SARAH: Hey, welcome back. We are joined today by our favorite diabetologist, Dr. Amber Healy. And that is not to be offensive to the other diabetologist out there, but we really like Amber Healing. So today we are gonna talk about everyone's favorite topic at the beginning of the new year, the ADA standards of care 2025. So the topic for this particular video, we are gonna talk today about chapter 13 in the ADA standards of care and, uh, diabetes care in older adults. So, Amber Healy, where should we start in there? I think you and I might have talked about a particular table. That maybe where we're gonna start. 

AMBER: Yeah. So, you know, a lot of these chapters, they kind of go together, they tie in, and there's other places you can find your framework and then get into details. So, uh, actually in chapter six where they talk about glycemic goals and hypoglycemia, there's a really great figure 6.2 and what that really focuses on is individualizing the hemoglobin A1C target to the person. And that becomes really important with our older adults because, uh, older adults vary in their functionality, their comorbid conditions, uh, different considerations, things that matter to them. So like they, they have a great framework in that chapter, but I would like to draw your attention first to just looking at what you consider when you individualize those targets because they tie together. 

SARAH: That's perfect. And actually, that will go right into our next discussion because we're talking about what matters for that individual. And so moving on to chapter 13, which is the chapter on older adults. Um, we wanted to talk today about the four Ms framework. And I know that that is a figure R table 13.1. So what can you tell me about this? So the four Ms, what, what can you tell me about the four Ms? 

AMBER: So it's a, it's the framework of, you know, where we approach a patient. So what's their mentation?

SARAH: Mentation? 

AMBER: Are they able to remember to take their medications? Do they have underlying dementia? Like, and if you're not completely sure, they do recommend neurocognitive evaluation at age 65 and older. Um, at, at initial visits as needed. You know, you know, at the, when you feel like it, it may be warranted.  Um, there's been a change. You also, you know, making sure does the patient have any anxiety, depression, diabetes, distress that you need to be aware of. You know, and when it comes to their own coping skills with their self-care and even their ability to utilize technology, which I know we can talk about a little bit more. Um, and they also then mobility, that's mobility's important. Because, you know, if you've got issues with dexterity that determines what you do for a patient. If you have issues with, um, vision and hearing or you know, leg, leg function, foot deformities, uh, the comorbid condition that we see, diabetes with, diabetes of neuropathy. So all of these are things we need to consider when we're looking at the whole patient. 

SARAH: Awesome. So we have mentation mobility. What's next now?

AMBER: Medication. So like what, I know you love drugs. 

SARAH: Did somebody say medication?

AMBER: I did say medication. You know, and so like things to consider, like what is the patient's treatment burden? Like the polypharmacy, we have to think about how many pills are they taking? I can they take an injection? Do they have a history of adverse reactions to other medications? Can they afford it? You know, a lot of the meds that we now recommend are hard to get because they have really high copays.  And then, um, what is their social and family support? Are they at home with somebody? Do they have a really engaged caregiver? Are they in a long-term care facility? Where they have people that keep an eye on things and like, how complex should this medication regimen be just for this one? So important condition in the context of everything else that they deal with in a day. And then we have to worry about hypoglycemia. Because hypoglycemia can precipitate a fall. You know, and falls lead to broken bones and that can completely change the trajectory of a, a patient's life. 

SARAH: Yeah, Absolutely. So we've done mentation, mobility, medications 

AMBER: And the fourth one is what matters. So matters or the fourth m 

SARAH: Nice, matters. Okay. 

AMBER: So what are the, what are the individual and the, even the family sometimes, what is the, the goal and the expectations? What symptoms on medications? Like, you know, if they have, they're on medication with a specific side effect, what's a quality of life issue for them? What's not a quality of life issue for them? You know what, when it comes to their, their eating patterns, even like there are some people, they're not giving up no something. They're not giving up their pop, they're not giving up their cookies. Like, you know, where you have to meet them, where they are with their, you know, what their expectations are. And when you're considering this forum framework. You know, you even have to think about life expectancy. It's not a fun, uh, question to ask sometimes. 

