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Lithany Carmello
Contents:


  1. Related Articles
  2. CP Chronic Critical Illness
  3. Abstracts from the 11th International Congress of Behavioral Medicine | SpringerLink
  4. PHARMACOGENETICS AND PHARMACOGENOMICS

We must emphasize healthful eating patterns consisting of nutrient-dense, high-quality foods rather than specific nutrients to improve overall health regarding body weight; glycemic, BP, and lipid targets; and reductions in the risk of diabetes complications Choosing vegetables, legumes, whole grains, and high-fiber breakfast cereals is the best way to increase fiber consumption, although increasing fiber should be avoided in cases of delayed gastric emptying gastroparesis. Additionally, meeting fluid intake recommendations is important for preventing constipation and fecal impaction in older adults Palatability, availability, affordability, and the difficulty of achieving low-sodium recommendations in a nutritionally adequate diet are all important considerations Additionally, older adults are much more likely to suffer the adverse effects of alcohol due to changes in their ability to metabolize alcohol, particularly those taking multiple medications and those who are at increased risk of adverse events , For nursing home residents, some studies — suggest that it is better to use regular diets for nursing home residents with diabetes.

As the most common fluid and electrolyte disturbance in older adults, dehydration needs to be prevented and managed in people living in long-term care facilities Many interventions can reduce its prevalence , in this population and, notably, diuretics and antihypertensives should be carefully managed after admission to avoid contributing to fluid and electrolyte depletion. For community-dwelling older adults, maintaining a nutrient-dense diet is essential for promoting health and preventing nutrition-related complications Evidence indicates that restrictive diets impose significant risks of sarcopenia and malnutrition in community-dwelling older adults Glycemic management strategies must be adjusted to the individual needs of older patients.

Specific factors regarding certain drug classes are particularly important for older people with diabetes, especially those with CKD and heart disease. Metformin is highly effective, may reduce cardiovascular events and mortality, and does not cause hypoglycemia or weight gain 94 , 95 , , As clinical events that may precipitate acute kidney injury, such as radiocontrast dye, nephrotoxic drugs, hypotension, heart failure, and surgery, may cause metformin accumulation, with a potential risk for lactic acidosis, metformin use is often stopped when patients are hospitalized.

An additional concern is the development of vitamin B12 deficiency, and levels should be monitored yearly — Technical remark: To reduce the risk of hypoglycemia, avoid using sulfonylureas SUs and glinides, and use insulin sparingly. SUs, repaglinide, and nateglinide can cause hypoglycemia and weight gain. Glyburide should be avoided in older individuals because of a substantially increased risk of hypoglycemia compared with that of glimepiride and glipizide , , , Furthermore, these medications are associated with increased fracture rates and bone loss in women , ; thus, use in older women with underlying bone disease, such as osteoporosis, could potentially be problematic.

Dipeptidyl peptidase-4 DPP-4 inhibitors are generally well tolerated. Recently, both empagliflozin and canagliflozin have been shown to decrease major adverse cardiovascular events MACE , heart failure, and the progression of CKD , These compounds cause an obligate increase in urine volume and an increase in urogenital candida infections. Canagliflozin has also been shown to be associated with a decrease in bone mineral density at the hip, but not the femoral neck, lumbar spine, or distal radius , with a significant increase in fractures of arms and legs but not the spine Very rare cases of diabetic ketoacidosis have been reported in patients with T2D taking SGLT2 inhibitors, including patients over the age of 65 years , Glucagon-like peptide 1 GLP-1 receptor agonists increase insulin release, decrease glucagon secretion, delay gastric emptying, suppress appetite, and do not cause hypoglycemia; however, nausea is a common side effect Initial concern about an increased risk for pancreatitis has not been proven , In patients with T2D, insulin therapy is usually initiated when oral agents do not provide sufficient glycemic control Self-monitoring of blood glucose must be performed for insulin to be used safely and effectively.

Initially, a single long-acting insulin analog can be added as basal insulin therapy with dose adjustment to maintain fasting glucose in the desired range 79 , , Recently, insulin glargine U and insulin degludec, which are longer-acting basal insulins compared with insulin glargine U, showed overall similar levels of glycemic control but with less variability and hypoglycemia , If fasting glucose is near goal but the HbA1c remains above goal, rapid-acting insulin can be added first, prior to the largest meal and then prior to other meals, as necessary 79 , , Additionally, premixed insulins neutral protamine hagedorn with regular or analog insulin given twice daily may be a simpler approach , but the lack of flexibility, especially in patients who may skip or delay meals, may increase the risk of hypoglycemia Increasing from one to three or four injections per day means moving from a less complex to a more complex regimen, which may be limiting 79 , , The complexity of the treatment regimen must be balanced against the treatment goals and risks of hypoglycemia.

