Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association

Comparative safety and cardiovascular effectiveness of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in nursing homes

AIM

Studies examining the safety and effectiveness of sodium-glucose cotransporter-2 inhibitors (SGLT2is) versus glucagon-like peptide-1 receptor agonists (GLP-1RAs) among community-dwelling adults may not generalize to nursing home (NH) residents, who are typically older and more multimorbid. We compared the safety and cardiovascular effectiveness of SGLT2is and GLP-1RAs among US NH residents.

MATERIALS AND METHODS

Eligible individuals were aged ≥66 years with type 2 diabetes mellitus and initiated an SGLT2i or GLP-1RA in an NH between 2013 and 2018. Safety outcomes included fall-related injuries, hypoglycaemia, diabetic ketoacidosis (DKA), urinary tract infection or genital infection, and acute kidney injury in the year following treatment initiation. Cardiovascular effectiveness outcomes included death, major adverse cardiovascular events and hospitalization for heart failure. Per-protocol adjusted hazard ratios (HR) were calculated using stabilized inverse probability of treatment and censoring weighted cause-specific hazard regression models accounting for 127 covariates.

RESULTS

The study population included 7710 residents (31.08% SGLT2i, 68.92% GLP-1RA). Compared with GLP-1RA initiators, SGLT2i initiators had higher rates of DKA (HR 1.95, 95% confidence limits 1.27, 2.99) and death (HR 1.18, 95% confidence limits 1.02, 1.36). Rates of urinary tract infection or genital infection, acute kidney injury, major adverse cardiovascular events, and heart failure were also elevated, while rates of fall-related injuries and hypoglycaemia were reduced, but all estimates were imprecise and highly compatible with no difference.

CONCLUSIONS

SGLT2is do not have superior, and may have inferior, effectiveness compared with GLP-1RAs for cardiovascular and mortality outcomes in NH residents. Residents initiating SGLT2is should be monitored closely for DKA.

National trends in utilisation of glucose lowering medicines by older people with diabetes in long-term care facilities

AIMS

To examine national trends in glucose lowering medicine (GLM) use among older people with diabetes in long-term care facilities (LTCFs) during 2009-2019.

METHODS

A repeated cross-sectional study of individuals ≥65 years with diabetes in Australian LTCFs (n = 140,322) was conducted. Annual age-sex standardised prevalence of GLM use and number of defined daily doses (DDDs)/1000 resident-days were estimated. Multivariable Poisson or Negative binomial regression models were used to estimate adjusted rate ratios (aRRs) and 95 % confidence intervals (CIs).

RESULTS

Prevalence of GLM use remained steady between 2009 (63.9%, 95 %CI 63.3-64.4) and 2019 (64.3%, 95 %CI 63.9-64.8) (aRR 1.00, 95 %CI 1.00-1.00). The percentage of residents receiving metformin increased from 36.0% (95 %CI 35.3-36.7) to 43.5% (95 %CI 42.9-44.1) (aRR 1.01, 95 %CI 1.01-1.01). Insulin use also increased from 21.5% (95 %CI 21.0-22.0) to 27.0% (95 %CI 26.5-27.5) (aRR 1.02, 95 %CI 1.02-1.02). Dipeptidyl peptidase-4 inhibitor use increased from 1.0% (95 %CI 0.9-1.1) to 21.1% (95 %CI 20.7-21.5) (aRR 1.24, 95 %CI 1.24-1.25), while sulfonylurea use decreased from 34.4% (95 %CI 33.8-35.1) to 19.3% (95 %CI 18.9-19.7) (aRR 0.93, 95 %CI 0.93-0.94). Similar trends were observed in DDDs/1000 resident days.

CONCLUSIONS

The increasing use of insulin and ongoing use of sulfonylureas suggests a need to implement evidence-based strategies to optimise diabetes care in LTCFs.

Continuous Glucose Monitoring-Guided Insulin Administration in Long-Term Care Facilities: A Randomized Clinical Trial

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.

Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life

INTRODUCTION

Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing.

OBJECTIVE

This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life.

METHODS

We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions.

RESULTS

Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing.

CONCLUSIONS

Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

Sliding Scale Insulin Use in Nursing Homes Before and After Onset of the COVID-19 Pandemic

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.

Use of Diabetes Medications before and after a Heart Failure-Related Hospitalization among Nursing Home Residents

OBJECTIVES

Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer cardiovascular benefits, whereas thiazolidinediones (TZDs) and sulfonylureas (SUs) increase cardiovascular risk. The objective of this study was to describe the use of SGLT-2is, GLP-1RAs, TZDs, and SUs before and after a heart failure (HF)-related hospitalization in nursing home (NH) residents with type 2 diabetes (T2D).

DESIGN

This was a cohort study using a 20% sample of Medicare claims linked with Minimum Data Set resident assessments.

SETTING AND PARTICIPANTS

The study population was long-stay NH residents with T2D and an HF-related hospitalization between January 1, 2013, and August 31, 2018. For individuals with multiple HF hospitalizations, 1 hospitalization was randomly selected.

METHODS

We ascertained diabetes medications using Medicare Part D claims during the 120 days before and after hospital discharge (or skilled nursing facility discharge, where applicable). We calculated (1) the proportion of study participants who received a medication class of interest during pre- and posthospitalization periods; (2) the proportion of continuous users; and (3) the proportion of posthospitalization users who were new users.

RESULTS

A total of 12,990 NH residents with T2D and an HF-related hospitalization were included (mean age 78 years, 66% female, 19% Black). Before hospitalization, 1.5% received TZDs, 14.1% received SUs, 1.2% received GLP-1RAs, and 0.3% received SGLT-2is. Among prehospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 49%, 62%, 60%, and 40% continued the medications, respectively. Among posthospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 37%, 10%, 28%, and 11%, respectively, were new users.

CONCLUSIONS

Among NH residents with hospitalized HF, GLP-1RAs and SGLT-2is were seldom used. TZDs and SUs were still used by many residents with T2D after HF hospitalizations.

IMPLEMENTATIONS

Barriers may exist in the use of newer diabetes medications to prevent heart failure in NH residents with T2D, which warrants further studies in older adults with multimorbidity.

