1
|
Yanaizumi R, Nagamine Y, Harada S, Goto T. Hypoglycemia in Terminally Ill Patients with Cancer with a History of Diabetes Mellitus Admitted to a General Ward: A Retrospective Observational Study. Palliat Med Rep 2024; 5:373-380. [PMID: 39281187 PMCID: PMC11392688 DOI: 10.1089/pmr.2024.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2024] [Indexed: 09/18/2024] Open
Abstract
Background Poor glycemic control may be a risk factor for hypoglycemia in terminally ill patients with cancer with a history of diabetes mellitus (DM). However, no guidelines have been established for achieving glycemic control in this patient population, and epidemiological information remains lacking. Objectives We aimed to investigate the prevalence of hypoglycemic episodes and provide epidemiological information on hypoglycemia in terminally ill patients with cancer with a history of DM admitted to a general ward. Design This was a single-center, retrospective, observational study. Setting/Subjects This study enrolled terminally ill patients with cancer with a history of DM, receiving palliative care at a hospital in Japan between January 2017 and July 2022. Measurements Data extracted from the patients' medical records were age, sex, body mass index, primary cancer, liver metastases, dialysis status, Eastern Cooperative Oncology Group performance status score, type and duration of DM, HbA1c level, and use of diabetes medications (antihyperglycemic agents and types and insulin) at the time of initial visit within 180 days of death. Results Among the 104 patients included in the analysis, hypoglycemic episodes occurred in 36 patients (34.6%). The total number of hypoglycemic episodes was 132, and the median number of hypoglycemic episodes for each patient during hospitalization was 2.5 (interquartile range, 1-6). Conclusions The prevalence of hypoglycemia in terminally ill patients with cancer with a history of DM who were admitted to a Japanese general ward was 34.6%. Further studies are needed to determine the frequency of hypoglycemia because of overtreatment in this patient population.
Collapse
Affiliation(s)
- Ryota Yanaizumi
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Yusuke Nagamine
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan
| | | | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan
| |
Collapse
|
2
|
Elsten EECM, Pot IE, Geijteman ECT, Hedman C, van der Heide A, van der Kuy PHM, Fürst CJ, Eychmüller S, van Zuylen L, van der Rijt CCD. Recommendations for Deprescribing of Medication in the Last Phase of Life: An International Delphi Study. J Pain Symptom Manage 2024:S0885-3924(24)00909-6. [PMID: 39094669 DOI: 10.1016/j.jpainsymman.2024.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
CONTEXT Medications may become inappropriate for patients in the last phase of life and may even compromise their quality of life. OBJECTIVE To find consensus on recommendations regarding deprescribing of medications for adult patients with a life expectancy of six months or less. METHODS Experts working in palliative care or other relevant disciplines were asked to participate in this international Delphi study. Existing tools for deprescribing of medication in the last phase of life were integrated in a list of 42 recommendations regarding potential deprescription of various medication types. In two Delphi rounds, experts were asked to rate their agreement with each recommendation on a 5-point Likert-scale (strongly agree-strongly disagree). Recommendations were accepted, if at least 70% of the experts (strongly) agreed, the interquartile range (IQR) was one or less, and less than 10% strongly disagreed. RESULTS About 47 experts from 10 countries participated (response rate 53%). In most cases (76%), consensus was reached on deprescribing recommendations for patients with a life expectancy of six months or less. The highest level of consensus was reached for recommendations on the deprescription of diuretics in case of decreasing fluid intake or increasing fluid loss, lipid modifying agents if prescribed for primary prevention, and vitamin K antagonists and direct oral anticoagulants in case of high bleeding risk. CONCLUSION A high level of consensus was reached on recommendations on potential deprescription of several medications for patients with a life expectancy of six months or less.
