1
|
Wondimkun YA, Caughey GE, Inacio MC, Air T, Lang C, Sluggett JK. Glucose-lowering medicines use before and after entry into long-term care facilities. Diabetes Obes Metab 2024; 26:4966-4975. [PMID: 39223861 DOI: 10.1111/dom.15905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/09/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
AIM To examine changes in the use of glucose-lowering medicine (GLM) 12 months before and 12 months after long-term care facility (LTCF) entry among people with diabetes. MATERIALS AND METHODS A national retrospective cohort study was conducted using linked health and aged care data from the Registry of Senior Australians National Historical Cohort. Residents of LTCFs with diabetes aged 65 years or older from 2015 to 2019 were included. Prevalence of GLM use and the number of defined daily doses (DDDs) dispensed per 1000 resident-days were estimated quarterly (91-day) using Poisson regression models, or negative binomial regression when overdispersion was present. RESULTS Among the 50 993 residents studied (median age 84 years), the prevalence of GLM use was 58.4% (95% confidence interval [CI] 58.0%-58.8%) in the 9-12 months pre-LTCF entry and 56.3% (95% CI 55.9%-56.8%) in the 9-12 months post-entry. The number of DDDs/1000 resident-days increased from 1015.2 (95% CI 1002.3-1028.1) to 1253.8 (95% CI 1168.4-1339.3) during the same period. GLM use in the 3 months pre-entry was 56.8% (95% CI 56.4%-57.2%) compared with 61.7% (95% CI 61.3%-62.1%) in the 3 months post-entry, with the increased use driven mainly by insulin. No marked changes in the number of GLMs dispensed or GLM type were observed at 9-12 months post-entry compared with 3 months pre-entry. Among 22 792 individuals dispensed a GLM in the 3 months prior to LTCF entry, 50.2% continued the same GLM at 9-12 months post-entry. CONCLUSIONS GLM use peaked in the first 3 months following LTCF entry, driven mainly by insulin, hence, residents may benefit from close monitoring of diabetes treatment during this period.
Collapse
Affiliation(s)
- Yohanes A Wondimkun
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Hawassa University, College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Gillian E Caughey
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Maria C Inacio
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Tracy Air
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Catherine Lang
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Janet K Sluggett
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| |
Collapse
|
2
|
Krecic MR, Meyer J, Chavanu KJ. Paucity of Published Data and Protocols for Hypoglycemia Management in Long-term Care. Sr Care Pharm 2024; 39:373-381. [PMID: 39358878 DOI: 10.4140/tcp.n.2024.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
Background: Older people with diabetes are at high risk for hypoglycemia. Implementing a hypoglycemia treatment protocol in long-term care (LTC) settings may positively affect patient-related outcomes and health care resource utilization and costs. Anecdotal experience indicates little has been studied and published regarding this clinical practice. Objective: To identify hypoglycemia treatment protocols established for LTC settings and assess their effects on patient-related outcomes and health care resource use. Data Sources: The authors performed a systematic literature search of English-language articles and abstracts published between January 1, 2003 (PubMed), or 2018 (Google Scholar) and May 10, 2023. Search terms were "hypoglycemia," "diabetes mellitus," "longterm care," "nursing facilities," "assisted living facilities," "geriatrics," "elderly," "aged," "disabled," "disease management," "evidence-based medicine," "clinical protocols," "guideline," "glucagon," and/or "blood glucose." Included were publications with hypoglycemia treatment and management protocols or hypoglycemia-specific recommendations for LTC settings. DATA SYNTHESIS: The authors identified 405 articles and abstracts, removed 36 duplicates, screened 369 titles/ abstracts, and analyzed the full text for 93. Five met the inclusion criteria. Two originated from the American Diabetes Association: 2016 position statement regarding the management of diabetes in LTC and skilled nursing facilities, and 2023 standard-of-care guideline for managing older people with diabetes. One included the results after implementing an overall diabetes clinical care management algorithm in LTC facilities. A 2020 abstract and 2019 article were the only 2 publications involving specific hypoglycemia treatment protocols in LTC settings. Conclusion: This systematic literature search identified lack of published hypoglycemia treatment protocols in LTC settings and their effects on patient outcomes.
Collapse
Affiliation(s)
- Matthew R Krecic
- Xeris Pharmaceuticals, Inc., Publications and Medical Communications, Chicago, Illinois
| | - James Meyer
- Xeris Pharmaceuticals, Inc., Publications and Medical Communications, Chicago, Illinois
| | - Kathleen J Chavanu
- Xeris Pharmaceuticals, Inc., Publications and Medical Communications, Chicago, Illinois
| |
Collapse
|
3
|
Idrees T, Castro-Revoredo IA, Oh HD, Gavaller MD, Zabala Z, Moreno E, Moazzami B, Galindo RJ, Vellanki P, Cabb E, Johnson TM, Peng L, Umpierrez GE. Continuous Glucose Monitoring-Guided Insulin Administration in Long-Term Care Facilities: A Randomized Clinical Trial. J Am Med Dir Assoc 2024; 25:884-888. [PMID: 38460943 PMCID: PMC11283256 DOI: 10.1016/j.jamda.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES To evaluate the efficacy of real-time continuous glucose monitoring (rt-CGM) in adjusting insulin therapy in long-term care facilities (LTCF). DESIGN Prospective randomized clinical trial. SETTINGS AND PARTICIPANTS Insulin-treated patients with type 2 diabetes (T2D) admitted to LTCF. METHODS Participants in the standard of care wore a blinded CGM with treatment adjusted based on point-of-care capillary glucose results before meals and bedtime (POC group). Participants in the intervention (CGM group) wore a Dexcom G6 CGM with treatment adjusted based on daily CGM profile. Treatment adjustment was performed by the LTCF medical team, with a duration of intervention up to 60 days. The primary endpoint was difference in time in range (TIR 70-180 mg/dL) between treatment groups. RESULTS Among 100 participants (age 74.73 ± 11 years, 80% admitted for subacute rehabilitation and 20% for nursing home care), there were no significant differences in baseline clinical characteristics between groups, and CGM data were compared for a median of 17 days. There were no differences in TIR (53.38% ± 30.16% vs 48.81% ± 28.03%, P = .40), mean daily mean CGM glucose (184.10 ± 43.4 mg/dL vs 190.0 ± 45.82 mg/dL, P = .71), or the percentage of time below range (TBR) <70 mg/dL (0.83% ± 2.59% vs 1.18% ± 3.54%, P = .51), or TBR <54 mg/dL (0.23% ± 0.85% vs 0.56% ± 2.24%, P = .88) between rt-CGM and POC groups. CONCLUSIONS AND IMPLICATIONS The use of rtCGM is safe and effective in guiding insulin therapy in patients with T2D in LTCF resulting in a similar improvement in glycemic control compared to POC-guided insulin adjustment.
Collapse
Affiliation(s)
- Thaer Idrees
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | | | - Hyungseok D Oh
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Monica D Gavaller
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Zohyra Zabala
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Emmelin Moreno
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Bobak Moazzami
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Elena Cabb
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Theodore M Johnson
- Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA; Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Limin Peng
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA.
| |
Collapse
|
4
|
Tat DP, Zullo AR, Mor V, Hayes KN. Sliding Scale Insulin Use in Nursing Homes Before and After Onset of the COVID-19 Pandemic. J Am Med Dir Assoc 2024; 25:459-464. [PMID: 38307122 PMCID: PMC10923121 DOI: 10.1016/j.jamda.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVE To characterize sliding-scale insulin (SSI) use in US nursing homes (NHs) before and after the COVID-19 pandemic. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS A total of 129,829 US NH residents on SSI (01/2018-06/2022) across 12 NH chains with a common electronic health record system. METHODS Among all residents with at least 1 administration of SSI documented in the electronic medication administration record, we described resident demographics, frequency of SSI monotherapy vs combination therapy with another diabetes medication, number of daily capillary blood glucose readings ("fingersticks"), and hypoglycemia (capillary blood glucose <70 mg/dL) and hyperglycemia after first SSI use. We used interrupted time series analysis (ITS) with segmented linear regression models to examine whether the monthly prevalence of SSI use changed at and after the onset of the COVID-19 pandemic (March 2020). RESULTS There were 129,829 unique NH residents with SSI use [51% women, average age 71.3 (SD 11.7) years]. Of these, 36% of residents received SSI monotherapy and 64% received SSI combination therapy. Residents on SSI received an average of 3.96 (SD 1.41) fingersticks per day. Overall, 26% of SSI users experienced a hypoglycemic event within 30 days of the first SSI dose. The ITS analysis identified a step decrease in the rate of SSI use following the onset of the COVID-19 pandemic (43 fewer SSI users per 1000 insulin users) but no change in overall trend over time from before the onset of the pandemic. CONCLUSIONS AND IMPLICATIONS SSI use and fingerstick burden are high in NH residents. Hypoglycemia occurred commonly among residents on SSI. Future research should compare the safety and effectiveness of SSI monotherapy vs other diabetes medication regimens to guide person-centered prescribing decisions in NHs.
