Building Competency in Diabetes Education THE ESSENTIALS

CHANGES ACROSS THE LIFESPAN| 4-41

• Meglitinides are a safer alternative to glyburide in patients with irregular eating habits. • Long-acting basal analogues are associated with lower frequency of hypoglycemia than NPH or human 30/70 insulin (3,91).

Deprescribing There has been considerable attention directed lately to the issue of polypharmacy and the need for “deprescribing”, especially in the elderly population. The Sloan survey showed that 44% of older men and 57% of older women (>65) were using five or more drugs to treat a variety of comorbid conditions; 11% were using 10 or more drugs (96). The Law of Therapeutic Parsimony states that minimum drug preparations and doses are to be used as long as they are able to achieve optimal outcomes. However, polypharmacy is common among older adults with multimorbidities because clinicians prescribe a group of evidence-based medications oriented to each disease; this often results in a risky accumulation. Each guideline is supported by evidence, but there is no guideline that addresses medication regimens for multiple concurrent diseases and their aggregated effects (91). In view of the combined adverse drug reactions, exponential cost and adherence issues, recommendations have been made in regard to deprescribing. This process must be individualized with consideration given to the benefit versus risk ratio, length of life expectancy, frailty, cognition and risk for hypoglycemia.

Recommendations for deprescribing include (3,71,76,80,96): • Reconsider blood pressure and statin drugs • Simplify insulin regimens:

o In type 2 diabetes, consider basal insulin with an OHA or GLP-1 o In type 1 diabetes, consider replacing MDI with “basal plus” insulin regimen

Cognition There are many factors that contribute to cognitive decline in the older age group but it continues to be debated as to the magnitude of the effect diabetes has on this natural process. We do know that having diabetes is a known risk factor for the development of both vascular and neurodegenerative (Alzheimer’s) dementia which, in turn, has a detrimental effect on self care (94,98). Memory, learning, attention and mental flexibility are all aspects of cognition that