For patients with arthritis of their hands, the use of insulin pens, or other assistive appliances, can be helpful. Recently, fixed doses of GLP-1 receptor agonists and basal insulin, insulin degludec and liraglutide IDegLira and insulin glargine and lixisenatide LixiLan , have become available in a single syringe, and thus only one injection is needed. A low dosage of the combination is started, and then the dosage is gradually titrated upward. Because T2D slowly worsens over time , increasing dosages and numbers of medications may be needed to control glucose levels.

However, the sequence in which drugs should be added after metformin is not clear. Recent recommendations indicate that GLP-1 receptor agonists and SGLT2 inhibitors be prescribed early, given their beneficial cardiovascular outcomes 24 , In general, the more drugs that are prescribed, the poorer is adherence to a particular regimen Of critical importance is the avoidance of hypoglycemia, which can have devastating outcomes in older patients. Thus, SUs and insulin should be avoided if at all possible. Hypertension is a well-known risk factor for cardiovascular and kidney disease.

Primary Care Physician

The goals of treatment and the specific medications used for treatment may differ between patients with diabetes and those without diabetes, particularly older adults. If lower BP targets are selected, careful monitoring of such patients is needed to avoid orthostatic hypotension. Choosing a BP target involves shared decision-making between the clinician and patient, with full discussion of the benefits and risks of each target. Thus, this level was recommended by the Eighth Joint National Committee evidence-based guideline for the management of high blood pressure in adults This recommendation was based primarily on the SPRINT data; however, the guideline acknowledged the lack of randomized trial data supporting this target in patients with diabetes Thus, treatment approaches and goals are controversial.

Many clinicians may opt for this lower target in patients at high CVD risk after careful discussion of the pros and cons of such increased intensity of treatment with the patient. Importantly, consideration should also be given to a higher BP target if the patient develops symptomatic orthostatic hypotension, and medications that tend to cause orthostatic hypotension should be avoided Additionally, prescribing one or more hypertension medications to be taken at bedtime may have additional CVD benefits Several studies have demonstrated a reduction in the progression of diabetic CKD with the use of angiotensin-converting enzyme ACE inhibitors and angiotensin receptor blockers ARBs in patients with hypertension and advanced CKD — Subsequent head-to-head studies have shown that these two drug classes are essentially equivalent for diabetic CKD Neither drug class has been shown to significantly reduce the risk of stroke — Therefore, ACE inhibitors and ARBs should be the first-line therapy used for the treatment of hypertension in older patients with diabetes and should be included when more than one medication is needed, especially if albuminuria is present Nonetheless, these two drug classes should not be used together, especially in patients with CKD, due to increased risks of hyperkalemia and acute kidney injury The need for more than one drug to treat hypertension is common in patients with T2D The question of the third or fourth drugs to be added after renin-angiotensin system blockers and calcium blockers has not been addressed in either controlled clinical trials or meta-analyses.

If coronary artery disease is significant, a beta-blocker may be appropriate and can be added as a fourth drug to a prior three-drug regimen If a beta-blocker is used, carvedilol has been shown to have fewer metabolic effects than metoprolol Notably, when BP is not controlled with three or more medications, referral to a hypertension specialist is indicated For patients aged 80 years old and older or with short life expectancy, we advocate that LDL-C goal levels should not be so strict.

Related Articles

Epidemiological evidence documents that diabetes is an independent risk factor for CVD in both men and women. Furthermore, in patients with diabetes, all major cardiovascular risk factors, including cigarette smoking, hypertension, and high serum cholesterol — , add to the degree of risk for CVD in older patients with diabetes. Individuals with diabetes have more than twice the risk for CVD than do those who do not have diabetes. Cholesterol-lowering treatment with statins is equally efficacious in reducing RR and more effective in reducing absolute CVD events in older adults than in younger individuals because the older patients have a higher absolute risk for CVD.

Most studies indicate that diabetic dyslipidemia in older adults is undertreated Numerous studies have confirmed the relationship between hypercholesterolemia and CVD, including myocardial infarction and stroke. Similarly, in large RCTs and multiple meta-analyses, statin use has been found to be effective in primary and secondary prevention when using myocardial infarction, revascularization and stroke as endpoints , However, these LDL-C levels are high enough to support the development of atherosclerosis Because LDL-C may be normal but LDL particles may be small , risk stratification should be used to determine the level of LDL-C that should be achieved in older patients with diabetes using statins.