Collapse
Affiliation(s)
- Eline E C M Elsten
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands; Department of Public Health (E.E.C.M.E., A.V.D.H.), Erasmus Medical Center, University Medical Center Rotterdam, Netherlands
| | - Iris E Pot
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands
| | - Christel Hedman
- R & D Department (C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden; Department of Molecular Medicine and Surgery (C.H.), Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences (C.H.), Lund University, Lund, Sweden; Institute for Palliative Care (C.H., C.J.F.), Lund University and Region Skåne, Lund, Sweden
| | - Agnes van der Heide
- Department of Public Health (E.E.C.M.E., A.V.D.H.), Erasmus Medical Center, University Medical Center Rotterdam, Netherlands
| | - P Hugo M van der Kuy
- Department of Hospital Pharmacy (H.V.D.K.), Erasmus Medical Center, Rotterdam, Netherlands
| | - Carl-Johan Fürst
- Institute for Palliative Care (C.H., C.J.F.), Lund University and Region Skåne, Lund, Sweden
| | - Steffen Eychmüller
- University Center for Palliative Care (S.E.), University Hospital Inselspital Bern, Bern, Switzerland
| | - Lia van Zuylen
- Department of Medical Oncology (L.V.Z.), Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology (E.E.C.M.E., I.E.P., E.C.T.G., C.C.D.V.D.R.), Erasmus Medical Center, Cancer Institute Rotterdam, Netherlands
| |
Collapse
|
3
|
Boockvar KS, Huan T, Curyto K, Lee S, Intrator O. Increase in blood pressure precedes distress behavior in nursing home residents with dementia. PLoS One 2024; 19:e0298281. [PMID: 38687764 PMCID: PMC11060555 DOI: 10.1371/journal.pone.0298281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/22/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Distress behaviors in dementia (DBD) likely increase sympathetic nervous system activity. The aim of this study was to examine the associations among DBD, blood pressure (BP), and intensity of antihypertensive treatment, in nursing home (NH) residents with dementia. METHODS We identified long-stay Veterans Affairs NH residents with dementia in 2019-20 electronic health data. Each individual with a BP reading and a DBD incident according to a structured behavior note on a calendar day (DBD group) was compared with an individual with a BP reading but without a DBD incident on that same day (comparison group). In each group we calculated daily mean BP from 14 days before to 7 days after the DBD incident day. We then calculated the change in BP between the DBD incident day and, as baseline, the 7-day average of BP 1 week prior, and tested for differences between DBD and comparison groups in a generalized estimating equations multivariate model. RESULTS The DBD and comparison groups consisted of 707 and 2328 individuals, respectively. The DBD group was older (74 vs. 72 y), was more likely to have severe cognitive impairment (13% vs. 8%), and had worse physical function scores (15 vs. 13 on 28-point scale). In the DBD group, mean systolic BP on the DBD incident day was 1.6 mmHg higher than baseline (p < .001), a change that was not observed in the comparison group. After adjusting for covariates, residents in the DBD group, but not the comparison group, had increased likelihood of having systolic BP > = 160 mmHg on DBD incident days (OR 1.02; 95%CI 1.00-1.03). Systolic BP in the DBD group began to rise 7 days before the DBD incident day and this rise persisted 1 week after. There were no significant changes in mean number of antihypertensive medications over this time period in either group. CONCLUSIONS NH residents with dementia have higher BP when they experience DBD, and BP rises 7 days before the DBD incident. Clinicians should be aware of these findings when deciding intensity of BP treatment.
Collapse
Affiliation(s)
- Kenneth S. Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, Alabama, United States of America
- Geriatrics Research, Education, and Clinical Center, Birmingham VA Health Care System, Birmingham, Alabama, United States of America
- Institute on Aging, The New Jewish Home, New York, New York, United States of America
| | - Tianwen Huan
- University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Geriatrics & Extended Care Data Analysis Center, Canandaigua VAMC, Canandaigua, New York, United States of America
| | - Kimberly Curyto
- VA Western New York Healthcare System, Center for Integrated Healthcare, Buffalo, New York, United States of America
| | - Sei Lee
- University of California, San Francisco, California, United States of America
- San Francisco VA Health Care System, San Francisco, California, United States of America
| | - Orna Intrator
- University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Geriatrics & Extended Care Data Analysis Center, Canandaigua VAMC, Canandaigua, New York, United States of America
| |
Collapse
|
4
|
ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 13. Older Adults: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S244-S257. [PMID: 38078580 PMCID: PMC10725804 DOI: 10.2337/dc24-s013] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
5
|
Huang ES, Sinclair A, Conlin PR, Cukierman-Yaffe T, Hirsch IB, Huisingh-Scheetz M, Kahkoska AR, Laffel L, Lee AK, Lee S, Lipska K, Meneilly G, Pandya N, Peek ME, Peters A, Pratley RE, Sherifali D, Toschi E, Umpierrez G, Weinstock RS, Munshi M. The Growing Role of Technology in the Care of Older Adults With Diabetes. Diabetes Care 2023; 46:1455-1463. [PMID: 37471606 PMCID: PMC10369127 DOI: 10.2337/dci23-0021] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 07/22/2023]
Abstract
The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregivers. Among people with diabetes, older adults are a distinct subpopulation in terms of their clinical heterogeneity, care priorities, and technology integration. The scientific evidence and clinical experience with these technologies among older adults are growing but are still modest. In this review, we describe the current knowledge regarding the impact of technology in older adults with diabetes, identify major barriers to the use of existing and emerging technologies, describe areas of care that could be optimized by technology, and identify areas for future research to fulfill the potential promise of evidence-based technology integrated into care for this important population.