Effects of light therapy on sleep and circadian rhythm in older type 2 diabetics living in long-term care facilities: a randomized controlled trial

Background

Light influences the secretion of melatonin in the body and regulates circadian rhythms, which play an important role in sleep and mood. The light level of rooms in long-term care facilities is usually far below the threshold required to regulate the body's circadian rhythm, and insufficient light can easily lead to sleep and mood disturbances among older residents in nursing homes. Therefore, the objective of this study was to investigate the effects of light therapy on sleep and circadian rhythm in older adults with type 2 diabetes residing in long-term care facilities.

Methods

This study was a prospective, single-blind, randomized controlled trial. Participants were randomly assigned to either the light therapy (LT) group or the control group and received the intervention for four weeks. Primary outcomes included the Pittsburgh Sleep Quality Index (PSQI) and objective sleep parameters recorded by a sleep monitoring bracelet, Morningness-Eveningness Questionnaire (MEQ). The secondary outcome included glycated serum protein (GSP). Data was collected at three time points: at baseline (T0), immediate post-treatment (T1), and 4-week follow-up (T2). A linear mixed model analysis was used to analyzed the data.

Results

We enrolled 45 long-term care residents. Compared with the control group, significant reductions in PSQI scores were observed at T1 and T2. At T2, the sleep score of objective sleep parameters was significantly higher in the LT group compared to the control group. Additionally, compared to the baseline T0, MEQ scores were significantly lower in the LT group at T1 and T2, with no significant difference in the control group. There was no significant difference between groups in glycated serum protein values at T1 and T2. However, compared to T0, glycated serum protein values decreased in the LT group while increased in the control group at T2.

Conclusion

Light therapy had a positive effect on subjective sleep quality and circadian rhythm time type in long-term care residents with type 2 diabetes, and had a possible delayed effect on objective sleep. However, no discernible alterations in blood glucose levels were detected in this study.

Surveillance and patient safety in nursing research: A bibliometric analysis from 1993 to 2023

AIMS

To identify and characterize the thematic foci, structure and evolution of nursing research on surveillance and patient safety.

DESIGN

Bibliometric analysis.

METHODS

Bibliometric methods were employed to analyse 1145 articles, using Bibliometrix and VOSviewer software.

DATA SOURCE

The Scopus bibliographic database was searched on April 7, 2023.

RESULTS

A keyword co-occurrence analysis found the most frequently occurring keywords to be: patient safety, nursing, nurses, adverse events, monitoring, critical care, quality improvement, vital signs, safety, alarm fatigue, education, nursing care, surveillance, clinical alarms, failure to rescue, evidence-based practice, acute care, clinical deterioration, communication, intensive care. Network mapping, clustering and time-tracking of the keywords revealed the focal themes, structure and evolution of the research field.

CONCLUSION

By assessing critical areas of the nursing research field, this study extends and enriches the current discourse on surveillance and patient safety for nursing researchers and practitioners. Critical challenges still have to be met by nurses, however, including the failure to rescue deteriorating patients. Further knowledge and understanding of surveillance and patient safety must be successfully translated from research to practice.

IMPLICATIONS FOR THE PROFESSION

This study highlights the gaps in nursing knowledge with regard to surveillance and patient safety and encourages nursing professionals to turn to evidence-based surveillance practices.

IMPACT

In addressing the problem of surveillance and its effect on patient safety, this study found that, in most clinical care settings, preventing failures to rescue and adverse patient outcomes still remains a challenge for the nursing profession. This study should have an impact on nursing academics' future research themes and on nursing professionals' future clinical practices.

REPORTING METHOD

Relevant EQUATOR guidelines have been adhered to by employing recognized bibliometric reporting methods.

Associations Between Postdischarge Care and Cognitive Impairment-Related Hospital Readmissions for Ketoacidosis and Severe Hypoglycemia in Adults With Diabetes

OBJECTIVE

Patients with severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) experience high hospital readmission after being discharged. Cognitive impairment (CI) may further increase the risk, especially in those experiencing an interruption of medical care after discharge. This study examined the effect modification role of postdischarge care (PDC) on CI-associated readmission risk among U.S. adults with diabetes initially admitted for DKA or SH.

RESEARCH DESIGN AND METHODS

We used the Nationwide Readmissions Database (NRD) (2016-2018) to identify individuals hospitalized with a diagnosis of DKA or SH. Multivariate Cox regression was used to compare the all-cause readmission risk at 30 days between those with and without CI identified during the initial hospitalization. We assessed the CI-associated readmission risk in the patients with and without PDC, an effect modifier with the CI status.

RESULTS

We identified 23,775 SH patients (53.3% women, mean age 65.9 ± 15.3 years) and 140,490 DKA patients (45.8% women, mean age 40.3 ± 15.4 years), and 2,675 (11.2%) and 1,261 (0.9%), respectively, had a CI diagnosis during their index hospitalization. For SH and DKA patients discharged without PDC, CI was associated with a higher readmission risk of 23% (adjusted hazard ratio [aHR] 1.23, 95% confidence interval 1.08-1.40) and 35% (aHR 1.35, 95% confidence interval 1.08-1.70), respectively. However, when patients were discharged with PDC, we found PDC was an effect modifier to mitigate CI-associated readmission risk for both SH and DKA patients (P < 0.05 for all).

CONCLUSIONS

Our results suggest that PDC can potentially mitigate the excessive readmission risk associated with CI, emphasizing the importance of postdischarge continuity of care for medically complex patients with comorbid diabetes and CI.

13. Older Adults: Standards of Care in Diabetes-2024

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.

Chronic Obstructive Pulmonary Disease, Part 5: Clinical Pearls for Comorbid COPD

Chronic obstructive pulmonary disease (COPD) is often diagnosed with other comorbid conditions. This can complicate therapy overall by contributing to adverse events leading to poor outcomes to not only COPD, but other comorbid conditions. This manuscript will discuss common comorbid conditions often seen with COPD, update vaccination recommendations for COPD patients, and provide information regarding smoking cessation in COPD. The senior care pharmacist has an important role where they can recommend medication adjustments to potentially avoid these adverse events, immunize their patients appropriately, and provide assistance with smoking cessation to improve not only COPD outcomes but outcomes associated with other comorbid conditions.