Calculated non-HDL, which reflects all atherogenic particles, adds to the assessment of atherogenicity. Furthermore, risk stratification can be achieved by a number of CVD risk calculators, and, when indicated, coronary artery calcium may enhance risk stratification Apolipoprotein B measurement can be useful in some patients to help refine their LDL treatment goal. A role for LDL-C in hyperglycemic patients became apparent in several early large clinical trials [ e. In contrast to statins, fibrates did not cause a significant reduction in stroke events compared with placebo in clinical trials.

In general, high-dose statin therapy is indicated for all patients with diabetes, irrespective of age, unless specifically contraindicated. Furthermore, although LDL-C levels are not necessarily elevated in patients with diabetes, statins still have a profound effect on the prevention of CVD, and thus all patients with T2D should be treated with statins.

Caveat: Most, but not all, studies support the value of statin use in the prevention of CVD in patients with diabetes. As described in the technical remark, the Writing Committee did not rigorously evaluate the evidence for specific LDL-C targets in older patients with diabetes. Therefore, we refrained from proposing specific LDL-C targets. The reader is referred to numerous guidelines and consensus statements that address this important topic Table 6.

CP Chronic Critical Illness

In statin-intolerant patients, ezetimibe may be administered to inhibit cholesterol absorption from the gastrointestinal tract In this trial, many of the patients were older than 65 years, and the CVD benefit was observed primarily in patients with diabetes , PCSK9 inhibitors have been approved for patients who are unable to reach the LDL goal with the maximally tolerated statin dose, those with clinical CVD on high-dose statins who have not reduced their LDL-C levels to target , , and those with familial hypercholesterolemia.

The use of fibrates, as demonstrated in the Fenofibrate Intervention and Event Lowering in Diabetes FIELD study, resulted in no significant benefit regarding the primary endpoint or mortality, and it is therefore not recommended for CVD prevention in patients with diabetes. There is also evidence that fenofibrate may be valuable in preventing the progression of retinopathy , Aging and diabetes have a profound effect on the cardiovascular system structure and function that increases the risk of CHF.

Aging increases vascular stiffness and reduces elasticity, leading to increased SBP, myocyte hypertrophy, and impaired diastolic function Diabetes increases the risk of CHF due to associated comorbidities such as hypertension and complications such as macrovascular and microvascular disease and also directly affects the myocardium, causing cardiomyopathy — Therefore, the prevalence of CHF in older people with diabetes is high, reaching up to Patients with both diabetes and CHF are at particular risk of adverse events. CHF at baseline was independently associated with cardiovascular mortality HR, 2.

CHF medications act in essentially the same way in those with and without diabetes. Nevertheless, the cardiovascular safety of the various classes of hypoglycemic medications is less well understood. Hyperglycemia increases the risk of CHF and hence should be controlled, although no direct evidence supports a reduction in the risk of CHF by treating hyperglycemia. Despite the common coexistence of diabetes and CHF in older people, optimal management is not fully evidence-based due to a lack of clinical trials in this age group.

For this reason, treatment according to the recently published clinical practice guidelines is recommended Table 6. No associations of SUs, insulin, acarbose, or glinides with CHF or mortality were found — , but one study did suggest a possible link between glinides and heart failure Moreover, rosiglitazone increased the risk of all-cause mortality HR, 1.

A limited meta-analysis of seven RCTs reported that the risk for CHF was less with pioglitazone than with rosiglitazone 1. A more comprehensive meta-analysis of 94 RCTs demonstrated that pioglitazone was associated with reduced all-cause mortality OR, 0. The HR was significant for saxagliptin HR, 1. Notably, the ability of these studies to detect CHF hospitalization risk with certainty may be limited, and further evidence is needed. In advanced CHF, palliative care with a focus on symptom control is effective in improving quality of life as well as reducing hypoglycemic medications in frail older people, as they are often unnecessarily overtreated , The cardiovascular safety profile of the SGLT2 inhibitor dapagliflozin has also recently been studied in a large randomized, placebo-controlled study median duration of 4.

A key result was a lower rate of cardiovascular death or hospitalization for heart failure 4. This appears to confirm a view held that these benefits are likely a class effect In contrast to the effects on the heart, an increase in lower extremity amputations was observed in patients taking canagliflozin in another long-term cardiovascular outcome study CANVAS , and the Food and Drug Administration FDA now requires a boxed warning regarding this effect of this medication Aging and diabetes have a synergistic effect on the structure and function of the vascular system that increases the risk of vascular disease.