Collapse
Affiliation(s)
- Darlene P Tat
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA
| | - Andrew R Zullo
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Vincent Mor
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Kaleen N Hayes
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA.
| |
Collapse
|
5
|
Surlari Z, Ciurcanu OE, Budala DG, Butnaru O, Luchian I. An Update on the Interdisciplinary Dental Care Approach for Geriatric Diabetic Patients. Geriatrics (Basel) 2023; 8:114. [PMID: 38132485 PMCID: PMC10743251 DOI: 10.3390/geriatrics8060114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
Diabetes mellitus is a prevalent health issue escalating worldwide that gives rise to numerous problems. Periodontal disorders are recognized as the sixth consequence associated with diabetes mellitus. Research shows that dental health affects overall health, and this knowledge is changing the dental field. The correct choice of glucose goal levels and the optimal selection of glucose-lowering medications are determined by a comprehensive geriatric assessment, an estimate of life expectancy, and a rationale for therapy at regular intervals in elderly diabetics. This article provides an overview of the correlation between diabetes and oral health, with a specific emphasis on xerostomia, periodontal disease, and dental caries. Thus, dentists play a significant role within the allied health profession by contributing to the provision of oral care for those diagnosed with diabetes, with a special focus on geriatric patients.
Collapse
Affiliation(s)
- Zenovia Surlari
- Department of Fixed Prosthodontics, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universității Street, 700115 Iasi, Romania;
| | - Oana Elena Ciurcanu
- Department of Dental Surgery, Grigore T. Popa University of Medicine and Pharmacy, Universitatii Street 16, 700115 Iasi, Romania;
| | - Dana Gabriela Budala
- Department of Implantology, Removable Prostheses, Dental Prostheses Technology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitătii Street, 700115 Iasi, Romania
| | - Oana Butnaru
- Department of Biophysics, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Ionut Luchian
- Department of Periodontology, Grigore T. Popa University of Medicine and Pharmacy, Universitatii Street 16, 700115 Iasi, Romania
| |
Collapse
|
6
|
Sampietro L, Cirone M, Lione L, Gonella D, Testino G, Bottaro LC, Torre E. New perspectives in management of diabetes in long-term care facilities. Minerva Endocrinol (Torino) 2023; 48:127-129. [PMID: 36719703 DOI: 10.23736/s2724-6507.23.03994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | - Luca Lione
- Unit of Diabetology, ASL2, Savona, Italy
| | | | | | | | - Enrico Torre
- Unit of Endocrinology, Diabetology and Metabolic Diseases, ASL3, Genoa, Italy -
| |
Collapse
|
7
|
Maruoka H, Hamada S, Hattori Y, Arai K, Arimitsu K, Higashihara K, Saotome S, Kobayashi A, Watanabe N, Kurata N, Kishimoto K, Kojima T. Changes in chronic disease medications after admission to a Geriatric Health Services Facility: A multi-center prospective cohort study. Medicine (Baltimore) 2023; 102:e33552. [PMID: 37233437 PMCID: PMC10219748 DOI: 10.1097/md.0000000000033552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/28/2023] [Indexed: 05/27/2023] Open
Abstract
Older adults often receive polypharmacy, including some medications for chronic diseases. Nutritional management after admission to a nursing home may enable to deprescribe some chronic disease medications. This study aimed to investigate the status of deprescribing of chronic disease medications among nursing home residents, and to assess the appropriateness based on changes of laboratory test values and nutritional status. A multi-center prospective cohort study was conducted in 6 Geriatric Health Services Facilities, a major type of nursing homes in Japan. Newly admitted residents aged ≥ 65 years who took ≥1 medication for hypertension, diabetes, or dyslipidemia at admission were recruited. Participants who stayed for 3 months were included in the analysis. Medications at admission and 3 months after admission and situations for deprescribing were investigated. Changes in body mass index, blood pressure, laboratory tests (e.g., cholesterol and hemoglobin A1c levels), energy intake, and International Classification of Functioning, Disability and Health staging were evaluated. Sixty-nine participants (68% female, 62% aged ≥ 85 years) were included. At admission, 60 participants had medications for hypertension, 29 for dyslipidemia, and 13 for diabetes. Those receiving lipid-modifying drugs (mainly statins) decreased from 29 to 21 (72%; P = .008), since their cholesterol levels was within the normal range or was low at admission, and they had no history of cardiovascular events. However, there were no statistically significant changes in the frequencies of antihypertensive drugs (60 to 55; 92%; P = .063) or antidiabetic drugs (13 to 12; 92%; P = 1.000). During the 3-month observation, body mass index and diastolic blood pressure decreased, while energy intake and serum albumin level increased. Nutritional management after admission to a ROKEN may facilitate appropriate deprescribing of lipid-modifying drugs, by offseting the effects of discontinuation of these drugs.
Collapse
Affiliation(s)
- Hiroshi Maruoka
- Yokohama Aobanosato Geriatric Health Services Facility, Yokohama, Japan
- Division of Social Pharmacy, Department of Healthcare and Regulatory Sciences, School of Pharmacy, Showa University, Tokyo, Japan
| | - Shota Hamada
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
- Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yukari Hattori
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuaki Arai
- Division of Social Pharmacy, Department of Healthcare and Regulatory Sciences, School of Pharmacy, Showa University, Tokyo, Japan
- Ooarai Geriatric Health Services Facility, Ibaraki, Japan
| | - Kayoko Arimitsu
- Nursing Plaza Kouhoku Geriatric Health Services Facility, Yokohama, Japan
| | | | - Saiko Saotome
- Onahama Tokiwaen Geriatric Health Services Facility, Fukushima, Japan
| | - Asami Kobayashi
- Rehabilitation Port Yokohama Geriatric Health Services Facility, Yokohama, Japan
| | - Noriko Watanabe
- Yokohama Aobanosato Geriatric Health Services Facility, Yokohama, Japan
| | - Naomi Kurata
- Division of Social Pharmacy, Department of Healthcare and Regulatory Sciences, School of Pharmacy, Showa University, Tokyo, Japan
| | - Keiko Kishimoto
- Division of Social Pharmacy, Department of Healthcare and Regulatory Sciences, School of Pharmacy, Showa University, Tokyo, Japan
| | - Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
8
|
Pandya N, Jung M, Norfolk A, Goldblatt C, Trenery A, Sieradzan R. Medication Prescribing for Type 2 Diabetes in the US Long-Term Care Setting: Observational Study. J Am Med Dir Assoc 2023:S1525-8610(23)00299-2. [PMID: 37094748 DOI: 10.1016/j.jamda.2023.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES To characterize prescribing of glucose-lowering medication annually and to quantify the annual frequency of hypoglycemia among residents in long-term care (LTC) facilities with type 2 diabetes mellitus (T2DM). DESIGN Serial cross-sectional study using a deidentified real-world database comprising electronic health records from LTC facilities. SETTING AND PARTICIPANTS Individuals eligible for this study were ≥65 years old with T2DM and recorded stay of ≥100 days at an LTC facility in the United States in any of 5 study years (2016-2020), excluding individuals receiving palliative or hospice care. METHODS Drug orders (prescriptions) for glucose-lowering medications for each LTC resident with T2DM in each calendar year were summarized by administration route (oral or injectable) and by drug class as ever-prescribed (ie, multiple prescriptions were included once), overall and stratified by age subgroup, <3 vs ≥3 comorbidities, and obesity status. We calculated the annual percentage of patients ever prescribed glucose-lowering medication each year, overall and by medication category, who experienced ≥1 hypoglycemic events. RESULTS Among 71,200 to 120,861 LTC residents with T2DM included each year from 2016 to 2020, 68% to 73% (depending on the year) were prescribed ≥1 glucose-lowering medications, including oral agents for 59% to 62% and injectable agents for 70% to 71%. Metformin was the most commonly prescribed oral agent, followed by sulfonylureas and dipeptidyl peptidase 4 inhibitors; basal plus prandial insulin was the most commonly prescribed injectable regimen. Prescribing patterns remained relatively consistent from 2016 to 2020, both overall and by patient subgroup. During each study year, 35% of LTC residents with T2DM experienced level 1 hypoglycemia (glucose ≥54 to <70 mg/dL), including 10% to 12% of those prescribed only oral agents and ≥44% of those prescribed injectable agents. Overall, 24% to 25% experienced level 2 hypoglycemia (glucose concentration <54 mg/dL). CONCLUSIONS AND IMPLICATIONS Study findings suggest that opportunities exist for improving diabetes management for LTC residents with T2DM.