Collapse
Affiliation(s)
| | | | - Paul R. Conlin
- Harvard Medical School, Boston, MA
- Veteran Affairs Boston Healthcare System, Boston, MA
| | - Tali Cukierman-Yaffe
- Division of Endocrinology, Diabetes, and Metabolism, Ramat Gan, Israel
- Sheba Medical Centre, Ramat Gan, Israel
- Epidemiology Department, Sackler Faculty of Medicine, Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | | | | | - Sei Lee
- University of California San Francisco, San Francisco, CA
| | | | - Graydon Meneilly
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Naushira Pandya
- Department of Geriatrics, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL
| | | | - Anne Peters
- University of Southern California, Los Angeles, CA
| | - Richard E. Pratley
- AdventHealth Diabetes Institute, AdventHealth Translational Research Institute, AdventHealth, Orlando, FL
| | | | | | | | | | | |
Collapse
|
6
|
Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Golden SH, Mathioudakis NN, Maruthur NM. A National Physician Survey of Deintensifying Diabetes Medications for Older Adults With Type 2 Diabetes. Diabetes Care 2023; 46:1164-1168. [PMID: 36800554 PMCID: PMC10234750 DOI: 10.2337/dc22-2146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE To determine physicians' approach to deintensifying (reducing/stopping) or switching hypoglycemia-causing medications for older adults with type 2 diabetes. RESEARCH DESIGN AND METHODS In this national survey, U.S. physicians in general medicine, geriatrics, or endocrinology reported changes they would make to hypoglycemia-causing medications for older adults in three scenarios: good health, HbA1c of 6.3%; complex health, HbA1c of 7.3%; and poor health, HbA1c of 7.7%. RESULTS There were 445 eligible respondents (response rate 37.5%). In patient scenarios, 48%, 4%, and 20% of physicians deintensified hypoglycemia-causing medications for patients with good, complex, and poor health, respectively. Overall, 17% of physicians switched medications without significant differences by patient health. One-half of physicians selected HbA1c targets below guideline recommendations for older adults with complex or poor health. CONCLUSIONS Most U.S. physicians would not deintensify or switch hypoglycemia-causing medications within guideline-recommended HbA1c targets. Physician preference for lower HbA1c targets than guidelines needs to be addressed to optimize deintensification decisions.
Collapse
Affiliation(s)
- Scott J. Pilla
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Rabia Jalalzai
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Nancy L. Schoenborn
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cynthia M. Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sherita H. Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nestoras N. Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nisa M. Maruthur
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
7
|
ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Jeffrie Seley J, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 13. Older Adults: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S216-S229. [PMID: 36507638 PMCID: PMC9810468 DOI: 10.2337/dc23-s013] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
8
|
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
|
9
|
Polypharmacy in Hospice and Palliative Care. Clin Geriatr Med 2022; 38:693-704. [DOI: 10.1016/j.cger.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Ali S, Curtain CM, Bereznicki LR, Salahudeen MS. Actual drug-related harms in residential aged care facilities: a narrative review. Expert Opin Drug Saf 2022; 21:1047-1060. [PMID: 35634890 DOI: 10.1080/14740338.2022.2084071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods. AREAS COVERED The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms. EXPERT OPINION The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.
Collapse
Affiliation(s)
- Sheraz Ali
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Colin M Curtain
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Luke Re Bereznicki
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Mohammed S Salahudeen
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| |
Collapse
|
12
|
Pilla SJ, Shahidzadeh Yazdi Z, Taylor SI. Individualized Glycemic Goals for Older Adults Are a Moving Target. Diabetes Care 2022; 45:1029-1031. [PMID: 35561130 PMCID: PMC9375443 DOI: 10.2337/dci22-0004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Scott J. Pilla
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Zhinous Shahidzadeh Yazdi
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Simeon I. Taylor
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
13
|
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
14
|
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW A patient's prognosis and risk of adverse drug effects are important considerations for individualizing care of older patients with diabetes. This review summarizes the evidence for risk assessment and proposes approaches for clinicians in the context of current clinical guidelines. RECENT FINDINGS Diabetes guidelines vary in their recommendations for how life expectancy should be estimated and used to inform the selection of glycemic targets. Readily available prognostic tools may improve estimation of life expectancy but require validation among patients with diabetes. Treatment decisions based on prognosis are difficult for clinicians to communicate and for patients to understand. Determining hypoglycemia risk involves assessing major risk factors; models to synthesize these factors have been developed. Applying risk assessment to individualize diabetes care is complex and currently relies heavily on clinician judgment. More research is need to validate structured approaches to risk assessment and determine how to incorporate them into patient-centered diabetes care.
Collapse
Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA.
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elbert S Huang
- Division of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| |
Collapse
|
18
|
Abstract
In the United States, the adult population that will need hospice and palliative care is expected to double in the next 40 years. In primary care, providers are often faced with tough decisions on how to manage patients' medications at the end of life. This article describes how to deprescribe in the last year of life.
Collapse
|