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Increased arterial wall thickening and stiffening and reduced compliance occur with aging With diabetes, endothelin vasoconstrictor and procoagulant production increases, and nitric oxide production vasodilator decreases, shifting the balance toward a vasoconstrictor, procoagulant, proliferative, and proinflammatory state that leads to the development of atherosclerosis Contributors to progressive atherosclerosis include hyperglycemia, dyslipidemia, obesity, and hypertension Moreover, diabetes increases the risk of ischemic stroke by twofold, independently of BP, as well as the RR of in-hospital or day stroke-related mortality.

Diabetes substantially increases the risk of peripheral arterial disease and its associated mortality by nearly twofold and increases peripheral arterial disease—related costs and length of hospital stay , According to one recent study, there is little or no increase in risk of mortality, myocardial infarction, or stroke if the following five risk factors are within normal ranges in patients with T2D: HbA1c, LDL, albuminuria, smoking status, and BP Although the available evidence suggests that large reductions in the classic complications of T2D, mainly myocardial infarction, stroke, amputations, and mortality, have occurred during the past 20 years , the burden of atherosclerosis in older patients with diabetes remains substantial, and multifactorial intervention in this age group is essential.

Moreover, the ADA also notes that addressing multiple cardiovascular risk factors at the same time can lead to greater benefits Lifestyle interventions including exercise and weight loss in obese older patients reduce intrahepatic fat content, increase insulin sensitivity, and improve overall metabolic risk factors for atherosclerosis 11 , Clinical trials have shown that in older patients with diabetes, tight glycemic control with HbA1c no lower than 7. Furthermore, metformin treatment is associated with improved cardiovascular outcomes, regression of atherosclerosis, and low risk of lactic acidosis — In a recently completed randomized trial of canagliflozin vs placebo in T2D mean age of Moreover, results from the LEADER trial demonstrated significant cardiovascular benefits from liraglutide in comparison with placebo The thiazolidinedione rosiglitazone was previously shown to increase the risk of myocardial infarction OR, 1.

The FDA has now entirely lifted the risk evaluation and mitigation strategy for rosiglitazone. A meta-analysis of clinical trials of hypertension treatment in T2D showed that cardiovascular outcomes reached a plateau after attaining an SBP of mm Hg.

Abstracts from the 11th International Congress of Behavioral Medicine | SpringerLink

A more recent meta-analysis confirmed the cardiovascular benefits of lowering SBP to mm Hg but demonstrated that further reduction is associated with an increased risk of cardiovascular death, with no stroke reduction benefit All antihypertensive medications can be used in the treatment of hypertension in older people with diabetes, as no difference in mortality was observed with one drug class over the others, and the benefit may be due to the reduction in BP rather than a class effect The benefit of statins in reducing cardiovascular risk is established.

However, the evidence in older people is largely extrapolated from trials in younger populations. Interestingly, the addition of fibrate or niacin to statin therapy has shown no extra cardiovascular benefit , Older patients with diabetes have a high burden of atherosclerosis and are likely to benefit from aspirin therapy after assessment of their bleeding risk , Overall, frail older individuals with diabetes are unnecessarily overtreated, and reducing polypharmacy in this group may improve their quality of life.

The primary prevention of cardiovascular events in older patients with diabetes is challenging because of a general lack of evidence for safe and effective treatment in this age group. Older patients with diabetes have a higher baseline cardiovascular risk and therefore are likely to benefit more from risk reduction than are younger patients without diabetes. However, this group of patients is largely heterogeneous with various levels of functional ability and life expectancy, which should be considered, as the current evidence is not generalizable to patients with poor functional status or multiple comorbidities or those with limited life expectancy.

Aspirin use in secondary prevention of CVD is now well established and has been shown to be effective in reducing cardiovascular morbidity and mortality in patients with a history of CVD The main adverse effect is an increased risk of gastrointestinal bleeding. The excess risk may be as high as 5 per per year in real-world settings The evidence for use of aspirin in primary prevention, however, has been conflicting and unclear.

Currently, the use of aspirin for primary prevention must remain a decision by the clinician on an individualized basis. Responses to standardized questionnaires suggest that vision loss due to diabetic retinopathy may significantly reduce quality of life and that treatment satisfaction may be significantly affected by the severity of macular edema — Retinopathy and neuropathy may affect the ability of a person to safely operate a motor vehicle The duration of diabetes predicts the presence of retinopathy, and control of hyperglycemia profoundly affects the onset and progression of diabetic retinopathy in both T1D and T2D 78 , , — In addition to poor glycemic control, the presence of albuminuria, hypertension, and dyslipidemia predict retinopathy — Furthermore, the observed present-day decline in the prevalence and incidence of retinopathy and vision impairment is thought to be the result of improved management of hyperglycemia, hypertension, and dyslipidemia , Treatment with fenofibrate in trials intended for assessing cardiovascular protection has suggested that this drug may reduce the progression of diabetic retinopathy, but continued treatment beyond the closing of the clinical trials may be required to confer this benefit — , , , There is worldwide interest in developing evidence to support the use of fenofibrate for limiting the progression of diabetic retinopathy, but its safety and efficacy might best be justified by evidence from trials that are designed to examine visual and retinal findings as their primary outcome measures.