Collapse
Affiliation(s)
- Naushira Pandya
- Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Molly Jung
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | | | | | | | | |
Collapse
|
9
|
Naqvi SH, Osundolire S, Goldberg RA, Lapane KL, Nunes AP. Unhealed Pressure Ulcers Among Nursing Home Residents with Diabetes. Arch Gerontol Geriatr 2023; 111:104969. [PMID: 37004252 DOI: 10.1016/j.archger.2023.104969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/12/2023] [Accepted: 02/19/2023] [Indexed: 02/27/2023]
Abstract
INTRODUCTION Nearly a third of US nursing home residents have diabetes mellitus. These residents have an increased risk of pressure ulcer (PU) development and progression; however, little is known about the characteristics of their PUs or the role of other risk factors. This study estimates the prevalence of PUs, describes characteristics of PUs, and quantifies associations between risk factors and PUs in nursing home residents with diabetes. METHODS We conducted a cross-sectional study of nursing home residents aged ≥50 years with diabetes mellitus using national 2016 Minimum Data Set 3.0 data. Pressure ulcers were defined as the presence of any stage PU and by subgroups of stage and tissue type. Prevalence estimates of PUs were calculated overall and by covariate subgroups. Unadjusted and adjusted odds ratios were calculated using logistic regression. RESULTS The prevalence of any unhealed PU was 8.1%. Of those with a PU, 19.4% had at least two ulcers and the most common subtypes were identified as unstageable and stage 2 ulcers. These were most often treated by pressure reducing devices. In our fully adjusted model, risk factors that were strongly associated with PUs were related to mobility, nutrition, incontinence, and infections. CONCLUSION We observed that the prevalence of PUs remains high in nursing home residents with diabetes and that higher stage ulcers were common in this population. Our adjusted model highlights the importance of suspected risk factors in the development of PUs. Further research is needed to understand the unique needs of nursing home residents with diabetes.
Collapse
|
10
|
Nguyen B, James Deardorff W, Shi Y, Jing B, Lee AK, Lee SJ. Fingerstick glucose monitoring by cognitive impairment status in Veterans Affairs nursing home residents with diabetes. J Am Geriatr Soc 2022; 70:3176-3184. [PMID: 35924668 PMCID: PMC9705158 DOI: 10.1111/jgs.17962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/07/2022] [Accepted: 06/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels. METHODS We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/- metformin but no insulin), (4) long-acting insulin (+/- oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission. RESULTS Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation = 1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status. Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact). CONCLUSION NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration in monitoring decisions. Future studies should determine whether decreasing fingersticks in NH residents with moderate/severe cognitive impairment can reduce burdens without compromising safety.
Collapse
Affiliation(s)
- Brian Nguyen
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - William James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sei J Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| |
Collapse
|
11
|
Lederle LI, Steinman MA, Jing B, Nguyen B, Lee SJ. Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes. J Am Geriatr Soc 2022; 70:2019-2028. [PMID: 35318647 PMCID: PMC9283249 DOI: 10.1111/jgs.17735] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/02/2022] [Accepted: 02/12/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting. METHODS We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose-lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c. RESULTS Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long-acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14-1.65 and OR 1.35, 95% CI 1.10-1.66, respectively). Severe functional impairment (MDS-ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56-0.95). Hypoglycemia was not associated with decreased odds of overtreatment. CONCLUSIONS Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification.
Collapse
Affiliation(s)
- Lauren I. Lederle
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Michael A. Steinman
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Bocheng Jing
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Brian Nguyen
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Sei J. Lee
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| |
Collapse
|
12
|
Idrees T, Castro-Revoredo IA, Migdal AL, Moreno EM, Umpierrez GE. Update on the management of diabetes in long-term care facilities. BMJ Open Diabetes Res Care 2022; 10:10/4/e002705. [PMID: 35858714 PMCID: PMC9305812 DOI: 10.1136/bmjdrc-2021-002705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.
Collapse
Affiliation(s)
- Thaer Idrees
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Iris A Castro-Revoredo
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Alexandra L Migdal
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Emmelin Marie Moreno
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
13
|
Hayes KN, Mor V, Zullo AR. Electronic Health Records to Rapidly Assess Biosimilar Uptake: An Example Using Insulin Glargine in a Large U.S. Nursing Home Cohort. Front Pharmacol 2022; 13:855598. [PMID: 35600866 PMCID: PMC9114471 DOI: 10.3389/fphar.2022.855598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Large healthcare administrative databases, like Medicare claims, are a common means to evaluate drug policies. However, administrative data often have a lag time of months to years before they are available to researchers and decision-makers. Therefore, administrative data are not always ideal for timely policy evaluations. Other sources of data are needed to rapidly evaluate policy changes and inform subsequent studies that utilize large administrative data once available. An emerging area of interest in both pharmacoepidemiology and drug policy research that can benefit from rapid data availability is biosimilar uptake, due to the potential for substantial cost savings. To respond to the need for such a data source, we established a public-private partnership to create a near-real-time database of over 1,000 nursing homes’ electronic health records to describe and quantify the effects of recent policies related to COVID-19 and medications. In this article, we first describe the components and infrastructure used to create our EHR database. Then, we provide an example that illustrates the use of this database by describing the uptake of insulin glargine-yfgn, a new exchangeable biosimilar for insulin glargine, in US nursing homes. We also examine the uptake of all biosimilars in nursing homes before and after the onset of the COVID-19 pandemic. We conclude with potential directions for future research and database infrastructure.
Collapse
Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States
- *Correspondence: Kaleen N. Hayes,
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, United States
| | - Andrew R. Zullo
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, United States
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
| |
Collapse
|
14
|
Abstract
The increasing incidence of type 2 diabetes in the general population as well as enhanced life expectancy has resulted in a rapid rise in the prevalence of diabetes in the older population. Diabetes causes significant morbidity and impairs quality of life. Managing diabetes in older adults is a daunting task due to unique health and psychosocial challenges. Medical management is complicated by polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain. Health care providers now have several traditional and contemporary pharmacologic agents to manage diabetes. Avoidance of hypoglycemia is critical; however, evidence-based guidelines are lacking due to the paucity of clinical trials in older adults. For many in this population, maintaining independence is more important than adherence to published guidelines to prevent diabetes complications. The goal of diabetes care in older adults is to enhance the quality of life without subjecting these patients to intrusive and complicated interventions. Recent technological advancements such as continuous glucose monitoring systems can have crucial supplementary benefits in the geriatric population.
Collapse
|
15
|
Stasinopoulos J, Wood SJ, Bell JS, Manski-Nankervis JA, Hogan M, Sluggett JK. Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review. J Am Med Dir Assoc 2021; 22:1889-1897.e5. [PMID: 34004183 DOI: 10.1016/j.jamda.2021.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs). DESIGN Systematic review. SETTING AND PARTICIPANTS Residents with T2DM and aged ≥60 years living in LTCFs. MEASURES Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs. RESULTS Fifteen studies were included. Prevalence of potential overtreatment (5%-86%, n = 15 studies) and undertreatment (1.4%-35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%-74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%-14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment. CONCLUSIONS AND IMPLICATIONS The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.
