditions are quite subtle. Many times, patients themselves or their caregivers and we as clinicians don’t recognize them. However, they do impact patients’ ability to perform self-care and manage their therapy, especially if it is complex therapy. So, it is important to recognize what geriatric syndromes are and whether the patient has them or not.
Wysham: I’d like to just clarify a little bit. We’re identifying two different risks, at least in my view. One is understanding how geriatric syndromes might impact the quality and the duration of life expectancy, and the other is the ability of people to carry out their self-care.
Maybe you can provide a little bit of clarification on how we identify those patients who really are older, maybe by their chronological age, and how the other aspect, the effects of chronic care of their chronic disease, [intersects with age].
Munshi: You are absolutely right. The same conditions that we describe in geriatric syndrome could also be comorbidities. That’s what you are mentioning. Comorbidities could be that as well as other cardiovascular conditions or stroke or many other comorbid conditions that are actually what we in geriatrics think of as competing comorbidities. When somebody has this condition, or even [something like] cancer, how important is diabetes management for them, considering the impact of these comorbidities on life expectancy and so forth? That is absolutely a part of consideration. The geriatric syndrome is more like coexisting conditions that impact self-care and the patient’s ability to perform their day-to-day diabetes care. There are fine differences, but it’s essentially one big overall picture of what else is going on with that patient.
Wysham: Can you review the risks of overly aggressive diabetes management in older adults?
Munshi: Yes. As we know, typically, one of the major differences between older and younger adults with diabetes is having comorbidities. We know that everybody is managing some of the common comorbidities or conditions, such as high cholesterol or high blood pressure. Diabetes is a little bit different in that the goal for glycemia has upper level and lower level. So, there is a target that has both too high or too low levels that are not necessarily worrisome in other chronic conditions. So, when we think about what the goal should be for any individual, we want to think about the benefits of lowering the high glucose and the risk of going too low.
Now, the benefit of lowering high blood glucose is typically avoiding long-term complications vs low glucose, which causes poor outcomes such as falls, fractures, a decline in cognition, or even cardiac events. As we get older, that benefit and risk assessment needs to be done more carefully because as we get older, into the 80s and 90s, the risks of someone having low blood sugar and having a fall and fracture and ending up in a nursing home are much more worrisome than a concern about long-term complications that they may not have time to develop.
The other side of that equation is how that overtreatment or the complexity of the regimen impacts a patient’s quality of life. Another concern that we have is that overly complex treatment may make the patient stressed and they’ll have difficulty following those regimens, and that can impact their and their caregiver’s quality of life.
Wysham: That’s very important information. Thinking about the patient and addressing their concerns about good glycemic control vs their risks of being overly treated, how do you address that older patient who wants to keep their A1c less than 7%? That comes up in my practice literally every day.
Munshi: I think part of it is explaining it to the patient. Patients come in and say, but I have fought for years to keep my A1c under 7%. Why are you saying that? Are you giving up on me? The idea is that I start by asking them questions and talking about why we are doing that. Why do you think we are trying to keep your A1c under 7%? Typically, we start at that point and talk about the development of long-term complications.
In geriatrics, we are fond of talking about time to benefit. How long does it take for a tight control to benefit, which in diabetes is somewhere around 5-7 years? So, what are the risks of keeping your A1c under 7%, especially if you are on medications that have a high risk for hypoglycemia?
I think gradually, showing them the logic behind why we are doing this and the fact that it is not giving up on them, but rather making sure that the benefits of the treatment remain without the risk of the treatment.
Wysham: My comment on this is that it might take 20 years for your high blood sugar to have a major impact, but hypoglycemia can kill you today. That’s what I try to explain to people, but you know, it doesn’t always work. Some of them still insist, or they’ll come in the next visit and say they’re sorry their A1c is 7.1% and want it to be under 7%.
Speaking of A1c, a recent article that was published confirmed something that you actually showed over 10 years ago: A1c is a poor surrogate for the risk for hypoglycemia. Do you want to review that concept with the audience?
Munshi: That is one of the primary ways you could convince the patient because A1c is a mean glucose value over the past 3 months. So the mean glucose does not show excursions. You could have glucose at 440 mg/dL every day, and your mean glucose might come up somewhere where it is reasonable.
It also does not show how many times or how long the person spends in low blood sugar when you check the mean glucose. So we are now fortunate to have excellent technology, which is now becoming a lot more common in practice and covered by many insurance companies, especially continuous glucose monitoring (CGM).
It has also shown us the fallibility of A1c, especially on the other side. When we measure A1c, we are measuring glycation of the red blood cell (RBC) molecule. When the RBC molecule does not live for 3 months, we presume that it’s a normal lifespan of RBC. If the turnover of RBC is not normal, then actually the value of A1c may not be appropriate or reflect the true glycemia either.
Conditions such as anemia, blood loss, and acute infection — the conditions that actually make that A1c value unreliable — occur very commonly in our older population. That’s another reason why A1c may not be appropriate for treatment changes. When a patient has a concern about their A1c value, and I’m really worried about them having a hypoglycemia episode, having a professional CGM, which is just a 2-week pattern that does not necessarily require patient input, can show me and the patient how much time they’re spending in low glucose. It’s not just about falls and fractures, but the cognitive impairment, right? The brain only uses glucose to function, and most older adults are really worried about cognitive impairment, and that many times convinces them that let’s just not go overboard, especially if there is no benefit of doing this tight control.