Periodic screening is justified for detecting vision-threatening retinopathy at an early stage and for offering measures to reduce its progression Panretinal photocoagulation is the mainstay of treatment of proliferative retinopathy but may produce an exacerbation of diabetic macular edema, a condition that affects a substantial number of older patients — Rather, the risk is associated with duration of diabetes and HbA1c Such data, together with the impact of retinal edema on vision, suggest that a large number of older patients might experience improvements in vision and quality of life from anti-VEGF therapy.

Intravitreal anti-VEGF therapy may be the most effective front-line modality for macular edema and may be an alternative to panretinal photocoagulation in the treatment of proliferative diabetic retinopathy , — Notably, Medicare claims data suggest that diabetic retinopathy may be associated with an increased risk of age-related macular degeneration Open-angle glaucoma and cataracts occur more commonly among persons with diabetes , Moreover, the risk for glaucoma increases with the duration of diabetes and fasting hyperglycemia.

Among older persons with T2D or T1D for 5 years, these additional risks lead us not only to endorse the recommendation of the ADA for an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist but also to suggest screening thereafter at least annually , The prevalence of diabetic neuropathy appears to be increasing and is correlated with increased age, duration of diabetes, higher HbA1c, and lifelong glycemic control — Persons treated with metformin and having neuropathic manifestations should be evaluated because metformin may cause vitamin B12 deficiency.

The heterogeneity of peripheral and autonomic neuropathies in diabetes necessitates consideration of a differential diagnosis, especially if manifestations are lateralized or atypical — Persons with diabetes are at increased risk of falls and hip fracture — Thus, inquiry about falls should occur at least annually Evidence is inconclusive on whether specific glycemic targets or antihyperglycemic treatment regimens promote falls — Thiazolidinediones and SGLT-2 inhibitors might worsen fall-related outcomes by increasing fracture risk , , Furthermore, hypoglycemia may be a risk factor for adverse outcomes of falls 73— Pharmacologic therapy for painful diabetic neuropathy requires caution in older adults, with special concern for polypharmacy, oversedation, and orthostasis , — Neuropathy is associated with increased risk of falls in older individuals with diabetes , , — , and exploratory studies have found associations between diabetic neuropathy and abnormalities in gait, posture, and balance — Physical therapy interventions for those with functional deficits may reduce risk factors for falls and possibly the actual rate of falls and fractures — Referrals might specify imbalance, unsteadiness on feet, abnormality in gait, foot drop, history of falling, neuropathic foot ulcer, lack of coordination, or other functional deficits or consequences traceable to neuropathy.

Lower extremity amputation for nontraumatic indications is performed relatively infrequently but with higher incidence among individuals with diabetes, and individuals in some populations and geographic areas are at disproportionate risk for this situation — Evidence possibly linking amputation to canagliflozin therapy is preliminary Variably reported individual patient risk factors for lower extremity amputation may include peripheral sensory neuropathy, autonomic neuropathy, gait abnormalities, peripheral vascular disease, foot ulcer, history of previous amputation, certain foot deformities, greater body mass, chronic renal failure, poor vision, older age, and higher HbA1c — Foot ulcer increases amputation risk and utilization of medical care — However, further research is necessary to confirm trends in amputation rates and to establish whether a program of comprehensive foot care or specific management strategies for established foot complications may reduce the risk for amputation among older persons with diabetes , , — We endorse the standard of care concerning foot care as expressed by the ADA, which recommends patient self-care education, specifies the content and frequency of periodic comprehensive foot evaluations, recommends a multidisciplinary approach for foot ulcers and high-risk feet, and presents indications for referral for further vascular assessment, ongoing preventive care, and lifelong surveillance by foot care specialists Examiners should identify any history of foot ulcer, poorly fitted footwear, loss of protective sensation, vascular insufficiency, foot deformity, or preulcerative lesion.