Collapse
Affiliation(s)
- Jacquelina Stasinopoulos
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.
| | - Stephen J Wood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Carlton, VIC, Australia
| | | | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; University of South Australia, UniSA Allied Health and Human Performance, Adelaide, SA, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| |
Collapse
|
16
|
Pandya N, Hames E, Sandhu S. Challenges and Strategies for Managing Diabetes in the Elderly in Long-Term Care Settings. Diabetes Spectr 2020; 33:236-245. [PMID: 32848345 PMCID: PMC7428662 DOI: 10.2337/ds20-0018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Diabetes affects a large number of patients in the long-term care (LTC) setting, and their care is often complicated because of multimorbidity, diabetes-related complications, disability, dependency on caregivers, and geriatric syndromes, including frailty and cognitive impairment. This population includes patients receiving short-term rehabilitation in skilled nursing facilities, those who are residents in LTC facilities, and those receiving palliative or end-of-life care. An individualized approach to care based on clinical complexity, diabetes trajectory, and patients' preferences and goals is required. Such patients may experience one or more transitions of care and decline in condition. They are also prone to adverse drug events, cardiovascular events, and hypoglycemia. Facility-related challenges include varying staff competencies and practitioner preferences, inconsistent interdisciplinary communication, overly complex medication regimens, and poorly implemented care transitions.
Collapse
Affiliation(s)
- Naushira Pandya
- Department of Geriatrics, Nova Southeastern University, Fort Lauderdale, FL
| | - Elizabeth Hames
- Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL
| | | |
Collapse
|
17
|
Davis GM, DeCarlo K, Wallia A, Umpierrez GE, Pasquel FJ. Management of Inpatient Hyperglycemia and Diabetes in Older Adults. Clin Geriatr Med 2020; 36:491-511. [PMID: 32586477 PMCID: PMC10695675 DOI: 10.1016/j.cger.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Diabetes is one of the world's fastest growing health challenges. Insulin therapy remains a useful regimen for many elderly patients, such as those with moderate to severe hyperglycemia, type 1 diabetes, hyperglycemic emergencies, and those who fail to maintain glucose control on non-insulin agents alone. Recent clinical trials have shown that several non-insulin agents as monotherapy, or in combination with low doses of basal insulin, have comparable efficacy and potential safety advantages to complex insulin therapy regimens. Determining the most appropriate diabetes management plan for older hospitalized patients requires consideration of many factors to prevent poor outcomes related to dysglycemia.
Collapse
Affiliation(s)
- Georgia M Davis
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Kristen DeCarlo
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave, Chicago, IL 60611, USA
| | - Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave, Chicago, IL 60611, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA.
| |
Collapse
|
18
|
Da Porto A, Coracina A, Fiore V, Masi S, Fontana L, Marnini P, Felace G. Quality of care to institutionalized patients with diabetes in Italy: a national survey. Eur Geriatr Med 2020; 11:753-759. [PMID: 32504422 DOI: 10.1007/s41999-020-00329-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/29/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the epidemiology of diabetes and quality of care of institutionalized patients with diabetes in Italian nursing homes. More specifically, to evaluate the adherence to the national/international guidelines for the management of older people with diabetes. METHODS Data related to the epidemiology of diabetes and the quality of care were collected from questionnaires sent to 41 nursing homes. Data were extracted from papers, electronic medical records and validated operating protocols regulating the management of patients with diabetes in various homes. Completed questionnaires were returned in electronic format and centrally processed. RESULTS Out of 4692 residents, 906 (19.3%) had diabetes. Among these residents, excluding patients undergoing diet treatment, more than half were on insulin treatment (alone or in combination with oral antidiabetic agents). The critical findings can be summarized as follows: a lack of shared diagnostic-therapeutic protocols, specifically related to evaluation of frailty; the preparation of nutritional and physical activity plans; the clarification of the objectives of the treatment; the timing of insulin administration (frequent use of sliding scale); the frequency and timing of capillary blood glucose; metabolic control methods; hypoglycemia and hyperglycemia treatment; and the scant use of new drugs that do not cause hypoglycemia. CONCLUSION Our data revealed substantial heterogeneity in the treatment of nursing home residents with diabetes in Italy with many discrepancies between what is recommended in the guidelines and real-world practice. The implementation of local diagnostic-therapeutic protocols shared by all caregivers should be encouraged and properly funded to overcome communication problems between doctors and nurses and eventually improve the quality of care for institutionalized patients with diabetes.
Collapse
Affiliation(s)
| | - Anna Coracina
- Diabetologic Unit of Cittadella (PD), Cittadella, Italy
| | - Vincenzo Fiore
- Internal and Geriatric Medicine Unit Tivoli (RM), Tivoli, Italy
| | - Stefano Masi
- Diabetes Unit of Nocera Inferiore (SA) and Ottaviano (NA), Ottaviano, Italy
| | - Lucia Fontana
- Ambulatorial Activities ACISMOM (Latina and Viterbo), Viterbo, Italy
| | | | | | | |
Collapse
|
19
|
Glycemic Over- and Undertreatment in VA Nursing Home Residents with Type 2 Diabetes: a Retrospective Cohort Study. J Gen Intern Med 2020; 35:1900-1902. [PMID: 31705477 PMCID: PMC7280465 DOI: 10.1007/s11606-019-05479-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
|
20
|
Mudra AK. The Boomers Come of Age. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
21
|
Chen SM, Lin HS, Atherton JJ, MacIsaac RJ, Wu CJJ. Effect of a mindfulness programme for long-term care residents with type 2 diabetes: A cluster randomised controlled trial measuring outcomes of glycaemic control, relocation stress and depression. Int J Older People Nurs 2020; 15:e12312. [PMID: 32103635 DOI: 10.1111/opn.12312] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/09/2020] [Accepted: 01/18/2020] [Indexed: 12/12/2022]
Abstract
AIMS The aim of this study was to determine physical, behavioural and psychosocial effects of a newly developed mindfulness programme for older adults with type 2 diabetes relocating to long-term care facility. BACKGROUND Taiwan is viewed as an "aged society" with significant proportion of the population living in a long-term care facility. Approximately one third of residents living in long-term care facilities have been diagnosed with type 2 diabetes, and disruption to management of their glycaemic levels is at risk for up to one year after relocating to a long-term care facility. DESIGN A cluster randomised controlled trial was used to examine the effects of a newly developed mindfulness programme on outcomes of glycaemic levels, relocation stress and depression. METHODS A total of 140 participants were recruited from six long-term care facilities in Southern Taiwan. A mindfulness programme was delivered over 9 weeks and consisted of meditations, education and exercise techniques that were delivered by a Registered Nurse trained in mindfulness strategies. Participants in the control group received routine care as provided in the facilities, including routine check-ups at diabetes clinics as necessary. Data were analysed by Johnson-Neyman technique and generalised estimating equations. RESULTS In total, 120 residents completed the study. The majority of patients were female (64.8%), and 83.5% of the sample were financially supported by their children. The results showed significant improvements in glycated haemoglobin (HbA1c), relocation stress (Wald χ2 = 78.91) and depression (Wald χ2 = 45.70) between groups. In the intervention group, the mean of HbA1c levels showed 16.4% reduction (Mean differences = 1.3; SD = 0.3). However, there were no significant differences in relocation stress and depression within groups. CONCLUSION The results provided positive effects of the mindfulness programme for older people with diabetes moving into long-term care facilities. The programme will assist in future planning for diabetes care in long-term care facilities. IMPLICATIONS FOR PRACTICE To incorporate the mindfulness program into existing diabetes education programs for older people living in LTCFs. Further investigation on the sustainability of the mindfulness program is warranted.
Collapse
Affiliation(s)
- Shu-Ming Chen
- Department of Nursing, School of Nursing, Fooyin University, Kaohsiung, Taiwan
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, Kaohsiung, Taiwan
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital (RBWH), Herston, Qld, Australia.,Queensland University of Technology (QUT), Brisbane, Qld, Australia.,University of the Sunshine Coast (USC), Sippy Downs, Qld, Australia.,University of Queensland (UQ), St Lucia, Qld, Australia
| | - Richard J MacIsaac
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne & University of Melbourne, Fitzroy, Vic, Australia
| | - Chiung-Jung Jo Wu
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast (USC), Sippy Downs, Qld, Australia.,Royal Brisbane and Women's Hospital (RBWH), Herston, Qld, Australia.,Mater Medical Research Institute-University of Queensland (MMRI-UQ), South Brisbane, Qld, Australia
| |
Collapse
|
22
|
Niznik JD, Hunnicutt JN, Zhao X, Mor MK, Sileanu F, Aspinall SL, Springer SP, Ersek MJ, Gellad WF, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes. J Am Geriatr Soc 2020; 68:736-745. [PMID: 32065387 DOI: 10.1111/jgs.16360] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING VA CLCs. PARTICIPANTS A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7-day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90-day cumulative incidence of deintensification. RESULTS More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0-7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50-.66). Compared with non-sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31-1.88), except for basal insulin (aRR = .59; 95% CI = .52-.66). The only resident factor associated with increased likelihood of deintensification was documented end-of-life status (aRR = 1.12; 95% CI = 1.01-1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75-.96), obesity (aRR = .88; 95% CI = .78-.99), and peripheral vascular disease (aRR = .90; 95% CI = .81-.99) were associated with decreased likelihood of deintensification. CONCLUSION Deintensification of treatment regimens occurred in less than one-half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736-745, 2020.