Adoption of sodium-glucose cotransporter-2 inhibitors among prescribers caring for nursing home residents

BACKGROUND

Sodium-glucose cotransporter-2 inhibitor (SGLT2I) use has increased among community-dwelling populations, but little is known about how clinicians have prescribed them for US nursing home (NH) residents. We described the adoption of SGLT2Is by prescribers caring for long-stay NH residents by clinician specialty and over time, compared with sulfonylureas, an older diabetes medication class.

METHODS

We conducted a retrospective cohort study of prescribers of SGLT2Is and sulfonylureas for all long-stay US NH residents aged 65 years or older (2017-2019). Using 100% of Medicare Part D claims linked to prescriber characteristics data, we identified all dispensings of SGLT2Is and sulfonylureas for long-stay NH residents and their associated prescribers. We described the distribution of prescriber specialties for each drug class over time as well as the number of NH residents prescribed SGLT2s versus sulfonylureas. We estimated the proportions of prescribers who prescribed both drug classes versus only sulfonylureas or only SGLT2Is.

RESULTS

We identified 36,427 unique prescribers (SGLT2I: N = 5811; sulfonylureas: N = 35,443) for 117,667 NH residents between 2017 and 2019. For both classes, family medicine and internal medicine physicians accounted for most prescriptions (75%-81%). Most clinicians (87%) prescribed only sulfonylureas, 2% prescribed SGLT2Is only, and 11% prescribed both. Geriatricians were least likely to prescribe only SGLT2Is. We observed an increase in the number of residents with SGLT2I use from n = 2344 in 2017 to n = 5748 in 2019.

CONCLUSIONS

Among NH residents, most clinicians have not incorporated SGLT2Is into their prescribing for diabetes, but the extent of use is increasing. Family medicine and internal medicine physicians prescribed the majority of diabetes medications for NH residents, and geriatricians were the least likely to prescribe only SGLT2Is. Future research should explore provider concerns regarding SGLT2I prescribing, particularly adverse events.

The Growing Role of Technology in the Care of Older Adults With Diabetes

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.

Geriatric Syndromes in Older Adults with Diabetes

Over one-quarter of adults ≥65 years old have diabetes in the United States. Guidelines recommend individualization of glycemic targets in older adults with diabetes as well as implementing treatment strategies that minimize risk for hypoglycemia. Patient-centered management decisions should be informed by comorbidities, the individual's capacity for self-care, and the presence of key geriatric syndromes that may impact self-management and patient safety. Key geriatric syndromes include cognitive impairment, depression, functional impairments (eg, vision, hearing, and mobility challenges), falls and fractures, polypharmacy, and urinary incontinence. Screening for geriatric syndromes in older adults is recommended to inform treatment strategies and optimize outcomes.

Medication Prescribing for Type 2 Diabetes in the US Long-Term Care Setting: Observational Study

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.

Research Progress on the Construction and Application of a Diabetic Zebrafish Model

Diabetes is a metabolic disease characterized by high blood glucose levels. With economic development and lifestyle changes, the prevalence of diabetes is increasing yearly. Thus, it has become an increasingly serious public health problem in countries around the world. The etiology of diabetes is complex, and its pathogenic mechanisms are not completely clear. The use of diabetic animal models is helpful in the study of the pathogenesis of diabetes and the development of drugs. The emerging vertebrate model of zebrafish has many advantages, such as its small size, large number of eggs, short growth cycle, simple cultivation of adult fish, and effective improvement of experimental efficiency. Thus, this model is highly suitable for research as an animal model of diabetes. This review not only summarizes the advantages of zebrafish as a diabetes model, but also summarizes the construction methods and challenges of zebrafish models of type 1 diabetes, type 2 diabetes, and diabetes complications. This study provides valuable reference information for further study of the pathological mechanisms of diabetes and the research and development of new related therapeutic drugs.

Initiation of iGlarLixi Versus Basal-Bolus Insulin in Adults With Type 2 Diabetes Advancing From Basal Insulin Therapy: The SoliComplex Real-World Study

Background

When type 2 diabetes is suboptimally controlled with basal insulin, prandial insulin injections are commonly added (i.e., a basal-bolus insulin regimen), which can increase treatment burden and hypoglycemia risk. The once-daily injectable iGlarLixi is an alternative treatment.

Methods

This retrospective analysis of the U.S. Optum Clinformatics database compared outcomes in adults (≥18 years of age) with type 2 diabetes who previously received basal insulin and were newly initiated on iGlarLixi or basal-bolus insulin therapy. Cohorts were propensity score-matched in a 1:1 ratio on baseline characteristics, and imbalances were adjusted in multivariate analyses. Subgroup analyses were performed for people ≥65 years of age and those with a baseline A1C ≥9%. The primary end point was persistence with therapy at 12 months in the overall population. Secondary end points were treatment adherence, health care resource utilization (HCRU), costs, any hypoglycemia, and A1C change at 12 months.

Results

Cohorts each comprised 1,070 participants. Treatment persistence at 12 months was statistically significantly higher for iGlarLixi versus basal-bolus insulin therapy (43.7 vs. 22.3%, hazard ratio 0.51, 95% CI 0.46-0.57, adjusted P <0.001). Adherence was numerically higher for iGlarLixi, and hypoglycemia events, HCRU, and costs were numerically lower for iGlarLixi. A1C reduction from baseline was slightly greater for basal-bolus insulin. Results for both subgroups (≥65 years of age and baseline A1C ≥9%) were similar to those of the overall population.

Conclusion

In this observational study, initiation of once-daily iGlarLixi versus basal-bolus insulin was associated with higher persistence, lower hypoglycemia, and similar A1C reduction without increasing HCRU or costs regardless of age or A1C. iGlarLixi could be an alternative to basal-bolus insulin, particularly for older adults with type 2 diabetes who require treatment simplification with lower hypoglycemia risk.