For patients with altered gait due to neuropathy, local foot deformity, or unhealed ulcers, exercise programs may need to focus on non—weight-bearing activities Furthermore, specialty care may be required to determine the appropriateness of off-loading devices, monitoring of foot skin temperature, use of therapeutic footwear, and need for vascular or podiatric surgical interventions , , Lower extremity amputation is associated with reduced survival and a reduction in physical health-related quality of life, as well as delayed recovery and impaired return to baseline function among nursing home residents 1 , , The risk factor of vascular insufficiency must be considered among persons with diabetic foot ulcers , The goals of lower extremity revascularization in older patients include maintenance of functional capacity and independent living status.

Observational studies suggested similar limb salvage rates but less short-term mortality and morbidity after endovascular surgical revascularization , Notably, the decline in GFR reduces the clearance of insulin and many diabetes medications and increases the risk of hypoglycemia , The general recommendation for annual measurement of urinary albumin-to-creatinine ratio and eGFR should also be carried out in older adults However, progressive loss of GFR can occur in the absence of albuminuria In patients with an estimated limited lifespan who have normal urinary albumin excretion, the prognostic value of annual measurement of urinary albumin excretion over and above indicating an increased risk of CVD is likely minimal Table 7.

TE vs KP Part 1

Reduced kidney function results in a prolongation of insulin half-life and a decrease in insulin requirements All insulin preparations can be used in patients with CKD, and no specific reductions in dosing are necessary for patients. Postprandial rapid-acting insulin with a dose adjustment for the amount eaten may help patients with varying food intakes. SUs and their metabolites are renally cleared, leading to an increased risk of hypoglycemia as GFR declines.

Pioglitazone and rosiglitazone are hepatically metabolized and can be used in CKD without dosage adjustment , However, fluid retention limits their use in CKD, and they are associated with increased fracture rates and bone loss Thus, use in patients with underlying bone disease such as renal osteodystrophy or osteoporosis could potentially be problematic. The DPP-4 inhibitors sitagliptin, saxagliptin, and alogliptin undergo some renal clearance and require dosage adjustment in patients with reduced eGFR see Table 7.

Only a small amount of linagliptin is cleared renally, and no dosage adjustment is indicated with a reduced GFR In general, these drugs are very well tolerated. Interestingly, empagliflozin and canagliflozin have been shown to delay the progression of CKD , The clearance of exenatide decreases as the GFR declines Nausea is a common side effect of these drugs and could potentially be problematic in older patients with compromised intake, especially those with progressing CKD. Neither bromocriptine dopamine receptor agonist nor colesevelam bile acid sequestrant has been studied in patients with advanced CKD.

Although it is clear that life expectancy for patients with T1D is improving , the number of people reaching 60 years and older is unknown. There appears to be two reasons for the increasing number of older adults with T1D. First, those diagnosed with childhood T1D have taken advantage of the improved therapies for glycemic management and nonglycemic measures for the prevention and treatment of long-term complications.

Second, for reasons that are unclear, the number of cases of adult-onset T1D has increased. This phenomenon provides opportunities for the study of a population that numerically was not common in the past. In general, near normal glycemic targets are reserved for individuals with shorter durations of diabetes prior to the development of microvascular or macrovascular complications.

Furthermore, the aggressiveness of glucose control needs to be balanced against the risks of hypoglycemia, which is generally a more dangerous side effect of insulin therapy in an older population. Certain cognitive test scores were worse in these individuals than in a control group matched for age and duration of T1D. Routine self-care of T1D requires sufficient cognitive capabilities due to the complexity of disease management.

One report noted that in a group of patients with T1D mean age and duration of diabetes 60 and 38 years, respectively over a 4-year period, the decline in cognitive function was no different from that in an aged-matched control group However, patients with a history of severe hypoglycemia or CVD were more susceptible to cognitive decline than were the control patients. Cognitive decline in older adults with T1D often requires simplification of insulin regimens e. The typical reduced physical function of older adults may be exacerbated by T1D.

Neuropathy, visual impairment, and hypoglycemia unawareness may make driving an impossible task. In addition to these complications, arthritis, chronic pain, and other conditions are frequently observed in this population diabetic cheiroarthropathy , presenting barriers to independent living.

As functionality becomes more limited, the role of the caregiver becomes more critical. Even fewer data are available to guide clinicians for these common clinical problems. The presence of diabetic kidney disease generally results in lower BP targets, although the specific goals are controversial BP targets with or without kidney disease have not been studied in older adults with T1D.

Likewise, RCTs for the treatment of hypercholesterolemia have not been studied in patients with T1D, let alone in older patients with T1D. Because the duration of diabetes seems to be a risk factor for CVD, which is also the leading cause of mortality , it seems appropriate that most older adults with T1D should be treated similarly to those with T2D.