Collapse
Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Jacob N Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Florentina Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sydney P Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Portland, Maine
| | - Mary J Ersek
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Veterans Experience Center; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| |
Collapse
|
23
|
Mitratza M, Kunst AE, Harteloh PPM, Nielen MMJ, Klijs B. Prevalence of diabetes mellitus at the end of life: An investigation using individually linked cause-of-death and medical register data. Diabetes Res Clin Pract 2020; 160:108003. [PMID: 31911247 DOI: 10.1016/j.diabres.2020.108003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/12/2019] [Accepted: 12/31/2019] [Indexed: 11/17/2022]
Abstract
AIMS Although diabetes mellitus at the end of life is associated with complex care, its end-of-life prevalence is uncertain. Our aim is to estimate diabetes prevalence in the end-of-life population, to evaluate which medical register has the largest added value to cause-of-death data in detecting diabetes cases, and to assess the extent to which reporting of diabetes as a cause of death is associated with disease severity. METHODS Our study population consisted of deaths in the Netherlands (2015-2016) included in Nivel Primary Care Database (Nivel-PCD; N = 18,162). The proportion of deaths with diabetes (Type 1 or 2) within the last two years of life was calculated using individually linked cause-of-death, general practice, medication, and hospital discharge data. Severity status of diabetes was defined with dispensed medicines. RESULTS According to all data sources combined, 28.7% of the study population had diabetes at the end of life. The estimated end-of-life prevalence of diabetes was 7.7% using multiple cause-of-death data only. Addition of general practice data increased this estimate the most (19.7%-points). Of the cases added by primary care data, 76.3% had a severe or intermediate status. CONCLUSIONS More than one fourth of the Dutch end-of-life population has diabetes. Cause-of-death data are insufficient to monitor this prevalence, even of severe cases of diabetes, but could be enriched particularly with general practice data.
Collapse
Affiliation(s)
- Marianna Mitratza
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Anton E Kunst
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter P M Harteloh
- Department of Health and Care, Statistics Netherlands, The Hague, the Netherlands
| | - Markus M J Nielen
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands
| | - Bart Klijs
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Health and Care, Statistics Netherlands, The Hague, the Netherlands
| |
Collapse
|
24
|
Ledesma G, Umpierrez GE, Morley JE, Lewis-D'Agostino D, Keller A, Meinicke T, van der Walt S, von Eynatten M. Efficacy and safety of linagliptin to improve glucose control in older people with type 2 diabetes on stable insulin therapy: A randomized trial. Diabetes Obes Metab 2019; 21:2465-2473. [PMID: 31297968 DOI: 10.1111/dom.13829] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/25/2019] [Accepted: 07/07/2019] [Indexed: 12/30/2022]
Abstract
AIM To assess the addition of linagliptin as an alternative to insulin uptitration in older people with type 2 diabetes on stable insulin therapy. MATERIALS AND METHODS This phase 4, randomized, multicentre, double-blinded, placebo-controlled, 24-week study recruited individuals on stable insulin, with baseline HbA1c 7.0%-10.0%, aged ≥60 years and body mass index ≤45 kg/m2 . HbA1c and fasting plasma glucose were measured at study visits, and participants assessed glycaemic control with a self-monitoring blood glucose device. Adverse events (AEs) were reported during the study. RESULTS Three hundred and two participants were randomized 1:1 to linagliptin 5 mg qd and placebo, with one third of patients from Japan. Study population age and HbA1c (baseline mean ± SD) were 72.4 ± 5.4 years and 8.2 ± 0.8%, respectively; ~80% of participants were aged ≥70 years; 80% had macrovascular complications, one third had a baseline estimated glomerular filtration rate <60 mL/min/1.73 m2 ; and half had been diagnosed with diabetes for >15 years. Linagliptin significantly improved glucose control at 24 weeks (HbA1c-adjusted mean change vs. placebo: -0.63%; P <0.0001) and the probability of achieving predefined HbA1c targets without hypoglycaemia (HbA1c <8.0%: OR 2.02; P <0.05 and HbA1c <7.0%: OR 2.44; P <0.01). Linagliptin versus placebo was well tolerated, with similar incidences of AEs, including clinically important hypoglycaemia (blood glucose <54 mg/dL) or severe hypoglycaemia. CONCLUSIONS Addition of linagliptin improves glucose control without an excess of hypoglycaemia in older patients with type 2 diabetes on stable insulin therapy.
Collapse
Affiliation(s)
| | | | - John E Morley
- Division of Geriatric Medicine, Saint Louis University, St. Louis, Missouri
| | | | - Annett Keller
- Global BDS, Boehringer Ingelheim Pharma GmbH & Co, KG, Ingelheim, Germany
| | - Thomas Meinicke
- TA CardioMetabolism, Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Sandra van der Walt
- International Project Management Cardiometabolic/CNS, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | |
Collapse
|
25
|
Seidu S, Kunutsor SK, Topsever P, Hambling CE, Cos FX, Khunti K. Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes. Diabetes Obes Metab 2019; 21:1668-1679. [PMID: 30938038 DOI: 10.1111/dom.13724] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/19/2019] [Accepted: 03/27/2019] [Indexed: 02/06/2023]
Abstract
AIM To assess deintensification approaches and rates and evaluate the harm and benefits of deintensification with antidiabetic medication and other therapies among older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions. METHODS We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science and Cochrane databases to 30 October 2018. Data were extracted on baseline characteristics, details on deintensification and outcomes, and was synthesized using a narrative approach. RESULTS Ten studies (observational cohorts and interventional studies) with data on 26 558 patients with comorbidities were eligible. Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but the majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4%-75%. The majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes, falls or hospitalizations on deintensification. On adverse events and mortality, no significant differences were observed among the comparison groups in the majority of studies. CONCLUSION Available but limited evidence suggests that the benefits of deintensification outweigh the harm in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with diabetes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population.
Collapse
Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
| | - Setor K Kunutsor
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, NHS Foundation, National Institute for Health Research Bristol, Biomedical Research Centre, University Hospitals Bristol Trust and University of Bristol, Bristol, UK
| | - Pinar Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Clare E Hambling
- Department of Public Health and Primary Care, School of Clinical Medicine, Cambridge, UK
| | - Francesc X Cos
- Diabetes & Metabolic Medicine, Jordi Gol Institute for Research in Primary Care, The Foundation University Institute for Primary Health, Barcelona, Spain
| | - Kamlesh Khunti
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
| |
Collapse
|
26
|
LaManna J, Litchman ML, Dickinson JK, Todd A, Julius MM, Whitehouse CR, Hyer S, Kavookjian J. Diabetes Education Impact on Hypoglycemia Outcomes: A Systematic Review of Evidence and Gaps in the Literature. DIABETES EDUCATOR 2019; 45:349-369. [PMID: 31210091 DOI: 10.1177/0145721719855931] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE The primary purpose of this study is to report a systematic review of evidence and gaps in the literature among well-conducted studies assessing the impact of diabetes education on hypoglycemia outcomes and secondarily reporting the impact on other included target outcomes. METHODS The authors used a modified Cochrane method to systematically search and review English-language titles, abstracts, and full-text articles published in the United States between January 2001 and December 2017, with diabetes education specified as an intervention and a directly measurable outcome for hypoglycemia risk or events included. RESULTS Fourteen quasi-experimental, experimental, and case-control studies met the inclusion criteria, with 8 articles reporting a positive impact of diabetes self-management education and support (DSMES) on hypoglycemia outcomes; 2 of the 8 reported decreased hypoglycemia events, and 1 reported decreased events in both the intervention and control groups. In addition, 5 studies targeted change in reported hypoglycemia symptoms, with all 5 reporting a significant decrease. DSMES also demonstrated an impact on intermediate (knowledge gain, behavior change) and long-term (humanistic and economic/utilization) outcomes. An absence of common hypoglycemia measures and terminology and suboptimal descriptions of DSMES programs for content, delivery, duration, practitioner types, and participants were identified as gaps in the literature. CONCLUSIONS Most retained studies reported that diabetes education positively affected varied measures of hypoglycemia outcomes (number of events, reported symptoms) as well as other targeted outcomes. Diabetes education is an important intervention for reducing hypoglycemia events and/or symptoms and should be included as a component of future hypoglycemia risk mitigation studies.
