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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.
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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.
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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.
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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
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Lam K, Gan S, Nguyen B, Jing B, Lee SJ. Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes. J Am Geriatr Soc 2022; 70:2008-2018. [PMID: 35357692 PMCID: PMC9283241 DOI: 10.1111/jgs.17771] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Guidelines discourage sliding scale insulin (SSI) use after the first week of a nursing home (NH) admission. We sought to determine the prevalence of SSI and identify factors associated with stopping SSI or transitioning to another short-acting insulin regimen. METHODS In an observational study from October 1, 2013, to June 30, 2017 of non-hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week, we compared the weekly prevalence of SSI versus two other short-acting insulin regimens - fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) - from week 2 to week 12 of admission. Among those on SSI in week 2, we examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty-related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes-related factors (e.g., HbA1c, long-acting insulin use, hyperglycemia, and hypoglycemia). RESULTS In week 2, 21% of our cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate-severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes-related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non-SSI short-acting insulin regimen than frailty-related factors. CONCLUSIONS SSI is the most common method of administering short-acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.
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Affiliation(s)
- Kenneth Lam
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
| | - Siqi Gan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Brian Nguyen
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Sei J. Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
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Munshi MN, Meneilly GS, Rodríguez-Mañas L, Close KL, Conlin PR, Cukierman-Yaffe T, Forbes A, Ganda OP, Kahn CR, Huang E, Laffel LM, Lee CG, Lee S, Nathan DM, Pandya N, Pratley R, Gabbay R, Sinclair AJ. Diabetes in ageing: pathways for developing the evidence base for clinical guidance. Lancet Diabetes Endocrinol 2020; 8:855-867. [PMID: 32946822 PMCID: PMC8223534 DOI: 10.1016/s2213-8587(20)30230-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/12/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023]
Abstract
Older adults with diabetes are heterogeneous in their medical, functional, and cognitive status, and require careful individualisation of their treatment regimens. However, in the absence of detailed information from clinical trials involving older people with varying characteristics, there is little evidence-based guidance, which is a notable limitation of current approaches to care. It is important to recognise that older people with diabetes might vary in their profiles according to age category, functional health, presence of frailty, and comorbidity profiles. In addition, all older adults with diabetes require an individualised approach to care, ranging from robust individuals to those residing in care homes with a short life expectancy, those requiring palliative care, or those requiring end-of-life management. In this Review, our multidisciplinary team of experts describes the current evidence in several important areas in geriatric diabetes, and outlines key research gaps and research questions in each of these areas with the aim to develop evidence-based recommendations to improve the outcomes of interest in older adults.
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Affiliation(s)
- Medha N Munshi
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | | | | | - Kelly L Close
- The diaTribe Foundation San Francisco, CA, USA; Close Concerns, San Francisco, CA, USA
| | - Paul R Conlin
- Harvard Medical School, Boston, MA, USA; Veteran Affairs Boston Healthcare System, Boston, MA, USA
| | - Tali Cukierman-Yaffe
- Division of Endocrinology, Diabetes and Metabolism, Gertner Institute, Ramat Gan, Israel; Sheba Medical Centre, Ramat Gan, Israel; Epidemiology Department, Sackler School of Medicine, Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel
| | | | - Om P Ganda
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - C Ronald Kahn
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - Elbert Huang
- Center for Chronic Disease Research and Policy, Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Lori M Laffel
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - Christine G Lee
- Division of Diabetes, Endocrinology and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sei Lee
- University of California San Francisco, San Francisco, CA, USA; Geriatrics and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - David M Nathan
- Harvard Medical School, Boston, MA, USA; Diabetes Research Center and Clinical Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Naushira Pandya
- Department of Geriatrics, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Aventura Hospital, Aventura, FL, USA
| | - Richard Pratley
- AdventHealth, AdventHealth Diabetes Institute, AdventHealth Translational Research Institute, Orlando, FL, USA
| | - Robert Gabbay
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - Alan J Sinclair
- King's College London, London, UK; Diabetes Frail, London, UK
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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.
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Affiliation(s)
- Naushira Pandya
- Department of Geriatrics, Nova Southeastern University, Fort Lauderdale, FL
| | - Elizabeth Hames
- Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL
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Alqabandi N, Haywood A, Kindl K, Khan S, Good P, Hardy J. Managing diabetes at the end of life – a retrospective chart audit of two health providers in Queensland, Australia. PROGRESS IN PALLIATIVE CARE 2019. [DOI: 10.1080/09699260.2019.1611721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Naeema Alqabandi
- School of Pharmacy and Pharmacology, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Alison Haywood
- School of Pharmacy and Pharmacology, Menzies Health Institute Queensland, Griffith University and Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Korana Kindl
- Palliative Care, St. Vincent’s Private Hospital, Brisbane and Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Sohil Khan
- School of Pharmacy and Pharmacology, Menzies Health Institute Queensland, Griffith University and Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Phillip Good
- Palliative Care, St. Vincent’s Private Hospital, Brisbane and Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Janet Hardy
- Department of Palliative and Supportive Care, Mater Health Services, Brisbane and Mater Research Institute – The University of Queensland, Brisbane, Australia
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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.
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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
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Morley JE. The Complexities of Diabetes in Older Persons. J Am Med Dir Assoc 2016; 17:872-4. [PMID: 27590405 DOI: 10.1016/j.jamda.2016.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/22/2016] [Indexed: 12/25/2022]
Affiliation(s)
- John E Morley
- Division of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO.
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