Nevertheless, clinicians should evaluate each patient individually, especially those who are nonobese and diagnosed later in life where less aggressive treatment may be warranted.

PHARMACOGENETICS AND PHARMACOGENOMICS

Moreover, older patients with diabetes display various comorbid illnesses and functional impairments Older patients with diabetes mellitus are frequently admitted to the hospital for non-diabetes—related problems such as cardiovascular and respiratory disorders and digestive, genitourinary, and infectious problems , Patients with diabetes may be admitted to general medical-surgical floors, straight to the intensive care unit, or to the operating room Frequently, hospitalized patients go from one condition or treatment to another in a very short time.

Various specialists and teams may be involved in the treatment process, complicating communication and ordering processes. Technical remark: An explicit discharge plan should be developed to re-establish long-term glycemic treatment targets and glucose-lowering medications as the patient transitions to posthospital care.

Glycemic targets for inpatient management of diabetes in older adults are established based on general guidelines while avoiding hypoglycemia Best practice requires concrete strategies for transitions of care within the hospital and upon discharge — The most common cause of glycemic variability in hospitalized patients with diabetes is a mismatch between caloric intake and insulin coverage.

Alimentary intake is frequently a problem for hospitalized patients and LTCF residents because of impaired appetite or inability to swallow or hold food down. Instead of a balanced meal, they might consume only fluids, frequently fruit juices, shakes, or dietary supplements that contain high concentrations of sugar and produce glycemic spikes. Using sliding scale regular insulin may lead to hypoglycemia and wide oscillations in blood glucose levels , Patients on enteral or parenteral nutrition and insulin develop hypoglycemia when feeding is stopped abruptly for various reasons Thus, safety measures must be in place at every institution.

Aiming at glycemia targets below this range is dangerous. Point-of-care glucose monitoring is helpful only when it is performed frequently and when a knowledgeable person reviews the data and makes appropriate adjustments , — Most hospitalized patients with diabetes are treated with insulin Most missteps in diabetes management occur not at the selection of the initial doses of insulin but because of poor follow-up and lack of appropriate and timely adjustments.

Whereas glycemia of critically ill patients is usually managed in the intensive care unit with IV insulin administration, most noncritically ill patients are treated with basal-bolus regimens. Hypoglycemia increases length of hospital stay and mortality — The presence of renal failure, poor nutrition, and sepsis is highly predictive of a high risk of hypoglycemia in older individuals.

Although a causal relationship between hypoglycemia and mortality has not been established, a strong association between hypoglycemia and more severe illness is likely , , An RCT comparing treatment with oral agents and basal insulin in older patients with T2D in LTCFs demonstrated that treatment within both arms resulted in a similar frequency of hypoglycemia , suggesting that a low daily dose of basal insulin is sufficient to achieve reasonable and safe glycemia in older patients.

Clearly, patients with T1D in institutional settings should never be left without insulin. Patients with late-stage cancer, organ failure, or pre—solid organ or post—solid organ or bone marrow transplant, patients on dialysis, and those in the intensive care unit present unique challenges.

Higher glycemic targets may be acceptable in patients with severe comorbidities and in terminally ill individuals. A simplified management approach is fully justified in these patients. Although measurements of HbA1c have earned their recognition in the diagnosis of diabetes mellitus and in the process of monitoring glycemic control in patients with diabetes , they can also help to assess the chronicity of hyperglycemia in patients admitted to the hospital who do not have a previous diagnosis of diabetes Admission HbA1c levels have been shown to correlate with greater morbidity and mortality in patients with acute myocardial infarction , , heart failure , and poor functional outcome after acute ischemic stroke The exact mechanism of these associations is not well understood, but one may surmise that chronic hyperglycemia has an adverse influence on the cardiovascular system in patients with undiagnosed diabetes or prediabetes.

Transition of care from hospital to home or to an LTCF rightfully represents a critical element in the treatment of older patients with diabetes. The most important aspect of successful transition is effective, detailed, and thorough bidirectional communication between the discharging and receiving teams of health care providers. Older patients newly diagnosed with diabetes during their hospital stay may present additional obstacles during transitions of care. These patients deal with the shock of a new chronic disease and may not have a clear ability to understand and integrate complicated medical regimens, changes in lifestyle, home glucose monitoring, and other challenges of diabetes.

The Writing Committee consisted of 10 content experts representing the following specialties: endocrinology, neurology, and geriatrics. Two of the committee members brought an international perspective to this guideline topic. This is in conformity with researched shows that a different component which have different mode of work of [1, 18, 11]. Toothpastes TP, TP, TP, action against microbes and that the type of toothpastes used TP and TP had more inhibitory effect on the bacterial determines the extent of microbial growth inhibition [23, 25].