Collapse
Affiliation(s)
- Jacqueline LaManna
- American Association of Diabetes Educators, Research Committee, Chicago, Illinois.,University of Central Florida, College of Nursing, Orlando, Florida
| | - Michelle L Litchman
- American Association of Diabetes Educators, Research Committee, Chicago, Illinois.,University of Utah, College of Nursing, Salt Lake City, Utah
| | - Jane K Dickinson
- American Association of Diabetes Educators, Research Committee, Chicago, Illinois.,Department of Health and Behavior Studies, Teachers College Columbia University, New York, New York
| | - Andrew Todd
- University of Central Florida, College of Nursing, Orlando, Florida
| | - Mary M Julius
- American Association of Diabetes Educators, Research Committee, Chicago, Illinois.,Northeast Ohio Veterans Administration (VA), Cleveland, Ohio
| | - Christina R Whitehouse
- American Association of Diabetes Educators, Research Committee, Chicago, Illinois.,Villanova University, M. Louise Fitzpatrick College of Nursing, Villanova, Pennsylvania
| | - Suzanne Hyer
- University of Central Florida, College of Nursing, Orlando, Florida
| | - Jan Kavookjian
- American Association of Diabetes Educators, Research Committee, Chicago, Illinois.,Auburn University, Harrison School of Pharmacy, Auburn University, Alabama
| |
Collapse
|
27
|
LeRoith D, Biessels GJ, Braithwaite SS, Casanueva FF, Draznin B, Halter JB, Hirsch IB, McDonnell ME, Molitch ME, Murad MH, Sinclair AJ. Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab 2019; 104:1520-1574. [PMID: 30903688 PMCID: PMC7271968 DOI: 10.1210/jc.2019-00198] [Citation(s) in RCA: 268] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/25/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults. CONCLUSIONS Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.
Collapse
Affiliation(s)
- Derek LeRoith
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Susan S Braithwaite
- Presence Saint Francis Hospital, Evanston, Illinois
- Presence Saint Joseph Hospital, Chicago, Illinois
| | - Felipe F Casanueva
- Complejo Hospitalario Universitario de Santiago, CIBER de Fisiopatologia Obesidad y Nutricion, Instituto Salud Carlos III, Santiago de Compostela, Spain
| | - Boris Draznin
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Jeffrey B Halter
- University of Michigan, Ann Arbor, Michigan
- National University of Singapore, Singapore, Singapore
| | - Irl B Hirsch
- University of Washington Medical Center–Roosevelt, Seattle, Washington
| | - Marie E McDonnell
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark E Molitch
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
28
|
Sinclair AJ, Gadsby R, Abdelhafiz AH, Kennedy M. Failing to meet the needs of generations of care home residents with diabetes: a review of the literature and a call for action. Diabet Med 2018; 35:1144-1156. [PMID: 29873423 DOI: 10.1111/dme.13702] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 12/20/2022]
Abstract
In residential care homes and aged-care facilities globally, between one in three and one in four residents may have diabetes, an often complex highly co-morbid illness that leads to frailty, dependency, disability and reduced life expectancy. Residents with diabetes also have a high risk of hypoglycaemia, avoidable hospital admissions, and represent one of the most difficult challenges to health professionals and care staff in optimizing their diabetes and medical care. This detailed review examines the literature relating to care home diabetes over the last 25 years to assess what has been achieved in characterizing residents with diabetes, and what we know about the various but limited intervention studies that have been carried out internationally. The guidance and guidelines that have been published to assist clinicians in planning effective and safe care for this rather vulnerable group of people with diabetes are also reviewed. The review presents the first diagrammatic representation of a likely physiological cascade depicting the mainly irreversible functional decline a resident with diabetes might experience, provides modern principles of care for each resident with diabetes, and identifies what priority recommendations are required to be implemented if diabetes care is to improve. The review concludes that action is required since diabetes care still remains fragmented, sub-optimal, and in need of investment, otherwise care home residents with diabetes will continue to have their needs unfulfilled.
Collapse
Affiliation(s)
- A J Sinclair
- Foundation for Diabetes Research in Older People and University of Aston, UK
| | - R Gadsby
- Warwick Medical School, Warwick, UK
| | - A H Abdelhafiz
- Department of Elderly Medicine, Rotherham General Hospital, UK
| | - M Kennedy
- Corio Medical Clinic, Victoria, Australia
| |
Collapse
|
29
|
Umpierrez GE, Cardona S, Chachkhiani D, Fayfman M, Saiyed S, Wang H, Vellanki P, Haw JS, Olson DE, Pasquel FJ, Johnson TM. A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial. J Am Med Dir Assoc 2018; 19:399-404.e3. [PMID: 29289540 PMCID: PMC6093296 DOI: 10.1016/j.jamda.2017.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities. DESIGN This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM. SETTINGS Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia. PARTICIPANTS A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%. INTERVENTION Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL. MEASUREMENTS Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers. RESULTS Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations. CONCLUSION Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.
Collapse
Affiliation(s)
| | | | | | - Maya Fayfman
- Department of Medicine, Emory University, Atlanta, GA
| | - Sahebi Saiyed
- Department of Medicine, Emory University, Atlanta, GA
| | - Heqiong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - J Sonya Haw
- Department of Medicine, Emory University, Atlanta, GA
| | - Darin E Olson
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Theodore M Johnson
- Department of Medicine, Emory University, Atlanta, GA; Birmingham/Atlanta VA GRECC
| |
Collapse
|
30
|
Tuo Y, Xiang M. mTOR: A double‐edged sword for diabetes. J Leukoc Biol 2018; 106:385-395. [DOI: 10.1002/jlb.3mr0317-095rr] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 09/05/2017] [Accepted: 09/14/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Yali Tuo
- Department of PharmacologySchool of PharmacyTongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Ming Xiang
- Department of PharmacologySchool of PharmacyTongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| |
Collapse
|
31
|
Hambling CE, Seidu SI, Davies MJ, Khunti K. Older people with Type 2 diabetes, including those with chronic kidney disease or dementia, are commonly overtreated with sulfonylurea or insulin therapies. Diabet Med 2017; 34:1219-1227. [PMID: 28498634 DOI: 10.1111/dme.13380] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2017] [Indexed: 01/11/2023]
Abstract
AIM To evaluate potential overtreatment with sulfonylurea and insulin therapies amongst older people with Type 2 diabetes, including those with chronic kidney disease or dementia. METHODS Using the ECLIPSE Live software tool, we developed a search to examine data on older people (age ≥ 70 years) with Type 2 diabetes, who were prescribed sulfonylurea or insulin therapies over the previous 90 days. Sixteen Norfolk general practices participated, representing a population of 24 661 older people, including 3862 (15.7%) with Type 2 diabetes. Of these, 1379 (35.7%) people were prescribed sulfonylurea or insulin therapies. Data extracted included age, sex, last recorded HbA1c value, renal function and dementia codes. RESULTS The median age of the study cohort was 78 years. A total of 644 people (47.8%) had chronic kidney disease (estimated GFR < 60 mL/min/1.73m2 ) and 60 people (4.35%) had dementia. The median (interquartile range) HbA1c concentration for the entire cohort was 58 (51-69) mmol/mol [7.5 (6.8-8.5)%], with no difference in median HbA1c between those with or without either chronic kidney disease or dementia. In total, 400 older people (29.9%) had an HbA1c concentration < 53 mmol/mol (7%), of whom 162 (12.1%) had HbA1c < 48 mmol/mol (6.5%). Stratified by prescription for sulfonylurea, insulin or combined insulin and sulfonylurea therapies, 282 (35.2%), 93 (24.2%) and 25 people (16.3%), respectively, had HbA1c < 53 mmol/mol (7.0%). Treatment to an HbA1c target of < 53 mmol/mol (7.0%) was as prevalent in those with chronic kidney disease or dementia as in those without. CONCLUSION In the present cohort of older people with Type 2 diabetes prescribed sulfonylurea or insulin therapies, overtreatment was common, even in the presence of comorbidities known to increase hypoglycaemia risk.