How the 2018 Japan Floods Impacted Nursing Home Admissions for Older Persons: A Longitudinal Study Using the Long-Term Care Insurance Comprehensive Database

OBJECTIVES

As disasters become more frequent because of global warming, countries across the world are seeking ways to protect vulnerable older populations. Although these conditions may increase nursing home admission (NHA) rates for older persons, we know of no studies that have directly tested this hypothesis.

DESIGN

This was a retrospective cohort study.

SETTING AND PARTICIPANTS

We analyzed data from long-term care insurance (LTCI) users in 3 Japanese prefectures that incurred heavy damage from the 2018 Japan Floods, which is the largest recorded flooding disaster in national history. Specifically, we extracted NHA data from the LTCI comprehensive database, both for disaster-affected and unaffected individuals.

METHODS

We employed the Cox proportional hazards model to calculate multivariate-adjusted hazard ratios (HRs) for NHAs within a 6-month period following the 2018 Japan Floods, with adjustments for potential confounding factors.

RESULTS

Of the 187,861 individuals who used LTCI services during the investigated period, we identified 2156 (1.1%) as disaster affected. The HR for NHA was significantly higher for disaster-affected (vs unaffected) individuals (adjusted HR 3.23: 95% CI 2.88‒3.64), and also higher than the HRs for older age (90-94 years vs 65-69 years: 2.29, CI 1.93‒2.70), cognitive impairment (severe impairment vs normal: 1.40, CI 1.25‒1.57), and physical function (bedridden vs independent: 2.27, CI 1.83‒2.70). According to our subgroup analyses, the adjusted HR for disaster-affected individuals unable to feed themselves was 6.00 (CI 3.68‒9.79), with a significant interaction between the 2 variables (P = .01).

CONCLUSIONS AND IMPLICATIONS

Natural disasters increase the risk of NHA for older persons, especially those who are unable to feed themselves. Health care providers and policymakers should understand and prepare for this emerging risk factor.

Effectiveness of the SUGAR intervention on hypoglycaemia in elderly patients with type 2 diabetes: A pragmatic randomised controlled trial

BACKGROUND

A pharmacist-led, individualised, educational intervention (SUGAR) was formulated to prevent hypoglycaemia among elderly patients with type 2 diabetes mellitus (T2DM) in Jordan.

OBJECTIVE(S)

To evaluate the effectiveness of the SUGAR intervention added to usual care compared with usual care only in preventing hypoglycaemic attacks in elderly patients with T2DM in Jordan.

METHODS

A single-centre, pragmatic, open-label, randomised controlled trial with embedded process evaluation was conducted at the outpatient clinics of a hospital in Jordan. Elderly patients (≥65 years) with T2DM and on sulfonylurea, insulin, or at least three anti-diabetic medications were recruited and parallelly randomised to the SUGAR intervention with usual care or the control (usual care) groups. The primary outcome was the rate of total hypoglycaemic attacks per patient after 3 months from randomisation. Secondary outcomes included rate of hypoglycaemia subtypes, the incidence of any and subtypes of hypoglycaemia, hypoglycaemia-free survival probability, and incidence of fasting hyperglycaemia necessitating therapy modification. Outcomes were measured through glucose meters and diaries, assessed at 3 months, and analysed by intention to treat.

RESULTS

A total of 212 participants (mean age 68.98 years, 58.96% men) were randomly allocated (106 in each group), with 190 (89.62%) participants completing the study. The mean of total hypoglycaemic attacks was less in the intervention group compared with the control group (3.91 [SD 7.65] vs. 6.87 [SD 11.99]; p < 0.0001) at three months. The intervention significantly reduced the rate of hypoglycaemia subtypes; the odds to experience any, severe, and symptomatic hypoglycaemia; and increased hypoglycaemia-free survival probability compared with the control group at three months. Incidence of fasting hyperglycaemia necessitating therapy modification was similar between groups.

CONCLUSIONS

The SUGAR intervention can prevent hypoglycaemia without increasing the risk of fasting hyperglycaemia warranting therapy adjustment in elderly Jordanians with T2DM.

Prognostic uncertainty in multiple sclerosis: A concept analysis

AIM

To report an analysis of the concept of prognostic uncertainty in patients with multiple sclerosis (MS).

BACKGROUND

The complexity and ambiguity involved in a diagnosis of MS lead to the occurrence of prognostic uncertainty among patients. A concept analysis is presented that analyses what prognostic uncertainty means to those experiencing the transition between relapsing-remitting multiple sclerosis and secondary progressive multiple sclerosis.

DESIGN

Concept analysis.

DATA SOURCES

PubMed, Ovid Medline, Cumulative Index for Nursing and Allied Health Literature databases were searched for literature published within the last 10 years using combinations of the terms prognostic and diagnostic uncertainty, and multiple sclerosis along with archival referencing.

METHODS

The Walker and Avant method was used to analyse the concept of prognostic uncertainty in patients with MS.

RESULTS

The defining attributes identified that provide additional context to prognostic uncertainty are illness uncertainty, intolerance of uncertainty and progressive dwindling. Related, contrary, model and borderline cases are presented to further discuss the application of the key attributes to the concept.

CONCLUSION

There are limited data on prognostic uncertainty and multiple sclerosis; however, patients and physicians express uncertainty in understanding one's disease trajectory and determining when a patient with relapsing-remitting multiple sclerosis has entered the secondary progressive multiple sclerosis disease course leading to ineffective communication and frustration.

RELEVANCE TO CLINICAL PRACTICE

Genetics and genomics have the potential to provide a prognostic factor for addressing the concept of uncertainty as it relates to persons with multiple sclerosis. Moving beyond the concept analysis, a case is made for nurse involvement in genetic and genomic research to conduct trials, translate, and apply these findings to clinical practice and nursing curricula, addressing the uncertainty experienced by those afflicted with chronic illnesses, such as multiple sclerosis.

13. Older Adults: Standards of Care in Diabetes-2023

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.

Nearly one in five older adults in Danish nursing homes live with type 2 diabetes

AIM

This study aimed to investigate the prevalence of type 2 diabetes (T2D) among Danish nursing home residents (aged ⩾65 years).

