Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus

Abstract

The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.

The Perspectives of Patients with Chronic Diseases and Their Caregivers on Self-Management Interventions: A Scoping Review of Reviews

“…Stigma was associated with severed relationships; social isolation; reduced work opportunities; and distress, depression, anxiety, and lowered self-esteem, self-worth, and patient self-efficacy [ 37 , 41 , 81 , 88 , 89 , 91 , 100 ]. In patients with T2DM, the perceived stigma was related to their experience of insulin self-injection [ 37 , 76 , 79 , 101 ]; in patients with COPD, the internalised stigma was evident when they described their disease as “self-inflicted” [ 41 ].…”

Getting back or giving back: understanding caregiver motivations and willingness to provide informal care

“…Within healthcare research the concept of clinical inertia, i.e. the recognition of the medical problem between a patient and a physician, but with failure to act upon this (Phillips et al, 2001 ; Valencia, Florez, & Palacio, 2019 ), has been shown to have negative health consequences (e.g. delayed treatment, Valencia et al, 2019 ).…”

“…the recognition of the medical problem between a patient and a physician, but with failure to act upon this (Phillips et al, 2001 ; Valencia, Florez, & Palacio, 2019 ), has been shown to have negative health consequences (e.g. delayed treatment, Valencia et al, 2019 ). It may be that a similar concept around inertia in caregiving may exist that prevents or delays caregivers in seeking necessary support when motivations falter or when care demands change.…”

Diabetes in Older People: Comprehensive Approach

“…given the low risk of hypoglycemia, the weight loss benefit, the potential benefits in comorbidities and the weekly administration [9]. Its use must be accompanied by adapted nutritional therapy, and appropriate physical activity recommendations (aerobic and resistance training) to avoid the loss of muscle mass, including strength, flexibility and balance exercises [10].…”