Collapse
Affiliation(s)
- C E Hambling
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester
- West Norfolk Clinical Commissioning Group, King's Lynn, Norfolk
| | - S I Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester
| | - M J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester
- University Hospitals of Leicester NHS Trusts, Leicester, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester
| |
Collapse
|
32
|
McCracken R, McCormack J, McGregor MJ, Wong ST, Garrison S. Associations between polypharmacy and treatment intensity for hypertension and diabetes: a cross-sectional study of nursing home patients in British Columbia, Canada. BMJ Open 2017; 7:e017430. [PMID: 28801438 PMCID: PMC5724061 DOI: 10.1136/bmjopen-2017-017430] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Describe nursing home polypharmacy prevalence in the context of prescribing for diabetes and hypertension and determine possible associations between lower surrogate markers for treated hypertension and diabetes (overtreatment) and polypharmacy. DESIGN Cross-sectional study. SETTING 6 nursing homes in British Columbia, Canada. PARTICIPANTS 214 patients residing in one of the selected facilities during data collection period. PRIMARY AND SECONDARY OUTCOME MEASURES Polypharmacy was defined as ≥9 regular medications. Overtreatment of diabetes was defined as being prescribed at least one hypoglycaemic medication and a glycosylated haemoglobin (HbA1c) ≤7.5%. Overtreatment of hypertension required being prescribed at least one hypertension medication and having a systolic blood pressure ≤128 mm Hg. Polypharmacy prescribing, independent of overtreatment, was calculated by subtracting condition-specific medications from total medications prescribed. RESULTS Data gathering was completed for 214 patients, 104 (48%) of whom were prescribed ≥9 medications. All patients were very frail. Patients with polypharmacy were more likely to have a diagnosis of hypertension (p=0.04) or congestive heart failure (p=0.003) and less likely to have a diagnosis of dementia (p=0.03). Patients with overtreated hypertension were more likely to also experience polypharmacy (Relative Risk (RR))1.77 (1.07 to 2.96), p=0.027). Patients with overtreated diabetes were prescribed more non-diabetic medications than those with a higher HbA1c (11.0±3.7vs 7.2±3.1, p=0.01). CONCLUSION Overtreated diabetes and hypertension appear to be prevalent in nursing home patients, and the presence of polypharmacy is associated with more aggressive treatment of these risk factors. The present study was limited by its small sample size and cross-sectional design. Further study of interventions designed to reduce overtreatment of hypertension and diabetes is needed to fully understand the potential links between polypharmacy and potential of harms of condition-specific overtreatment.
Collapse
Affiliation(s)
- Rita McCracken
- Department of Family Medicine, Providence Health Care, Vancouver, Canada
- Department of Family Practice, University of British Columbia, Vancouver, Canada
| | - James McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Margaret J McGregor
- Department of Family Practice, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, Canada
| | - Sabrina T Wong
- Department of Family Practice, University of British Columbia, Vancouver, Canada
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Scott Garrison
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| |
Collapse
|
33
|
Umpierrez GE, Pasquel FJ. Management of Inpatient Hyperglycemia and Diabetes in Older Adults. Diabetes Care 2017; 40:509-517. [PMID: 28325798 PMCID: PMC5864102 DOI: 10.2337/dc16-0989] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 11/02/2016] [Indexed: 02/03/2023]
Abstract
Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65-75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non-ICU settings; however, glycemic targets should be individualized in older adults on the basis of a patient's clinical status, risk of hypoglycemia, and presence of diabetes complications. Insulin is the preferred agent to manage hyperglycemia and diabetes in the hospital. Continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings are effective in achieving glycemic goals. Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin have been shown to be safe and effective and may represent an alternative to basal-bolus regimens in elderly patients. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin as well as education in basic skills for home management.
Collapse
Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Francisco J Pasquel
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
34
|
Patell R, Nigmatoulline D, Bena J, Kim DG, Messinger-Rapport B, Lansang MC. HYPERGLYCEMIA AND HYPOGLYCEMIA IN PATIENTS WITH DIABETES IN SKILLED NURSING FACILITIES. Endocr Pract 2017; 23:458-465. [PMID: 28156156 DOI: 10.4158/ep161502.or] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Endocrinologists are faced with a growing elderly patient population with diabetes mellitus (DM), some of whom are in skilled nursing facilities (SNFs). Efforts at managing their DM is hampered by concerns for hypoglycemia. This study aimed to determine the frequency of hypo- and hyperglycemia in SNFs, and associated factors. METHODS We reviewed medical records of 200 consecutive residents admitted to two SNFs in the Cleveland area in 2014 with documented DM, aged ≥65 years. Data collected included blood glucose (BG) levels and DM regimens. Frequency of hyper- and hypoglycemic events was noted. Since patients had different frequencies of BG checks, event-days were calculated. RESULTS Mean age, BG, and glycated hemoglobin (±SD) were as follows: 80.2 ± 8.2 years, 172.4 ± 40.3 mg/dL, and 7.5 ± 1.9% (59 mmol/mol), respectively. Seventy-one percent were on insulin alone, 15.5% on insulin and oral diabetes agents, and 13.5% on oral diabetes agent on admission. Patients with at least one event were as follows: 38% hypoglycemia, 3.5% severe hypoglycemia, 90.5% hyperglycemia, and 15% severe hyperglycemia. Event-days were: 3.4% hypoglycemia and 52.4% hyperglycemia. Risk of hypoglycemia was highest with concomitant sulfonylurea and prandial or sliding-scale insulin. Hyperglycemia risk was high in basal insulin-containing regimens. CONCLUSION Hypoglycemia was seen in one-third of patients, and hyperglycemia was common despite insulin use. Concomitant use of sulfonylurea and prandial or sliding-scale insulin is best avoided in this fragile population with hypo- and hyperglycemia. ABBREVIATIONS ADA = American Diabetes Association BG = blood glucose DM = diabetes mellitus GLP-1 = glucagon-like peptide 1 HBA1c = glycated hemoglobin LOS = length of stay NPH = neutral protamine Hagedorn SNF = skilled nursing facility SSI = sliding-scale insulin.
Collapse
|
35
|
Retornaz F, Grino M, Mari L, Oliver C. Assessment of Glycemic Control in Nursing Home Residents with Diabetes. J Nutr Health Aging 2017; 21:457-463. [PMID: 28346573 DOI: 10.1007/s12603-016-0776-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe glycemic control in nursing home residents with diabetes and to evaluate the relevance of HbA1c in the detection of hypoglycemia risk. DESIGN AND METHODS Diabetes treatment, geriatric assessment, blood capillary glucose (n= 24,682), and HbA1c were collected from medical charts of 236 southern France nursing home residents during a 4-month period. Glycemic control was divided into four categories: tight, fair, and moderate or severe chronic hyperglycemia using the High Blood Glucose Index or the analysis of blood glucose frequency distribution. Hypoglycemia episodes were identified by medical or biological records. RESULTS Glucose control was tight in 59.3 % and fair in 19.1 % of the residents. Chronic exposure to hyperglycemia was observed in 21.6 % of the residents (severe in 9.7 % and moderate in 11.9 %). Hypoglycemia was noticed in 42/236 (17.8%), in all categories of glycemic control. Relative hypoglycemia risk was significantly (P = 0.0095) higher in residents with moderate chronic hyperglycemia compared with those with tight control. The majority of residents with hypoglycemia (39/42) or chronic hyperglycemia (45/51) were insulin-treated. The relative risk of hypoglycemia was not significantly associated with HbA1c values. CONCLUSION Hypoglycemia risk in nursing home residents is observed in all categories of glycemic control. In tight control, the potency of antidiabetic treatment should be reduced. In chronic hyperglycemia, diet and treatment should be reevaluated in order to reduce glucose variability. HbA1c is not sufficient for hypoglycemia risk detection; capillary blood glucose monitoring is warranted for nursing homes residents with diabetes.