METHODS

Individuals with T2D in the Danish population of older adults in 2018 were identified using a Danish diabetes register based on administrative and clinical register data. Data on age, sex, type of housing, educational level and place of origin were obtained from various high-quality administrative registers. We calculated frequencies of T2D among older adults living in nursing homes and in other types of housing. We performed a multiple logistic regression analysis to estimate the odds ratio (OR) of T2D among people living in nursing homes and adjusted for sex, age, educational level and place of origin.

RESULTS

All Danish older adults aged ⩾65 years, alive and living in Denmark on 31 December 2018 were included (N=1,170,517). Nursing home residents accounted for 37,891 older adults, and of these, 19% had T2D, whereas 14% of older adults living in other types of housing had T2D. According to the multiple logistic regression analysis, nursing home residents had a higher OR of having T2D compared to older adults living in other types of housing (OR=1.47; confidence interval 1.43-1.51) when adjusting for socio-demographic factors.

CONCLUSIONS

The prevalence of T2D in nursing home residents exceeds the prevalence in the background population at ⩾65 years of age. This indicates a need for increased focus on individualised interdisciplinary care plans aimed at maintaining physical function and maximising quality of life for this group of vulnerable older adults.

Types of health-related procrastination in patients with type-2 diabetes: a qualitative content analysis

Background and objectives:

Health-related procrastination refers to a delay in the performance of health-related activities, which is a rather neglected subject despite being critical. Due to the adverse effects of procrastination on the care and treatment of patients with type-2 diabetes, it is necessary to explore procrastination among this group of patients through in-depth studies. The present research was conducted to explain different types of health-related procrastination in patients with type-2 diabetes.

Materials and methods

This qualitative study applied content analysis with 13 patients with type-2 diabetes selected via purposive sampling. Data were collected through individual and semi-structured interviews. The data were then analyzed using Lundman and Graneheim content analysis method.

Findings:

Based on the analysis of the data, instances of health-related procrastination in patients with type-2 diabetes were classified into six main categories, including minimizing self-care, poor adherence to treatment, poor nutritional habits, poor adherence to drug regimen, disregard for disease monitoring, and a sedentary lifestyle.

Conclusions

The results of this study provide an in-depth understanding of the various forms of health-related procrastination in patients with type-2 diabetes. These findings can be employed in the design, implementation, and monitoring of treatment and care programs targeting these patients.

Part Five: The Role of Deprescribing and Adjusting Glycemic Targets in Older People With Diabetes

The prevalence of diabetes continues to increase across the general population, including older people. Because of the changing needs of older people, glycemic targets are often relaxed. Deintensification of therapy or deprescribing becomes important to reduce risk of adverse effects and ensure optimal quality of life. The use of continuous glucose monitoring can be highly effective in determining areas for concern and potential opportunities for deprescribing.

Update on the management of diabetes in long-term care facilities

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.

Antihyperglycemic Drug Use in Long-Stay Nursing Home Residents with Diabetes Mellitus

BACKGROUND

About 29.2% of American adults ≥ 65 years of age have diabetes mellitus, but details regarding diabetes management especially among nursing home residents are dated.

OBJECTIVES

Evaluate the prevalence of antihyperglycemic agents in residents with diabetes mellitus and describe resident characteristics using major drug classes.

DESIGN

cross-sectional study.

SETTING

virtually all United States nursing homes.

PARTICIPANTS

141,636 residents with diabetes mellitus.

MEASUREMENTS

Minimum Data Set (2016) and Medicare Part D claims determined use of metformin, sulfonylureas, meglitinide analogs, alpha-glucosidase inhibitors, TZDs, DPP4 inhibitors, SGLT2 inhibitors, GLP1 agonists, as monotherapy and with basal insulin.

RESULTS

Seventy-two percent received antihyperglycemic drugs [most common: basal insulins (53.9% total; 46.9% with other non-insulin agents), metformin (35.5% total; 14.2% monotherapy), sulfonylureas (19.6% total; 6.3% monotherapy), and DPP4 inhibitors (12.2% total; 2.2% monotherapy)]. Sixty-three percent of meglitinide monotherapy versus 34.1% of metformin monotherapy users; and 38.3% meglitinide-basal insulin versus 22.2% metformin-basal insulin users were ≥85 years. Obesity was greater among users of GLP1 agonists compared to those receiving other agents (monotherapy: 60.5% versus 33-42%; with basal insulin: 76.2% versus 50-58%). End-stage renal disease was least prevalent among metformin users (monotherapy: 6.6%; with basal insulin: 8.8%) and most common among meglitinide monotherapy (19.6%) and GLP1 agonists with basal insulin (22%) users.

CONCLUSIONS

There is heterogeneity of diabetes treatment in nursing homes. Use of antihyperglycemic drugs with a higher risk of hypoglycemia, such as insulin with sulfonylureas or meglitinides, continue in nursing home residents.

Electronic Health Records to Rapidly Assess Biosimilar Uptake: An Example Using Insulin Glargine in a Large U.S. Nursing Home Cohort

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.

Nutrition and diabetes self-management in aged care: Exploring community-dwelling older adults' expectations

OBJECTIVES

To explore the diabetes self-management expectations of older adults with diabetes, not yet accessing residential aged care services. Admission to residential aged care (RAC) can create many interruptions to usual food choices and diabetes self-management, and we know little about the concerns of the emerging ageing population.

METHODS

This is a qualitative study employing focus groups and inductive thematic analysis involving 18 older adults with diabetes between the ages of 60 and 88, living in their own homes within an Australian city. Focus groups were recruited on a sequential basis and progressively analysed using an inductive process until data saturation was reached. Focus groups were digitally recorded and transcribed verbatim for thematic analysis.

RESULTS

Three key themes were generated: autonomy, individualised dietary management and the food service system. Older adults speculated that they would want a collaborative approach to maintain their health in ageing and to self-manage their diabetes while feasible. Participants wanted autonomy over food choices, flexible meal timings and quality meals. There was a significant anxiety that aged care staff and existing food service systems in RAC could not support these preferences.

CONCLUSIONS

Community-dwelling older adults with diabetes would highly value aged care services that facilitated autonomy, individualised nutrition support and flexibility, but feared this will not be feasible. The introduction of new diabetes and RAC guidelines may require an implementation plan to include the full food service system, from staff education to meal preparation, ordering and service.

