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Blood Glucose Cutoffs (ADA Diagnostic Criteria)

• A random plasma glucose ≥ 200 mg/dL diagnoses diabetes only when classical symptoms are present (polyuria, polydipsia, weight loss).
• All abnormal results should be confirmed with repeat testing, except when unequivocal hyperglycemia with symptoms is present.

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HbA1c Targets in the Elderly (ADA 2026 Standards)

• Hypoglycemia avoidance is the top priority in all elderly patients - it can worsen cognitive impairment and CVD.
• A highly functional 80-year-old may have the same HbA1c target (<7.0-7.5%) as a younger adult.
• Patients in long-term care/skilled nursing with cognitive impairment: HbA1c < 8.0-8.5% is reasonable.
• For those on CGM: Time in Range (TIR) 70-180 mg/dL ≥70%, time below range <70 mg/dL ≤4% for healthy elderly.

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• Normal FBS: <100 | Prediabetes: 100-125 | DM: ≥126
• Normal PPBS: <140 | Prediabetes: 140-199 | DM: ≥200
• HbA1c in healthy elderly: <7-7.5% | frail/complex: <8% | end-stage: symptom-based only

• PPBS and RBS are similarly upper-bound cutoffs (not a bilateral range in the same sense), since the lower limits are not clinically defined as diagnostic thresholds for these tests.
• For RBS, the 140 mg/dL figure represents the upper limit at which glucose is generally expected to return 2 hours after a meal in a non-diabetic individual.

When to Start Insulin in Diabetes

1. Absolute / Urgent Indications (Start Immediately)

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2. Failure of Oral Antidiabetic Agents (Most Common Reason in T2DM)

• HbA1c remains above target despite maximal doses of 2-3 oral agents + lifestyle changes
• Generally when HbA1c > 8-9% on optimised oral therapy
• Progressive beta-cell failure over time makes this inevitable in most T2DM patients

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3. Contraindications to Oral Agents

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4. Special Situations

• Newly diagnosed T2DM with very high HbA1c (>10-12%): Short course of intensive insulin to reduce glucotoxicity and induce beta-cell rest, then may step down to oral agents
• Steroid-induced diabetes: If FPG > 200 mg/dL, oral agents are usually insufficient - insulin required
• Pancreatic diabetes (post-pancreatectomy, chronic pancreatitis): Insulin is the treatment of choice

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Starting Regimen in T2DM (if initiating)

• Basal insulin first (e.g., glargine or detemir 10 units at bedtime, or 0.1-0.2 units/kg/day)
• Titrate by 2 units every 3 days targeting FBS 80-130 mg/dL
• Add prandial insulin if postprandial targets still not met (basal-plus or basal-bolus)

Basal-Bolus Insulin Calculation

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Step 1 - Calculate Total Daily Dose (TDD)

TDD = Weight (kg) × 0.7 units

• For Type 1 DM: 0.4-1.0 units/kg/day
• For Type 2 DM (insulin naive): start conservatively at 0.5-0.7 units/kg/day

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Step 2 - Split into Basal and Bolus

• Basal (e.g. Glargine/Detemir): ~25 units at bedtime or same time daily
• Total bolus: ~25 units divided across meals

Note: Some patients need a 40% basal / 60% bolus split. Adjust based on monitoring.

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Step 3 - Divide Bolus Across Meals

Per meal bolus = 0.1 units/kg/meal

ICR = 500 ÷ TDD (1 unit covers this many grams of carbohydrate)

• If meal has 60 g carbs → bolus = 60 ÷ 10 = 6 units

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Step 4 - Correction / Sensitivity Factor (ISF)

ISF tells you: how many mg/dL 1 unit of insulin will lower glucose

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Step 5 - Total Pre-Meal Dose

Total mealtime dose = Carb coverage dose + Correction dose

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Step 6 - Titration

• Basal titration: Increase by 1-2 units every 3 days until FBS < 100 mg/dL
• Bolus titration: Adjust by 10-20% if post-meal glucose consistently out of range
• Inject rapid-acting insulin 15 minutes before meals (unless pre-meal BG < 80 mg/dL, then inject at meal start)

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Quick Summary Box

TDD = Weight × 0.7
Basal = 50% TDD (once daily)
Bolus per meal = 50% TDD ÷ 3 meals
ICR = 500 ÷ TDD (grams carb per unit)
ISF = 1500 ÷ TDD (mg/dL drop per unit)
Correction = (Current BG - Target BG) ÷ ISF

Definition of Dementia

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Classic / Clinical Definition

Dementia is a decline in memory or other cognitive abilities from a previously higher level of function, leading to impaired activities of daily living (ADL).