Collapse
Affiliation(s)
- F Retornaz
- Dr Charles Oliver, Division of Geriatric Medicine, State Geriatric Centre, 176 Avenue de Montolivet, 13012 Marseille, Tel: 04 91 12 75 49, Fax: 04 91 12 75 52, e-mail:
| | | | | | | |
Collapse
|
36
|
Boonin A, Balinski B, Sauter J, Martinez J, Abbott S. A Retrospective Chart Review of Two Different Insulin Administration Systems on Glycemic Control in Older Adults in Long-Term Care. J Gerontol Nurs 2017; 43:10-16. [PMID: 28091686 DOI: 10.3928/00989134-20161215-04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The current retrospective chart review compared glycemic control and cost impact of two insulin administration systems, V-Go® versus usual care with standard of care (SOC) insulin injections, in eight patients residing in a nursing home (NH). A total of 1,937 blood glucose (BG) values were collected over 61 days. Significant improvements were observed for the V-Go versus SOC group in time in range 100 mg/dL to 200 mg/dL (V-Go 59.09% vs. SOC 34.02%; p < 0.001), reduced BG fluctuations as measured by standard deviation (V-Go 61.2 vs. SOC 92.1; p < 0.001), and improved mean daily BG (V-Go 159.38 mg/dL vs. SOC 223.86 mg/dL; p < 0.001). The estimated A1c change, calculated from BG values, decreased from 8.9% to 7.2% in the V-Go group and increased from 9.0% to 9.4% in the SOC group. Compared to SOC, use of V-Go decreased the mean time for insulin administration by nursing staff by 26.3 minutes per patient per day and associated labor costs by $328.75 per patient per month. Insulin administration with V-Go may improve glycemic control and reduce administration costs compared to existing care in the NH setting. [Journal of Gerontological Nursing, 43(1), 10-16.].
Collapse
|
37
|
Diabetes-Associated Factors as Predictors of Nursing Home Admission and Costs in the Elderly Across Europe. J Am Med Dir Assoc 2017; 18:74-82. [DOI: 10.1016/j.jamda.2016.09.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 11/18/2022]
|
38
|
Andreassen LM, Granas AG, Sølvik UØ, Kjome RLS. ‘I try not to bother the residents too much’ – the use of capillary blood glucose measurements in nursing homes. BMC Nurs 2016; 15:7. [PMID: 26855612 PMCID: PMC4743135 DOI: 10.1186/s12912-016-0129-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 01/26/2016] [Indexed: 01/21/2023] Open
|
39
|
Munshi MN, Florez H, Huang ES, Kalyani RR, Mupanomunda M, Pandya N, Swift CS, Taveira TH, Haas LB. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care 2016; 39:308-18. [PMID: 26798150 PMCID: PMC5317234 DOI: 10.2337/dc15-2512] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.
Collapse
Affiliation(s)
- Medha N Munshi
- Beth Israel Deaconess Medical Center and Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Hermes Florez
- Geriatric Research Education and Clinical Centers, Miami Veterans Affairs Healthcare System and University of Miami, Miami, FL
| | - Elbert S Huang
- Section of General Internal Medicine, The University of Chicago, Chicago, IL
| | - Rita R Kalyani
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Naushira Pandya
- Department of Geriatrics, Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, FL
| | | | | | | |
Collapse
|
40
|
Culley CM, Perera S, Marcum ZA, Kane-Gill SL, Handler SM. Using a Clinical Surveillance System to Detect Drug-Associated Hypoglycemia in Nursing Home Residents. J Am Geriatr Soc 2015; 63:2125-9. [PMID: 26456318 PMCID: PMC4778416 DOI: 10.1111/jgs.13648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine whether a clinical surveillance system could be used to detect drug-associated hypoglycemia events and determine their incidence in nursing home (NH) residents. DESIGN Retrospective cohort. SETTING Four NHs in western Pennsylvania. PARTICIPANTS Any resident of the four NHs who had a computer-generated alert detecting potential drug-associated hypoglycemia over a 6-month period were included. MEASUREMENTS Descriptive statistics were used to summarize all variables, including the frequency and distribution of alert type according to glucose threshold. Analyses were conducted according to numbers of alerts and residents. The medications associated with the drug-associated hypoglycemia alerts were identified, and frequency of their inclusion in alerts was calculated. Additional calculations included time to drug-associated hypoglycemic event alert from date of admission and frequency of events associated with postacute, short-stay (≤35 days) admissions. RESULTS Seven hundred seventy-two alerts involving 141 residents were detected. Ninety (63.8%) residents had a glucose level of 55 mg/dL or less, and 42 (29.8%) had a glucose level of 40 mg/dL or less. Insulin orders were associated with 762 (98.7%) alerts. Overall incidence of drug-associated hypoglycemia events was 9.5 per 1,000 resident-days. CONCLUSION Hypoglycemia can be detected using a clinical surveillance system. This evaluation found a high incidence of drug-associated hypoglycemia in a general NH population. Future studies are needed to determine the potential benefits of use of a surveillance system in real-time detection and management of hypoglycemia in NHs.
Collapse
Affiliation(s)
- Colleen M. Culley
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Subashan Perera
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Zachary A. Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA
| | - Sandra L. Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Steven M. Handler
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
41
|
Pasquel FJ, Powell W, Peng L, Johnson TM, Sadeghi-Yarandi S, Newton C, Smiley D, Toyoshima MT, Aram P, Umpierrez GE. A randomized controlled trial comparing treatment with oral agents and basal insulin in elderly patients with type 2 diabetes in long-term care facilities. BMJ Open Diabetes Res Care 2015; 3:e000104. [PMID: 26336609 PMCID: PMC4553905 DOI: 10.1136/bmjdrc-2015-000104] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Managing hyperglycemia and diabetes is challenging in geriatric patients admitted to long-term care (LTC) facilities. METHODS This randomized control trial enrolled patients with type 2 diabetes (T2D) with blood glucose (BG) >180 mg/dL or glycated hemoglobin >7.5% to receive low-dose basal insulin (glargine, starting dose 0.1 U/kg/day) or oral antidiabetic drug (OAD) therapy as per primary care provider discretion for 26 weeks. Both groups received supplemental rapid-acting insulin before meals for BG >200 mg/dL. Primary end point was difference in glycemic control as measured by fasting and mean daily glucose concentration between groups. RESULTS A total of 150 patients (age: 79±8 years, body mass index: 30.1±6.5 kg/m(2), duration of diabetes mellitus: 8.2±5.1 years, randomization BG: 194±97 mg/dL) were randomized to basal insulin (n=75) and OAD therapy (n=75). There were no differences in the mean fasting BG (131±27 mg/dL vs 123±23 mg/dL, p=0.06) between insulin and OAD groups, but patients treated with insulin had greater mean daily BG (163±39 mg/dL vs 138±27 mg/dL, p<0.001) compared to those treated with OADs. There were no differences in the rate of hypoglycemia (<70 mg/dL) between insulin (27%) and OAD (31%) groups, p=0.58. In addition, there were no differences in the number of hospital complications, emergency room visits, and mortality between treatment groups. CONCLUSIONS The results of this randomized study indicate that elderly patients with T2D in LTC facilities exhibited similar glycemic control, hypoglycemic events and complications when treated with either basal insulin or with oral antidiabetic drugs. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01131052.
Collapse
Affiliation(s)
- Francisco J Pasquel
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Winter Powell
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Limin Peng
- Departments of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Theodore M Johnson
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Christopher Newton
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dawn Smiley
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos T Toyoshima
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pedram Aram
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | |
Collapse
|
42
|
Abstract
With the aging of the population and longer life expectancies, the prevalence of population with multiple chronic medical conditions has increased. Difficulty managing these conditions as people age (because of changes in physical, functional, or cognitive abilities and the complexity of many treatment regimens), has led to more individuals with multiple medical conditions admitted to the long-term care facilities. Older adults with diabetes residing in the long-term facilities represent the most vulnerable of this cohort. Studies that specifically target diabetes management in older population are lacking and those that target diabetes management in the long-term care facilities are even fewer. The lack of knowledge regarding the care of the elderly residing in long-term care with diabetes may lead to treatment failure and higher risk of hyperglycemia, as well as hypoglycemia. In aging populations, hypoglycemia has the potential for catastrophic consequences. To avoid this, the management of older population with diabetes and other medical comorbidities residing in long-term care facilities requires a more holistic approach compared with focusing on individual chronic disease goal achievement.
Collapse
|
43
|
How to Manage Diabetes Mellitus in Older Persons in the 21st Century: Applying These Principles to Long Term Diabetes Care. J Am Med Dir Assoc 2013; 14:777-80. [DOI: 10.1016/j.jamda.2013.09.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 09/04/2013] [Indexed: 12/25/2022]
|