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Screening and Management of Hyperglycemia in the Geriatric Population Geriatric is defined as age 65+ years 1 Diabetes Management Screening Recommendations for IFG, IGT & DM FPG Annually 2 : if above 100 mg/dL confirm with consider checking postload glucose 2 repeat fasting glucose. Avoid OGTT if possible 2 if below 100 and high risk based on multiple risk factors and/or metabolic syndrome Diabetes Management Goals of Therapy: consider comorbidities before setting targets 1 : A1c < 7% if attainable without significant hypoglycemia 3 BP
Abbreviations AGI Alpha-Glucosidase Inhibitors ACE inhibitor Angiotensin Converting Enzyme Inhibitor ARB Angiotensin Receptor Blocker BAR Bile Acid Resin (colesevelam) CAD Coronary Artery Disease DPP-4 Dipeptidyl peptidase-4 Inhibitor FPG Fasting Plasma Glucose IFG Impaired Fasting Glucose IGT Impaired Glucose Tolerance GAD* Glutamic Acid Decarboxylase ICA* Islet Cell Antibodies OGTT Oral Glucose Tolerance Test SU Sulfonylurea TZD Thiazolidinedione *note: ICA and GAD antibodies usually take 1-2 weeks to be reported. If result is positive then patient has autoimmune mediated diabetes and insulin needs to be considered and oral agents may need to be discontinued Hypoglycemia: Autonomic hypoglycemic warning signs may not be recognized in older adults due to changes in counter regulatory hormone response. Symptoms of hypoglycemia are often mistaken for co-existing medical conditions including postural hypotension, Parkinson’s, dementia, traumatic brain injury or CVA. Patients that cannot communicate verbally with caregivers are at greater risk. References 1. Sinclair A, Finucane P, eds. Diabetes in Old Age. 2nd ed. Chichester, UK: John Wiley & Sons, Ltd; 2001. 2. Madden KM, Tedder G, Lockhart C. The oral glucose tolerance test induces myocardial ischemia in healthy older adults. Clinical and Investigative Medicine 2007;30(3):E118-26. 3. Chang AM, Smith MJ, Bloem CJ, Galecki AT, Halter JB. Effect of lowering postprandial hyperglycemia on insulin secretion in older people with impaired glucose tolerance. Am J Physiol Endocrinol Metab 2004;287(5):E906-11. 4. Meneilly GS, Cheung E, Tuokko H. Altered responses to hypoglycemia of healthy elderly people. J Clin Endocrinol Metab 1994;78(6):1341-8. 5. Munshi M, Grande L, Hayes M, et al. Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care 2006;29(8):1794-9. 6. Care California Healthcare Foundation/American Geriatrics Society Panel in Improving Care for Elders with D. Guidelines for Improving the Care of the Older Person with Diabetes Mellitus. J Am Geriatr Soc 2003;51(5s):265-80. 7. Katakura M, Naka M, Kondo T, et al. Prospective analysis of mortality, morbidity, and risk factors in elderly diabetic subjects: Nagano study. Diabetes Care 2003;26(3):638-44. 8. Lipscombe LL, Gomes T, Levesque LE, Hux JE, Juurlink DN, Alter DA. Thiazolidinediones and cardiovascular outcomes in older patients with diabetes. JAMA 2007;298(22):2634-43. 9. Durso SC. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA 2006;295(16):1935-40. 10. Kuo HK, Jones RN, Milberg WP, et al. Effect of blood pressure and diabetes mellitus on cognitive and physical functions in older adults: a longitudinal analysis of the advanced cognitive training for independent and vital elderly cohort. J Am Geriatr Soc 2005;53(7):1154-61. 11. McBean AM, Huang Z, Virnig BA, Lurie N, Musgrave D. Racial variation in the control of diabetes among elderly medicare managed care beneficiaries. Diabetes Care 2003;26(12):3250-6. 12. Holt RM, Schwartz FL, Shubrook JH. Diabetes care in extended-care facilities: appropriate intensity of care? Diabetes Care 2007;30(6):1454-8. 13. Bertoni AG, Hundley WG, Massing MW, Bonds DE, Burke GL, Goff DC, Jr. Heart failure prevalence, incidence, and mortality in the elderly with diabetes. Diabetes Care 2004;27(3):699-703. 14. Okereke OI, Kang JH, Cook NR, et al. Type 2 diabetes mellitus and cognitive decline in two large cohorts of community-dwelling older adults. J Am Geriatr Soc 2008;56(6):1028-36. 15. The ADVANCE Collaborative Group. Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med 2008;358(24):2560-72. 16. The Action to Control Cardiovascular Risk in Diabetes Study G. Effects of Intensive Glucose Lowering in Type 2 Diabetes. N Engl J Med 2008;358(24):2545-59. 17. European Diabetes Working Group for Older People. Clinical Guidelines for Type 2 Diabetes: European Union Geriatrics Medicine Society; 2004. H EALTH PLANS www.cfhp.com 79
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Table 1. Adult Preventive Services
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Recommended Adult Immunization Sche
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CRITERIA 19. Unresolved Problems Fr
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PREVENTION RECOMMENDATIONS 1. The E
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AsthmaMatters is an initiative deve
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According to the Centers for Diseas
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