• Acquired - decline from a previously higher baseline (not congenital)
• Cognitive - involves memory and/or other domains (language, executive function, visuospatial, attention, praxis)
• Functional - must impair daily life activities
• Consciousness is clear - dementia occurs in a clear sensorium (distinguishes it from delirium)
• Typically gradually progressive over months to years, though can be acute (e.g., after head injury)

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DSM-5 Terminology: "Major Neurocognitive Disorder"

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Cognitive Domains Affected (≥1 required)

1. Memory (learning and recall)
2. Language (aphasia)
3. Executive function (planning, abstraction)
4. Visuospatial/perceptual ability
5. Attention/concentration
6. Social cognition (behaviour, personality)

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Important Distinctions

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Types by Pattern

• Cortical dementia - prominent language, praxis, visuospatial disturbance (e.g., Alzheimer's)
• Subcortical dementia - slowing, executive dysfunction, motor features, memory retrieval problems (e.g., Huntington's, PSP)
• Primary dementia - neurodegenerative, usually irreversible (Alzheimer's, Lewy body, FTD)
• Secondary dementia - due to a treatable underlying cause (hypothyroidism, hydrocephalus, B12 deficiency, syphilis) - potentially reversible

Atrial Fibrillation - Treatment

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PILLAR 1 - Anticoagulation (Stroke Prevention)

CHA₂DS₂-VASc Score first

• Score ≥2 (men) or ≥3 (women) → anticoagulate
• Score 1 (men) or 2 (women) → consider anticoagulation
• Score 0 (men) or 1 (women) → no anticoagulation needed

Drug Choice

DOACs show equal or better stroke prevention with less bleeding vs warfarin, including in patients ≥75 years.

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PILLAR 2 - Rate Control

Rate targets

• Strict: HR < 80 bpm at rest
• Lenient (acceptable): HR < 110 bpm - comparable outcomes per RACE II trial, especially in older adults without symptoms/HF/CHD

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PILLAR 3 - Rhythm Control

• Symptomatic despite rate control
• First episode or new-onset AF
• AF-induced tachycardiomyopathy
• Younger patients (early rhythm control strategy - EAST-AFNET 4 trial)
• Heart failure with reduced EF

A. Cardioversion

Anticoagulate for ≥3 weeks before and ≥4 weeks after cardioversion (or use TEE to exclude LAA thrombus first).

B. Antiarrhythmic Drugs (AADs) for Maintenance of Sinus Rhythm

C. Catheter Ablation (Pulmonary Vein Isolation - PVI)

• First-line option for rhythm control in select patients (2023 ACC/AHA/HRS guidelines)
• Especially effective in paroxysmal AF, AF + HF, young symptomatic patients
• Reduces AF recurrence, improves QOL, and in HF patients may reduce mortality
• Patients treated with ablation have long-term rates of death, stroke, and dementia similar to non-AF patients

D. AV Node Ablation + Pacemaker

• Class IIa when all pharmacological therapy fails
• Creates deliberate complete heart block; pacemaker required

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PILLAR 4 - Risk Factor & Lifestyle Modification (2024 ESC "C-A-R" Framework)

• Obesity - weight loss reduces AF burden
• Hypertension - control BP aggressively
• Sleep apnea - treat OSA (reduces AF recurrence)
• Alcohol - reduce/stop
• Exercise - moderate regular exercise
• SGLT2 inhibitors - recommended in AF + HF regardless of EF (2024 ESC)
• Thyrotoxicosis - identify and treat reversible causes

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Special Situations