Supporting the 'lived expertise' of older adults with type 1 diabetes: An applied focus group analysis to characterize barriers, facilitators, and strategies for self-management in a growing and understudied population.

INTRODUCTION: There is a growing number of older adults (≥65 years) who live with type 1 diabetes. We qualitatively explored experiences and perspectives regarding type 1 diabetes self-management and treatment decisions among older adults, focusing on adopting care advances such as continuous glucose monitoring (CGM). METHODS: Among a clinic-based sample of older adults ≥65 years with type 1 diabetes, we conducted a series of literature and expert informed focus groups with structured discussion activities. Groups were transcribed followed by inductive coding, theme identification, and inference verification. Medical records and surveys added clinical information. RESULTS: Twenty nine older adults (age 73.4 ± 4.5 years; 86% CGM users) and four caregivers (age 73.3 ± 2.9 years) participated. Participants were 58% female and 82% non-Hispanic White. Analysis revealed themes related to attitudes, behaviours, and experiences, as well as interpersonal and contextual factors that shape self-management and outcomes. These factors and their interactions drive variability in diabetes outcomes and optimal treatment strategies between individuals as well as within individuals over time (i.e. with ageing). Participants proposed strategies to address these factors: regular, holistic needs assessments to match people with effective self-care approaches and adapt them over the lifespan; longitudinal support (e.g., education, tactical help, sharing and validating experiences); tailored education and skills training; and leveraging of caregivers, family, and peers as resources. CONCLUSIONS: Our study of what influences self-management decisions and technology adoption among older adults with type 1 diabetes underscores the importance of ongoing assessments to address dynamic age-specific needs, as well as individualized multi-faceted support that integrates peers and caregivers.

"Nothing is linear": Characterizing the determinants and dynamics of CGM use in older adults with type 1 diabetes.

AIMS: Continuous glucose monitoring (CGM) can reduce hypoglycemia in older adults with type 1 diabetes (T1D). We aimed to characterize factors that influence effective use in this age group. METHODS: Older adults with type T1D (age ≥ 65) and their caregivers participated in one of a series of parallel group model building workshops, a participatory approach to system dynamics involving drawing and scripted group activities. Data were synthesized in a qualitative model of the hypothesized system of factors producing distinct patterns of CGM use in older adults. The model was validated through virtual follow-up interviews. RESULTS: Data were collected from 33 participants (four patient-caregiver dyads, mean age 73.8 ± 4.4 years [range 66-85 years]; 16 % non-CGM users, 79 % pump users). The system model delineates drivers of CGM uptake, drivers of ongoing CGM use, and feedback loops that either reinforce or counteract future CGM use. Participants emphasized the importance of different sets of feedback loops at different points in the duration of CGM use. CONCLUSIONS: The holistic system model underscores that factors and feedback loops driving effective CGM use in older adults are both individualized and dynamic (e.g., changing over time), suggesting opportunities for staged and tailored age-specific education and support.

Non-islet cell tumor hypoglycemia in a patient with uterine carcinosarcoma.

•Non-islet cell tumor hypoglycemia (NICTH) is a rare cause of hypoglycemia in patients with uterine carcinosarcoma.•Complete surgical resection is the first-line treatment for NICTH.•In patients with tumors not amenable to complete resection, partial resection can provide improvement in severe hypoglycemia.

Acute ST-elevation myocardial infarction in two young women with cystic fibrosis and cystic fibrosis-related diabetes.

Ischemic heart disease is rarely reported in people with cystic fibrosis (PwCF) despite multiple potential risk factors. Here we report two cases of ST elevation myocardial infarction (STEMI), both in young women with cystic fibrosis (CF) and cystic fibrosis related diabetes (CFRD). These cases illustrate the importance of considering myocardial injury/infarction in the differential diagnosis of patients with CF and chest pain or shortness of breath, and addressing the growing risk of cardiovascular disease (CVD).

Efficacy and Safety of Direct Oral Anticoagulants Compared to Warfarin in Prevention of Thromboembolic Events Among Elderly Patients with Atrial Fibrillation.

Direct oral anticoagulants (DOACs), previously also known as novel oral anticoagulants (NOACs), have increased the therapeutic options for stroke prevention in atrial fibrillation (AF). Previous studies comparing their relative efficacy and safety do not address age-related differences, such as comorbidities and physical and social boundaries. This review aimed to summarize and compare the clinical and safety outcomes of DOACs and warfarin for stroke prevention in AF in the elderly population (≥ 65 years). We searched PubMed for randomized controlled trials and meta-analyses that compared DOACs and warfarin in elderly patients with AF. Stroke and systemic embolism (SSE) and major bleeding (MB) were primary outcomes. Secondary outcomes included ischemic stroke, all-cause mortality, intracranial bleeding, and gastrointestinal bleeding. Of 66 studies identified, one randomized control trial (RCT) and one meta-analysis were included. DOACs were at least as effective at reducing the risk of SSE as warfarin. DOACs demonstrated a minimal benefit for ischemic stroke (dabigatran, 110 mg, relative risk (RR) 1.08; edoxaban, 60 mg, RR 1.00; and apixaban, 5 mg, RR 0.99). DOACs associated with decreased risk of MB relative to warfarin include dabigatran, 110 mg; apixaban, 5 mg; and edoxaban, 60 mg (RR 0.80, 0.70, and 0.80, respectively), while dabigatran, 150 mg, and rivaroxaban, 20 mg, increased risk (RR 0.79 - 0.83, respectively). Dabigatran, 110 mg and 150 mg doses, and edoxaban increased the risk of gastrointestinal bleeding (RR 1.04, 1.12, and 1.23, respectively). Lower rates of SSE and intracranial bleeding were seen with DOACs compared to warfarin. Dabigatran, 150 mg, and rivaroxaban, 20 mg, were associated with higher MB in older elderly compared to warfarin. DOACs may be attractive alternatives to warfarin, but further studies are needed to make clinical recommendations.