The effect of the toothpastes was observed to toothpaste compared to the initial microbial count before produce inhibition on the microbial load as there were decrease treatment. This suggests that low concentration is required to 5. Conclusion effect inhibitory action against fungal and higher concentration In conclusion, within the limit of the research carried out is required for antibacterial activities.

This finding agreed with shows that there are lots of bacteria and other microorganism [1, 18, 11]. Streptococcus mutans, the range of decrease of living in our mouth. These bacteria attack the food left over that micro flora was 1. Some types of TP, TP and TP respectively when compared to the toothpaste contain ingredient in it like fluoride, which helps in original counts before treatments which was 2.

Another Formed in Situ and on Enamel Demineralization. Caries ingredient in tooth paste that help in fighting bacteria is Research 40 1 : Triclosan, an antibacterial agent. In view of the research work [12] Corbet EF Diagnosis of acute periodontal lesions. It is [14] Harshal TP Dental Caries: Risk Assessment and should be carried out to determine the safety of the toothpastes Treatment Solutions for an Elderly Population. Compendium of before use in human. Continuing Education in Dentistry. Essential References Microbiology for Dentistry, 2nd ed. Prevalence Livingstone. African Journal of Microbiology Hanada N Isolation of Opportunistic Pathogens in Dental Research.

Plaque, Saliva and Tonsil Sample from Elderly. Japanese Journal of Infectious Diseases. Journal of Dental Research. Biofilms, a New Approach to the Microbiology of Dental Plaque. Journal of Bacteriology. Bacterial Diversity in Human Subgingival P Antimicrobial Agents Chemotherapy. E, Imarenezor E.

Effect of mouthwashes on oral microflora. Continental Journal of Medical Research 3: 1—6. Clinical North Am. Trends in Microbiology. Exposure to fluoride of 5 : Ciencia and Satide Coletiva. Bacterial Morphology and — Staining, In: H. Prescott, Ed. Furgang D Whole mouth wash antimicrobial effect after oral hygiene: comparison of three dentifrice formulation. Consistency of plaque Journal of clinical periodontal.

Journal Periodontal Res. Effect of Sucrose Concentration on Dental Biofilm trial. He is also a creative element and musician in various Kosmische and Post-Punk bands in Melbourne. If you're an artist, or interested in the arts, I recommend you take a look at this site The square is relatively empty considering the time, and the fountain is off. It is quite a still evening. Scooters and sparse shouts echo off the almost unbroken line of building facades, and it is possible to hear the approximate dimensions of the space.

While none of the of the surfaces around the square are in any way absorbent, the comparative size of the two main axes especially facing the Basilica coupled with the completely open area above means that the reverberations do not become too oppressive, but are ever-present. As an experiment I recorded the space and then listened to the recording after noting my initial impressions.

What it is most obvious is the lack of selective focus that our ears and brains have naturally it is surmised that losing this ability is a primary reason for being 'hard of hearing' in older people, rather than an actual loss in the ability to hear sound in general. Without the recording I would have described the space as being relatively quiet, however as you can hear there is pretty much constant 'noise'.

What is also noticeable in the recording is the way all these sounds are effective in describing the space - the impulses arriving at the microphones are noticeably altered by the surfaces and geometry of and in the square. Warm tones. There a a few people near me where the fountain is at the south-west end of the square, their speech is more distinct and loud - individual voices can be made out. It is an interesting counterpoint to the muted roar of indistinguishable chatter of which no cadence of timbre can be made out, only that of its entirety - a real 'rhubarb rhubarb effect.

The fountain is on, adding the characteristic tinkle and splash to the predominantly human ambiance present in the square. The soft warm sound of flowing, bubbling water from the fountain pervades the mid-range frequencies. Underneath is the ever-present yet always changing low road of traffic bleeding in from the Passage de Colon. A taxi driving up the one-lane road down the north-west side of the square dominates the spectrum, surprisingly loud against the background.

Its doors slam as people disembark to my left, punctuating the ambiance even more than its progress did. Even just a few steps away from the fountain towards the Basilica the tonal qualities of the fountain change. A previously masked droning sound comes to the fore - it too - like the traffic and the fountain is constantly in flux, always changing, always the same.

Not a particularly large amount of variation, but present nonetheless. I decide it is a vacuum cleaner, though due to the constant nature of the sound and the qualities of the space working out exactly where it is coming from is almost impossible. Sometimes a follow-up question will be about what my favoured sound is. I don't have a specialty, but I think I could say with some degree of certainty that I find recording water to be quite rewarding.