SARAH: Right. So going back to mentation. Uh, we're gonna talk a little bit about technology and if you hear any beeping or shaking, that is not my brain. That is actually construction going on outside. So don't be alarmed. Don't be alarmed Dr. Healy. It's not in my brain.

AMBER: And it's not a CGM alarm. 

SARAH: It's not, it's not an alarm. No. Not a CGM, but since we're talking about CGMs And beeping. Let's talk more about technology. 

AMBER: Yeah. So, you know, I'm, a lot of times people think older adults aren't tech savvy. But you know, there have been studies that have been done in older adults to look at how they do on technology and actually the recommendations are that you offer it to them. You know? If the patient's comfortable, they're interested, they have the sup, either the, the desire themselves or the support from their family. Uh, to do, to utilize technology. It's actually recommended to recommend CGMs and then, and when it's appropriate for some of our type one older adults like insulin pumps and smart pens, uh, should definitely be considered if, if they're game for it. 

SARAH: I think that's exciting. I think that's awesome. Let's talk a little bit more about that too, because we know about with our older adults sometimes what their coverage. Their insurance coverage looks like. And so for people who do not have Medicaid, for the people who are on other types of insurance, tell me more about, um, a little bit about coverage for those and what you've seen. What needs to happen for people to be able to get those CGMs? 

AMBER: Yeah, so for Medicare, you know, we, we talked about this I know in another, uh, session. And um, a lot of them are on Medicare. So we're still mostly going through parachute. That third party software to determine who the durable medical equipment supplier is. And in order to qualify on Medicare for CGM.  Uh, the patient needs to be taking at least one injection of insulin a day. And so in your type one patients, that's not a big deal. Because they're usually, they're insulin dependent. But when we look at our type two folks who we've really been gearing our series toward, as long as they're taking a once daily long-acting insulin, 
they should qualify for the use of A CGM. 

SARAH: So when we talk about our older adults  We wanted to reiterate that table 6.2 where we started.  About treatment. We also discussed the four Ms. Which are found in this figure 13.1. Talked a little bit about technology and mentation in the older adult and the coverage of those CGMs. So is there anything else you'd like to add before we end this session? 

AMBER: I think medications are really important part of this. Those four Ms because there's considerate considerations you need to make. Like we said, if they've got an organ disease or a complication, uh, you need to think about, well what meds could make that worse?  What medications could actually be a benefit? So you know, as we continue to work on cardio, renal, metabolic, the whole picture. You know, we look at SGLT-2 inhibitors as an example. 'cause you know, they have indications in heart failure now. You can use that all the way down to A GFR of 20. And we know a lot of older adults have heart failure. They have kidney failure. Or kidney disease, not failure, you know, diabetes associated kidney disease. So, you know, thinking about that, but you know, if they have a lot of urinary tract infections, you kind of have or yeast infections, you kind of have to weigh the pros and the cons and look at that. What matters most to the patient, what affects their quality of life. And as you try to help with that, you know, we, we know metformin, if your renal function is dropped, your GFR is below 30. We should stop it. We know with, you know, uh, pioglitazone. That if the patient has osteoporosis or they have heart failure and swelling, probably not a great choice for them. And the other thing, you know, we weren't, when we worry about uh, mobility, we talked about frailty a little bit and sarcopenia, well there's been recently there's been more concern with the GLP-1s and what, what part of the weight are they losing? They still don't actually know the answer to that. But, you know, is it that the best choice in a patient? And then if somebody's got decreased appetite already and you're, you don't wanna promote malnutrition GLP-1, like if it further hampers their appetite. It may not be a great choice for them either. So there's a lot of different things you have to look at when you're picking meds, when you're adding the technology and looking at the whole patient. 

SARAH: That sounds fantastic. Alright. Thank you Dr. Healey. 

AMBER: You are welcome. 

SARAH: Thank you for joining us today as we talked about chapter 13 in the 2025 ADA standards of care and that's care for our older adults with diabetes. Have a great day.