Prevalence Rates and Characteristics of Malnutrition, Frailty, and Other Nutrition and Muscle Mass-Related Conditions Document Potential Quality of Care Gap for Medicare Patients in US Skilled Nursing Facilities

Changes to the payment structure of the United States (U.S.) healthcare system are leading to an increased acuity level of patients receiving short-term skilled nursing facility care. Most skilled nursing facility patients are older, and many have medical conditions that cannot be changed. However, conditions related to nutrition/muscle mass may be impacted if there is early identification/intervention. To help determine the diagnosis and potential impact of nutrition/muscle mass-related conditions in skilled nursing facilities, this study evaluated 2016–2020 US Medicare claims data. Methods aimed to identify a set of skilled nursing facility claims with one or more specific diagnoses (COVID-19, malnutrition, sarcopenia, frailty, obesity, diabetes, and/or pressure injury) and then to determine length of stay, discharge status, total charges, and total payments for each claim. Mean values per beneficiary were computed and between–group comparisons were performed. Results documented that each year, the total number of Medicare skilled nursing facility claims declined, whereas the percentage of claims for each study diagnosis increased significantly. For most conditions, potentially related to nutrition/muscle mass, Medicare beneficiaries had a shorter length of skilled nursing facility stays compared to those without the condition(s). Furthermore, a lower percentage of these Medicare beneficiaries were discharged home (except for those with claims for sarcopenia and obesity). Total claim charges for those with nutrition/muscle mass-related conditions exceeded those without (except for those with sarcopenia). We conclude that although the acuity level of patients in skilled nursing facilities continues to increase, skilled nursing facility Medicare claims for nutrition/muscle mass-related conditions are reported at lower levels than their likely prevalence. This represents a potential care gap and requires action to help improve patient health outcomes and skilled nursing facility quality metrics.

Do financial aspects affect care transitions in long-term care systems? A systematic review

Background

Suboptimal care transitions of older adults may ultimately lead to worse quality of care and increased costs for the health and social care systems. Currently, policies and financing often focus on care in specific settings only, and neglect quality of care during transitions between these settings. Therefore, appropriate financing mechanisms and improved care coordination are necessary for effective care transitions. This study aims to review all available evidence on financial aspects that may have an impact on care transitions in LTC among older adults.

Methods

This systematic review was performed as part of the European TRANS-SENIOR project. The databases Medline, EMBASE (Excerpta Medica Database) and CINAHL (Cumulated Index to Nursing and Allied Health Literature) were searched. Studies were included if they reported on organizational and financial aspects that affect care transitions in long-term care systems.

Results

All publications included in this review (19 studies) focused specifically on financial incentives. We identified three types of financial incentives that may play a significant role in care transition, namely: reimbursement mechanism, reward, and penalty. The majority of the studies discussed the role of rewards, specifically pay for performance programs and their impact on care coordination. Furthermore, we found that the highest interest in financial incentives was in primary care settings.

Conclusions

Overall, our results suggest that financial incentives are potentially powerful tools to improve care transition among older adults in long-term care systems and should be taken into consideration by policy-makers.

Trial registration

A review protocol was developed and registered in the International Prospective Register of Systematic Reviews (PROSPERO) under identification number CRD42020162566.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00829-y.

Defining Minimum Necessary Communication During Care Transitions for Patients on Antihyperglycemic Medication: Consensus of the Care Transitions Task Force of the IPRO Hypoglycemia Coalition

INTRODUCTION

Antihyperglycemic agents are significant contributors to adverse drug events, responsible for emergency department visits, hospitalizations, and death. Nationally, the rate of serious hypoglycemic events associated with these agents remains high despite widespread efforts to improve drug safety. Transitions of care between healthcare settings can lead to communication challenges between care professionals and increase the risk of adverse drug events. System-based improvements are needed to assure the safe transitions for patients with diabetes who are on antihyperglycemic agents. The objective of this study was to develop a consensus list of requisite elements that should be communicated between care settings during transitions of patients who are prescribed antihyperglycemic agents.

METHODS

The Island Peer Review Organization (IPRO) Hypoglycemia Coalition identified suboptimal transitions of care as a barrier to improving patient safety and quality of diabetes care. The Coalition formed a multidisciplinary Task Force with experts in the field of diabetes care. The Task Force created a draft list of requisite communication elements through literature review and deliberation on monthly conference calls. A blinded iterative Delphi process was subsequently performed to generate a consensus list of requisite communication elements that participating experts agreed were necessary to safely and effectively assume the management of patients with diabetes upon care transitions.

RESULTS

The Task Force completed a series of four iterative polls from September 2015 to August 2016, resulting in a final list of 22 requisite communication elements (the Diabetes Management Discharge Communication List), with the elements conceptually categorized into three domains: diagnosis and treatment, factors affecting glycemic control or patient risk, and patient self-management.

CONCLUSIONS

The Diabetes Management Discharge Communication List provides an initial framework for the development of diabetes-specific resources to improve clinical communication between care settings.

SHARE plus: Delivering a Telehealth CGM Data-Sharing Intervention to Older Adults and Their Care Partners

Care partners of older adults with type 1 diabetes often become part of the diabetes care team but lack knowledge of how to become involved with glucose management. This article describes a study confirming the feasibility of SHARE plus, a telehealth intervention involving continuous glucose monitoring and data-sharing to assist these individuals in working together on diabetes management. The intervention provides a strategy for increasing remote patient monitoring and facilitating care partner involvement in diabetes management.

Effects of dipeptidyl peptidase-4 inhibitors and sulphonylureas on cognitive and physical function in nursing home residents

AIMS

Dipeptidyl peptidase-4 inhibitors (DPP4Is) may mitigate hypoglycaemia-mediated declines in cognitive and physical functioning compared with sulphonylureas (SUs), yet comparative studies are unavailable among older adults, particularly nursing home (NH) residents. We evaluated the effects of DPP4Is versus SUs on cognitive and physical functioning among NH residents.