Wysham: I think that’s very important. I just want to emphasize that since we’re talking about older adults and the vast majority of them will have Medicare, the professional CGM is very well covered by Medicare without regard to background medications, and all of our patients on basal insulin with Medicare are candidates for CGM if it fits into their particular situation. To emphasize, we can use this technology with the majority of our patients to help them understand it. Speaking of advanced technologies, how do you decide when it’s appropriate for a patient to have, for instance, a personal CGM at their disposal?
Munshi: I think that’s probably the most contentious issue when I talk with my geriatrician colleagues versus my endocrinologist colleagues. I think what I would say is that we understand that older adults are not a homogeneous population. There are older adults who are very healthy, very capable, cognitively intact, and functionally intact vs older adults who are more frail and dependent. If we decide on the right technology for the right patient, then I think we can minimize the burden of the technology and maximize the benefit.
Whenever I think about technology, I ask myself three questions. First, why am I doing that? Is this because the patient requires more information about how his or her lifestyle is impacting the glucose level? Second, are you doing fine with your diet? And third, what does exercise do to your glucose level, or are your medications doing right for your glucose level? If that is the purpose, and that is the purpose for many of these healthy, functional people, then personal CGM is very appropriate as long as we tell them why we are doing that.
In many of my patients, it is the caregivers who are saying, I don’t know when mom has low blood sugar; what is the best way to find out? In that case, the CGM with the share feature would be a good one to use. Then we are decreasing the burden and increasing the benefit.
Then, there is a large cohort of patients who are not capable. They are frustrated and overwhelmed. As a clinician, I want to know what’s happening. Are they getting low overnight? Or how do I change the therapy? Because it seems like they are not doing well. Then, a professional CGM is the right thing to do.
So, if you think about it, there are three reasons why we are doing this. One is to decrease the risk for hypoglycemia. The second thing is to help them get better glycemic control. And the last thing is to improve quality of life. If we are doing it for the right reason and for the right patient, I think we can do well without increasing the burden.
Wysham: I think that’s all very important information. I also have that question, at least in my own practice: How and when do you take away technology? How do you make the decision when it’s appropriate to suggest that technology should be removed?
Munshi: I think you might be thinking about this for an insulin pump or the automated insulin delivery (AID). Usually, with CGM, it’s not necessary to take it away because the worst the patient can do is not use it appropriately, and if that happens, we can continue to educate them. The bigger problem comes when people who are on insulin pumps or AID systems who start getting multiple hypoglycemic episodes, and you can see that the caregivers are stressed about that.
It is a very difficult decision because people who are used to that, and especially most of them, have type 1 diabetes, and they really like that independence from monitoring and multidose insulin. I typically start telling them why I think that their technology is not working for them. Not only that, but it’s hurting them. It takes me many times — five, six, seven, eight visits — before I can convince some of them. Unfortunately, many times, they end up in the hospital because of the failure of the technology. Once they are in the hospital, the pump or the AID is taken away, and then they realize that there is no way to put it back on and carry on. That’s when they start not using that. I do hold the hope that as the AID is improving and becoming more patient-friendly and requiring less patient input, the frailest of all people with type 1 diabetes would be able to use them. We are not there yet.
Wysham: I think we’re pretty close with one of the AIDs in that they have shown pretty decent control even if patients don’t bolus. I wish we could lock the pump so that the patients can’t bolus. That’s one of the big issues that I frequently have, even to the point that patients are getting confused about how they treat hypoglycemia, and they actually think they need to bolus.
That leads us probably to our frailest of frail patients: the patients in assisted living or skilled nursing. What advice do you have about managing diabetes in those settings?
Munshi: I don’t know if I have a whole lot of advice; rather, I have concerns that we really need to do something about that. The reason is that these facilities are highly regulated facilities, and they require specific protocols that are embedded into their care protocols for different types of technologies to be used there.
There is no reason why CGM cannot be used efficiently. However, more studies are going to be required to approve their use. Then, we have to actually educate the staff of the long-term care facility, skilled nursing facility, or rehab facility on how to use them.
The biggest problem with these facilities is that the staff keeps on changing. So we need educational programs that are embedded in their inservices and so forth that can do that. This is not rocket science. We can do that. We just need resources, and we need some help in developing that.
As we talked about, more people are getting older, and older cohorts are going to require some rehab at some point or some assisted care facilities, and the time to prepare for that is now.
Wysham: I think that’s really important. And I share with you the frustration that we haven’t been able to move forward with the use of these technologies in these settings.
I want to thank you so much for sharing your advice with us. It was very interesting and very helpful.
Today, we’ve talked to Dr Munshi about the management of patients and older adults, how comorbidities can impact their care, and how we can use technologies to help improve the outcomes of our patients with diabetes.
I want to thank the audience for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on type 2 diabetes. This is Dr Carol Wysham for the Medscape InDiscussion Type 2 Diabetes Podcast.
Listen to additional seasons of this podcast.
Resources
Worldwide Trends in Diabetes Prevalence and Treatment From 1990 to 2022: A Pooled Analysis of 1108 Population-Representative Studies With 141 Million Participants
National Diabetes Statistics Report
Home Modifications for Older Adults: A Systematic Review
Geriatric Syndromes in Older Adults With Diabetes
The Relationship Between CGM-Derived Metrics, A1C, and Risk of Hypoglycemia in Older Adults With Type 1 Diabetes
Glycemic Control and Hypoglycemia in Patients Treated With Insulin Pump Therapy: An Observational Study
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