Hypoglycemia in elderly patients with diabetes increases the risk of cardiovascular and cerebrovascular events(1), progression of dementia(2), injurious falls(3), emergency department visits, and hospitalization(4). Hypoglycemic episodes are difficult to diagnose in this population and are easily missed by intermittent finger-stick measurements. Recent large studies(5) have shown lack of benefit and sometimes higher risk of morbidity and mortality with tight glycemic control, especially in older adults. Therefore, the American Geriatric Society and the American Diabetes Association recommend relaxing glycemic control for vulnerable patients(6) (A1C<8% instead of the usual <7%). However, whether relaxing the goal to A1C>8% improves the frequency of hypoglycemia in older patients remains unknown. Thus, we evaluated hypoglycemia in older diabetic patients with A1C>8% with continuous glucose monitoring (CGM)

OBJECTIVETo evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control. The American Diabetes Association guidelines recommend the assessment of age-specific barriers. However, the effect of such strategy on outcomes is unknown.RESEARCH DESIGN AND METHODSWe randomized 100 subjects aged ≥69 years with poorly controlled diabetes (A1C >8%) in two groups. A geriatric diabetes team assessed barriers and developed strategies to help patients cope with barriers for an intervention group. The control group received equal amounts of attention time. The active intervention was performed for the first 6 months, followed by a “no-contact” period. Outcome measures included A1C, Tinetti test, 6-min walk test (6MWT), self-care frequency, and diabetes-related distress.RESULTSWe assessed 100 patients (age 75 ± 5 years, duration 21 ± 13 years, 68% type 2 diabetes, 89% on insulin) over 12 months. After the active period, A1C decreased by −0.45% in the intervention group vs. −0.31% in the control group. At 12 months, A1C decreased further in the intervention group by −0.21% vs. 0% in control group (linear mixed-model, P < 0.03). The intervention group showed additional benefits in scores on measures of self-care (Self-Care Inventory-R), gait and balance (Tinetti), and endurance (6MWT) compared with the control group. Diabetes-related distress improved in both groups.CONCLUSIONSOnly attention between clinic visits lowers diabetes-related distress in older adults. However, communication with an educator cognizant of patients’ barriers improves glycemic control and self-care frequency, maintains functionality, and lowers distress in this population.

To learn how to improve telemedicine for adults >65, we asked primary care clinicians (“PCPs”) affiliated with one large Boston-area health system their views on using telemedicine (which included phone-only or video visits) with adults >65 during the COVID-19 pandemic. In open-ended questions, we asked PCPs to describe any challenges or useful experiences with telemedicine and suggestions for improving telemedicine as part of a larger web-based survey conducted between September 2020 and February 2021. Overall, 163/383 (42%) PCPs responded to the survey. Of these, 114 (70%) completed at least one open-ended question, 85% were non-Hispanic white, 59% were female, 75% were community-based, and 75% were in practice >20 years. We identified three major themes in participants’ comments including the need to optimize telemedicine; integrate telemedicine within primary care; and that PCPs had disparate attitudes towards telemedicine for older adults. To optimize telemedicine, PCPs recommended more effective digital platforms, increased utilization of home medical equipment (e.g., blood pressure cuffs), and better coordination with caregivers. For integration, PCPs recommended targeting telemedicine for certain types of visits (e.g., chronic disease management), enabling video access, and reducing administrative burdens on PCPs. As for PCP attitudes, some felt telemedicine enhanced the doctor-patient relationship, improved the patient experience, and improved show rates. Others felt that telemedicine visits were incomplete without a physical exam, were less rewarding, and could be frustrating. Overall, PCPs saw a role for telemedicine in older adults’ care but felt that more support is needed for these visits than currently offered.

Background and Purpose-Target blood pressure (BP) values for optimal cerebral perfusion after an ischemic stroke are still debated. We sought to examine the relationship between BP and cerebral blood flow velocities (BFVs) during daily activities. Methods-We studied 43 patients with chronic large vessel ischemic infarctions in the middle cerebral artery territory (aged 64.2Ϯ8.94 years; at 6.1Ϯ4.9 years after stroke) and 67 age-matched control subjects. BFVs in middle cerebral arteries were measured during supine baseline, sitting, standing, and tilt. A regression analysis and a dynamic phase analysis were used to quantify the BP-BFV relationship. Results-The mean arterial pressure was similar between the groups (89Ϯ15 mm Hg). Baseline BFVs were lower by approximately 30% in the patients with stroke compared with the control subjects (Pϭ0.0001). BFV declined further with postural changes and remained lower in the stroke group during sitting (Pϭ0.003), standing (Pϭ0.003), and tilt (Pϭ0.002) as compared with the control group. Average BFVs on the stroke side were positively correlated with BP during baseline (Rϭ0.54, Pϭ0.0022, the slope 0.46 cm/s/mm Hg) and tilt (Rϭ0.52, Pϭ0.0028, the slope 0.40 cm/s/mm Hg). Regression analysis suggested that BFV may increase approximately 30% to 50% at mean BP Ͼ100 mm Hg. Orthostatic hypotension during the first minute of tilt or standing was independently associated with lower BFV on the stroke side (Pϭ0.0008). Baseline BP-BFV phase shift derived from the phase analysis was smaller on the stroke side (Pϭ0.0006). Conclusion-We found that BFVs are lower in patients with stroke and daily activities such as standing could induce hypoperfusion. BFVs increase with mean arterial pressure Ͼ100 mm Hg. Dependency of BFV on arterial pressure may have implications for BP management after stroke. Further prospective investigations are needed to determine the impact of these findings on functional recovery and strategies to improve perfusion pressure during daily activities after ischemic stroke. (Stroke. 2010;41:61-66.)