MATERIALS AND METHODS

This new-user cohort study included long-stay NH residents aged ≥65 years from the 2007-2010 national US Minimum Data Set (MDS) clinical assessments and linked Medicare claims. We measured cognitive decline from the validated 6-point MDS Cognitive Performance Scale, functional decline from the validated 28-point MDS Activities of Daily Living scale, and hospitalizations or emergency department visits for altered mental status from Medicare claims. We compared 180-day outcomes in residents who initiated a DPP4I versus SU after 1:1 propensity score matching using Cox regression models.

RESULTS

The matched cohort (N = 1784) had a mean ± SD age of 80 ± 8 years and 73% were women. Approximately 46% had no or mild cognitive impairment and 35% had no or mild functional impairment before treatment initiation. Compared with SU users, DPP4I users had lower 180-day rates of cognitive decline [hazard ratio (HR) = 0.61, 95% confidence interval (CI) 0.31-1.19], altered mental status events (HR = 0.71, 95% CI 0.39-1.27), and functional decline (HR = 0.89, 95% CI 0.51-1.56), but estimates were imprecise.

CONCLUSIONS

Rates of cognitive and functional decline may be reduced among older NH residents using DPP4Is compared with SUs, but larger studies with greater statistical power should resolve the remaining uncertainty by providing more precise effect estimates.

Sarcopenia risk in nursing home residents using SARC-F: FIRST study findings

AIM

Sarcopenia is a common disorder of loss of muscle mass and function among older adults; however, few studies have examined screening instruments for sarcopenia risk in residential aged care services (RACS). The aims of this study were to measure sarcopenia risk in RACS residents using the SARC-F, describe factors associated with sarcopenia risk and examine the predictive validity of the SARC-F for 12-month mortality.

METHODS

This was a prospective cohort study carried out in South Australian RACS across 12 sites. In total, 541 residents (mean age 87.7 [7.3] years, 72.6% women) were included in the study. Sarcopenia risk was measured using a modified SARC-F (≥4 point cut point).

RESULTS

We identified 89.5% (n = 484) of residents at risk of sarcopenia. Significant (P > 0.05) predictors of sarcopenia risk in multivariable analysis included the presence of diabetes (relative risk [RR] = 1.08), classification as most-frail (RR = 1.06) and smaller Nursing Home Life Space Diameter (NHLSD) score (RR = 0.99). Mortality was observed in 20.9% (n = 113) of residents over a 12-month follow-up. Classification as at-risk of sarcopenia was a significant predictor of 12-month mortality; however, it had a poor area under the receiver operator curve (0.56), and a low positive predictive value (23.1%). The best performing cut-point of ≥7 also had poor discriminative ability (under the receiver operator curve = 0.66, positive predictive value = 30.8%).

CONCLUSIONS

Sarcopenia risk is extremely common among RACS residents and its presence is a significant contributor to 12-month mortality. Low discriminative ability for the SARC-F was noted across multiple cut-off scores for predicting mortality at 12 months. Diabetes management and promoting physical activity and nutrition among RACS residents are likely to influence sarcopenia risk positively. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

13. Older Adults: Standards of Medical Care in Diabetes-2022

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.

Management of Hyperglycemia in Older Adults with Type 2 Diabetes

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.

Continuous Glucose Monitoring Data Sharing in Older Adults with Type 1 Diabetes: A feasibility study (Preprint)

Background

Family members or friends (care partners [CPs]) of older adults with type 1 diabetes (T1DM) regularly become part of the diabetes care team, but they often lack knowledge about how to become involved to prevent hypo- and hyperglycemia. Continuous glucose monitoring (CGM) allows a person with diabetes to see their glucose levels continuously and to receive predictive alerts. A smartphone data-sharing app called the Follow app allows the person with diabetes to share continuous glucose numbers with others and to receive predictive alerts of impending hypo- and hyperglycemia. However, there are barriers to sharing this continuous glucose level data with CPs.

Objective

This study aimed to address the barriers to sharing CGM data. Our objective was to examine the feasibility of using CGM with the Follow app and a data-sharing intervention called SHARE plus in older adults with T1DM and their CPs. SHARE plus includes dyadic communication strategies, problem-solving strategies, and action planning to facilitate CGM data sharing.

Methods

Older adults with T1DM (n=20) and their CPs (n=20) received the SHARE plus intervention at baseline. People with diabetes wore the CGM for 12 weeks while sharing their glucose data using the Follow app with CPs. Feasibility data were analyzed using descriptive statistics.

Results

The SHARE plus intervention was feasible and was associated with high self-reported satisfaction for people with diabetes and their CPs as well as high adherence to CGM (mean 96%, SD 6.8%). Broad improvements were shown in the diabetes-related quality of life through the use of CGM in people with diabetes and their CPs. Although the majority of people with diabetes (11/20, 55%) were willing to share hyperglycemia data, several chose not to. The majority of people with diabetes (14/20, 70%) were willing to talk about glucose numbers with a CP.

Conclusions

Older adults with T1DM and their CPs identified having someone else aware of glucose levels and working together with a partner on diabetes self-management as positive aspects of the use of the SHARE plus intervention. Clinicians can use these results to provide data sharing coaching in older adults and their CPs.

Diabetes Mellitus in Older Women

Gestational diabetes mellitus and prediabetes are 2 features with research evidence for association with development of diabetes in older women. What matters to older women determines goals of management, lifestyle interventions, and medications. A dearth of palliative guidelines for management of diabetes at the end of life makes management challenging.

Comparative safety of dipeptidyl peptidase-4 inhibitors and sulfonylureas among frail older adults

BACKGROUND

Studies comparing dipeptidyl peptidase-4 inhibitors (DPP4Is) to sulfonylureas (SUs) are unavailable for frail older adults, especially nursing home (NH) residents. We examined the effects of DPP4Is versus SUs on severe adverse glycemic events, cardiovascular events, and death among NH residents.

METHODS

We conducted a national retrospective cohort study of long-stay NH residents aged ≥65 years using 2008-2010 national US Minimum Data Set clinical assessment data and linked Medicare claims. Exposure was new DPP4I versus new SU use assessed via Medicare Part D drug claims. One-year outcomes were severe hypoglycemia, severe hyperglycemia, acute myocardial infarction (AMI), heart failure (HF), major adverse cardiovascular events plus HF (MACE+HF), and death. We compared outcomes after propensity score matching using Cox proportional hazards regression models.

