Interview with Dr. Medha Munshi on the Changing Landscape of Diabetes Care
Medha N. Munshi, MD, a geriatrician and endocrinologist at Beth Israel Deaconess Medical Center, has dedicated her career to improving care for older adults. In 2001, she founded the Geriatric Diabetes Program at Joslin Diabetes Center, where she provides patient consultations and leads clinical research aimed at addressing the unique challenges faced by older adults with diabetes, developing strategies to improve their outcomes.
In a recent NEJM Evidence editorial, Munshi and co-author Elena Toschi, MD, Director of the Young Adult Program at Joslin, discuss research showing how new digital technologies can effectively support specific sub-populations of older adults with diabetes and should be integrated into their care.
We spoke with Dr. Munshi about her more than 20 years of experience in geriatric diabetes care and how digital tools are reshaping the landscape.
Question: How did you come to be the one who established the geriatric diabetes clinic at Joslin?
Munshi: When I started up the clinic in 2001, there was no such specialty as geriatric diabetes. I had finished my endocrine fellowship and then, when I started seeing patients in the geriatric clinic, everybody started sending me their patients with diabetes because they knew I was an endocrinologist.
I knew we needed a different approach to our older patients with diabetes. We needed to educate them differently than the way we educate younger people.
Q: Launching the Geriatric Diabetes Clinic obviously filled a niche that needed filling. Was this population being neglected or was there an increase in seniors with diabetes?
A: The Baby Boomers are aging and now we know that yes, a 60-year-old, a 70-year-old, an 80-year-old can be a very healthy, highly functional individual. But there are also people of the same age who are starting to have more difficulty, and we need to start thinking about them. So, I think it was the overall ageing of the population that demanded that we think differently about them.
Q: What is different about caring for older people with diabetes than caring for younger people?
A: In younger people, the goal of managing diabetes is to decrease the risk of complications down the road. In older people, it is not about that. It is about maintaining the the quality of life, the functionality you have today. The goals change, the patients' reason for caring for their diabetes, their why, changes over the course of the lifespan.
In addition, for older people, diabetes may not be the diagnosis that they are most worried about. It's a competing comorbidity, and their ability to manage their diabetes can get affected by their other concerns.
Q: How does caring for older adults with diabetes overlap with caring for younger people with the condition?
A: For both populations, just doing diabetes care without thinking about the patient's overall environment is not going to work. As their physician, you need to know what their support system is. You need to know what else is going on at home. Children usually have at least one parent, but a lot of my patients have no one, so how do you take care of those people?
When we launched the geriatric diabetes program, there were no guidelines for caring for this population. I started tabulating the clinical characteristics in the patients I was seeing. What is the cognitive function in those over 70? Do they have depression? That's how my first publication came to be. Eventually, over ten years, our first consensus guideline for the management of diabetes in older adults came out in 2012.
Q: And it's right around then that continuous glucose monitors (CGM) became more widely accessible and more user-friendly. How did this affect your practice?
A: (laughs) People would bring their pumps into me at the Joslin clinic and I would say, "You know, I am a geriatrician, technology is not what we do, you are in the wrong clinic."
But even as continuous glucose monitoring became more user friendly, they were still very hard for my patients to use. We started studying whether this new technology could benefit this aging population and whether they could adapt to use this technology.
Nobody likes it, but younger people have that cognitive plasticity to adapt to new technologies a bit faster. As people get older, it gets harder and harder, so the strategies need to change.
Q: How do the newer technologies assist with caring for older people with diabetes?
A: The current CGMs are very easy to use, and they give so much information. It's really a phenomenal feedback tool to motivate patients to improve their behaviors. They see, "If I go out and exercise, my blood sugars are better." That's more encouraging than anybody telling them to do it.
For the clinicians, the CGM gives the whole pattern. For example, instead of having data points which simply tell me there are a few highs, a few lows, I can see that overnight, the numbers are fine, but during the daytime they are high. So, I need to decrease the medicines that work overnight and increase the medicine that work during the daytime. It's truly precision medicine.
My point in the editorial was that, for more complex technologies such as automated insulin delivery systems (AID), there are data showing we do have a lot of older patients who can manage this technology, who like using it. But a lot of physicians who are managing them would say that they don't think their patients can do all that fancy footwork.
For those patients who are cognitively impaired, who may live alone or with an overwhelmed caregiver, we can simply change our strategy to avoid excessive burden to patients or caregivers. For example, there are different types of continuous glucose monitors; there are professional CGM which are simply a patch that measures glucose every five minutes for two weeks without the patient having to even be aware of it. Clinicians can look at the pattern and make therapeutic decisions based on CGM data.
On the other hand, insulin delivery systems such as insulin pumps or AIDs are a little bit harder because they still require a significant amount of input from the patient and require problem-solving capacity. In addition, there are tubes and there are insertions, so we are not quite there yet with a fully automated insulin delivery system. But I'm sure the technology will get there eventually.
Q: What advice would you give your fellow physicians who may have older adults with diabetes in their care?
A: Don't be afraid of technology. If you use the right technology for the right patient, it can make diabetes management safer and more effective, and we can decrease the burden to the level the patient can tolerate.
Q: What would you want your patient population and or their family caregivers to know?
A: I think we can reassure them that as technology evolves, we can work together to make it more usable and decrease the anxiety and stress and burden of managing their diabetes.
I think we do need to do some more work, especially for patients with type 1 diabetes, but, as I said, using the right technology for the right patient can make all the difference.
