Frailty and diabetes in older adults: Overview of current controversies and challenges in clinical practice

Abstract

R (2022) Frailty and diabetes in older adults: Overview of current controversies and challenges in clinical practice.

Continuous Glucose Monitoring in Older Adults: What We Know and What We Have Yet to Learn

“…Both frailty and dementia hold a complex bidirectional relationship with T2DM and seem to increase the likelihood of hypoglycemic episodes, in the presence of either T1DM or T2DM. 61,62 In such patients with frailty and with cognitive impairment, it is recommended to pursue deescalation of therapies that place patients at risk of hypoglycemia including sulfonylureas and rapid-acting insulins as well as individualize glycemic HbA1c targets based on degree of frailty. 63 While CGM use in the inpatient setting for older adults is promising as a tool for achieving adequate glycemic control while minimizing and even preventing episodes of hypoglycemia, there remain numerous areas in need of further research to promote evidence-based technology for this population.…”

“…Both frailty and dementia hold a complex bidirectional relationship with T2DM and seem to increase the likelihood of hypoglycemic episodes, in the presence of either T1DM or T2DM. 61,62 In such patients with frailty and with cognitive impairment, it is recommended to pursue de-escalation of therapies that place patients at risk of hypoglycemia including sulfonylureas and rapid-acting insulins as well as individualize glycemic HbA1c targets based on degree of frailty. 63…”

The Reasons for the Low Uptake of New Antidiabetic Drugs with Cardiovascular Effects—A Family Doctor Perspective

“…However, if insufficiently treated, hyperglycemia can lead to acute complications such as dehydration, poor wound healing and hyperglycemic hyperosmolar coma, which should be avoided [ 67 ]. There is a delicate balance between over-treating and suboptimal treating, which requires an individualized treatment approach, carefully planning both pharmacological and non-pharmacological treatments [ 68 ]. Sometimes, it is not clear how much the under-prescription of the guideline-recommended therapy to frail patients, and how much the frailty status per se, contributes to poor outcomes [ 69 ].…”

Recomendaciones en el manejo de la hiperglucemia en pacientes con diabetes mellitus según grado de fragilidad

“…• 1. Si se inicia, titular dosis para mejorar la tolerancia digestiva; si ya pautada → reducir dosis al 50% si FG<45 ml/min/1,73m 2 ; stop si <30 ml/min/1,73m 2 .…”

“…En este apartado, y para cualquier grado de fragilidad, seguimos manteniendo la metformina en primera línea, siempre y cuando sea tolerada, por sus beneficios en la sarcopenia57 , aunque la hemos señalado de color naranja por su potencial efecto de pérdida de peso modesta117 , que en este tipo de paciente no sería tan deseable, por lo que señalamos a continuación al iDPP-4 de color verde como fármaco prioritario para este tipo de pacientes de bajo peso.Evidentemente, en estos casos, los fármacos que puedan provocar un descenso más acusado de peso, como los iSGLT-2 y, sobre todo, los arGLP-1 (a pesar de cierto beneficio de estos en la sarcopenia)2,26 quedan descartados como línea terapéutica. En España, además, los arGLP-1 están financiados por el sistema público solo si existe un IMC basal de > 30 kg/m 2 , con lo que en este tipo de pacientes ya estarían totalmente excluidos.…”