RESULTS

The cohort (N = 2016) had a mean (SD) age of 81 (8.1) years and was 72% female. Compared with SU users, DPP4I users had a lower 1-year rate of severe hypoglycemic events (HR = 0.57, 95% CI 0.34-0.94), but statistically similar rates of severe hyperglycemic events (HR = 0.94, 95% CI 0.52-1.72), AMI (HR = 0.76, 95% CI 0.44-1.30), HF (HR = 1.01, 95% CI 0.79-1.30), MACE+HF (HR = 0.90, 95% CI 0.72-1.12), and death (HR = 0.97, 95% CI 0.86-1.10).

CONCLUSIONS

DPP4Is should be a preferred treatment option over SUs for NH residents and other frail older adults given the importance of avoiding hypoglycemia.

Elevated glycohemoglobin is linked to critical illness in CoVID-19: a retrospective analysis

Background

Several studies have explored hospitalization risk factors with the novel coronavirus disease 2019 (COVID-19) infection. Our goal was to identify clinical characteristics outside of laboratory or radiologic data associated with intubation or death within 7 days of admission.

Methods

The first 436 patients admitted to the University of Colorado Hospital (Denver metropolitan area) with confirmed COVID-19 were included. Demographics, comorbidities, and select medications were collected by chart abstraction. Missing height for calculating body mass index (BMI) was imputed using the median height for patients' sex and race/ethnicity. Adjusted odds ratios (aOR) were estimated using multivariable logistic regression and a minimax concave penalty (MCP) regularized logistic regression explored prediction.

Results

Participants had a mean [standard deviation (SD)] age 55 (17), BMI 30.9 (8.2), 55% were male and 80% were ethnic/racial minorities. Increasing age [aOR: 1.24 (1.07, 1.45) per 10 years], higher BMI (aOR 1.03 (1.00, 1.06), and poorly controlled diabetes [hemoglobin A1C (HbA1c) ⩾ 8] (aOR 2.26 (1.24, 4.12) were significantly (p < 0.05) associated with greater odds of intubation or death. Female sex [aOR: 0.63, 95% CI (0.40, 0.98); p value = 0.043] was associated with lesser odds of intubation or death. The odds of death and/or intubation increased 19% for every 1 unit increase in HbA1c value [OR: 1.19 (1.01, 1.43); p = 0.04]. Our final MCP model included indicators of A1C ⩾ 8, age > 65, sex, and minority status, but predicted intubation/death only slightly better than random chance [area under the receiver operating characteristic curve (AUC) = 0.61 (0.56, 0.67)].

Conclusion

In a hospitalized patient cohort with COVID-19, worsening control of diabetes as evidenced by higher HbA1c was associated with increased risk of intubation or death within 7 days of admission. These results complement and help clarify previous associations found between diabetes and acute disease in COVID-19. Importantly, our analysis is missing some known predictors of severity in COVID-19. Our predictive model had limited success, suggesting unmeasured factors contribute to disease severity differences.

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

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.

Diabetes Management According to Health Status in Older Adults with Type 2 Diabetes Staying in Geriatric Care Facilities

BACKGROUND

About 25% of adults >70 years suffer from type 2 diabetes. Due to the heterogeneity of the geriatric population, guidelines emphasize the need to individualize glycemic goals and simplify treatment strategies with the main focus of avoiding hypoglycemia. The aim of this study was to assess glycemic control in patients with type 2 diabetes in geriatric care facilities based on their individual health status.

METHODS

170 medical records of older adults with type 2 diabetes in geriatric care facilities were retrospectively assessed (64.7% female, age 80 ± 9 years; glycated hemoglobin 6.8% ± 3.6% [51 ± 16 mmol/mol]; body mass index 27.9 ± 5.8 kg/m2). Based on the individual health status, patients were allocated to three groups (healthy n = 27, complex n = 86, and poor n = 57).

RESULTS

The overall blood glucose (BG) value was highest in the poor health group with 188 ± 47 mg/dL (poor) vs 167 ± 42 mg/dL (complex) vs 150 ± 34 mg/dL (healthy). BG values of 1.6% (poor) vs 2.8% (complex) vs 1.5% (healthy) of patients were below 90 mg/dL. 36.8% (poor) vs 23.4% (complex) vs 18.5% (healthy) of patients received insulin as the main diabetes therapy, but of these only 14.3% (poor) vs 20% (complex) vs 40% (healthy) were treated with basal insulin.

CONCLUSIONS

Overall, BG values were higher in the poor and complex health group. There were a few low BG values in all groups. Although recommended by international guidelines, basal insulin therapy with its low complexity and low hypoglycemic risk is still underused, especially in the poor health group. Therefore, simplification of diabetes therapy should be considered further.

Hospitalization for Short-Term Diabetes-Related Complications: Focus on Patients Aged over 85 Years

(1) Background: The prevalence of diabetes in elderly people is frequently high. When occurring in the elderly, diabetes is often accompanied by complications and comorbidities, at least one in 60% and four or more in 40% of older people with diabetes. As far as short-term complications among the elderly are concerned, hypoglycemia and hyperglycemic crises prove to be frequent. The aim of this study was to investigate the difference in hospitalization for short-term diabetes complications in patients below and over 85 years of age. (2) Methods: Data were collected from hospital discharge records (HDRs) of all hospital admissions that occurred in Abruzzo Region, Italy, from 2006 to 2015. Only diabetic patients aged over 65 years were included. Outcomes included were diabetic ketoacidosis, hyperosmolar coma, hypoglycemic shock, iatrogenic hypoglycemic coma, and other diabetic comas. (3) Results: During the study period, 144,376 admissions were collected, 116,305 (80.56%) of which referred to patients below 85 years. Those aged over 85 years were significantly associated to all short-term diabetes-related complications with the exception of ketoacidosis. (4) Conclusions: In older diabetic patients, the avoidance of short-term diabetes complications are a greater concern than in younger patients. Diabetes management among very elderly patients should be tailored accordingly to patient characteristics.