Given that September is officially "Healthy Aging Month," we are of course thinking about what happens to insulin-dependent PWDs (people with diabetes) as they get older.
If you or a loved one with diabetes happen to be headed to a nursing home, it's pretty bad news: diabetes care in nursing homes sort of constitutes the perfect storm.
First, the population is aging, so there are more old folks now than ever before, and their numbers are growing. The over-65 crowd now makes up 15% of the population. Second, older people have high rates of type 2 diabetes; in fact, more than a quarter of Americans over the age of 65 have diabetes. And third, improvements in diabetes care have increased the lifespans of people with diabetes, although not always leaving them in the best form. The result?
An explosion in the number of nursing home patients with diabetes. An explosion that has left the medical community scrambling, patients and families confused, and—in some cases—trial lawyers drooling.
At last count, the CDC says there are 15,600 nursing homes in the United States, housing 1.4 million Long-Term Care (LTC) residents. Estimates vary, but an array of studies estimate that between 25-34% of this population has diabetes, and experts agree that this percentage will continue to grow in the coming decades.
It’s an expensive population. In 2012, the most recent year for which data is available, PWDs in long term care facilities racked up a medical tab of $19.6 billion, which works out to more than 12% of the entire national medical cost of diabetes. The costs are so great that some facilities have started charging extra for diabetes management.
With all that money spent, you’d expect great outcomes, wouldn’t you? Well… one study doing a chart review of 14 nursing homes couldn’t find a single patient who received the basic American Diabetes Association (ADA) standard of care.
Guidelines and Drug Recs
And just what is that standard? It’s been a moving target, but last February—for the first time—the ADA issued a detailed position statement on the diabetes care of elderly patients in long term care (LTC) facilities, as did a joint committee of the Japan Diabetes Society and the Japan Geriatrics Society. Earlier clinical guidance came from the American Medical Directors Association clinical practice guidelines, and the combined work of the International Association of Gerontology and Geriatrics, and the European Diabetes Working Party for Older People.
The various guidelines sync up pretty well, but taking the highlights from the ADA:
- Glycemic goals need to be personalized
- Simplified treatment regimens are preferred
- The “diabetes diet” is “outdated,” ineffective, and should be dropped
- The use of sliding scale insulin is to be avoided
The ADA isn’t alone on this last part. In fact, the use of sliding scale insulin was added to the American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication use in Older Adults (yep, that's a thing). Still, the ADAcontinues to think highly of basal insulins. In terms of other diabetes medications, Glyburide is called out by the ADA as the worst of the sulfonylureas in terms of hypo risk for an elderly population; TZD’s are to be avoided simply due to the number of contra-indications and the number of comorbidities in the population; and DPP4's were frowned upon due to lower efficacy—meaning they really just don’t work all that well—and they are dammed expensive, to boot.
What about that oldie but goodie, Metformin? The old standard of care was to discontinue the use of met at age 80, but recent research has many docs re-thinking that.
But wait a second, what are the glucose targets? As it turns out, that is where the devil is in the details.
The Hypo Reaper
The ADA didn’t pull any punches in their guidance, saying: “The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population.”
Well, the ACCORD study showed us that trying too hard to tame blood sugar can kill elderly people outright. But that’s just the tip of the iceberg in a nursing home. Here’s a scary and little-known fact: Falls are the leading cause of death from injury among seniors, and, of course, a hypo is a good recipe for a fall in an elder.
And there’s more.
Elderly patients are actually waaaaaay more likely to have bad hypos than those of us who are younger. Why? Let’s call it the biological aftershocks of the normal aging process. First, most elders—PWDs or not—have some level of impaired renal function. This interferes with the metabolism of sulfonylureas and insulin, prolonging their glucose-lowering effect, and thus increasing the hypo risk. Elders also exhibit slowed hormonal regulation and counter regulation, blunting the body’s normal response to a low. Plus, especially in a nursing home environment, elders suffer from variable appetite and food intake, slowed intestinal absorption, and the unpredictable effects of polypharmacy (a fancy word for the concurrent use of multiple medications, that likely interact in negative ways).
In fact, the ADA guidelines note that the “strongest predictors” of severe hypos are advanced age, recent hospitalization, and polypharmacy—which is pretty much the profile of a typical nursing home resident.
Slightly off topic, but of note, hypos present differently in the elderly. Instead of the heart pounding, sweaty, trembling lows we younger PWDs (and most nurses) are used to, hypos in the elderly present in a neuroglycopenic fashion with confusion, delirium, and dizziness with little or no physical signs until fainting.
Just Leave ‘em High?
OK, so if lows are so dangerous, why not just leave nursing home residents with high BGs? Well, that might be tempting, but this course, too, has its problems. Chronic highs lead to dehydration, funky electrolytes, urinary incontinence, and more.
So the ADA takes the middle ground, calling for avoidance of lows at all cost, while avoiding “severe” hyperglycemia. As for A1C, ADA calls for less than 8.5%, but notes that “many conditions” in the LTC patient can interfere with the A1C test. In many cases they just pretty much say, “forget the friggin’ A1C” and call for pre-meal glucose of up to 200 as being acceptable. For patients at the end of life, the ADA says the A1C, has “no role,” and further, that there is “no benefit” of glycemic control at all, except “avoiding symptomatic hyperglycemia.”
So let’s talk more about the end of life.
Lifespans and Lawsuits
High blood sugar kills. That’s no secret. But it’s a slow process. It takes time, at least half a dozen years. So how much time does the typical resident of a long-term care facility have left? Shockingly little. On average, residents live for only five months in a LTC facility before dying.
Is it bad care that kills them?
The lawyers want you to believe that.
The Internet is rife with so-called nursing home information sites like the official-looking Nursing Home Abuse Guide (from the law firm of Paul & Perkins) that lists a few lame statistics about diabetes and the elderly and then says, “Improper nursing home diabetic care may cause premature death or avoidable suffering to a loved one. If an individual believes that their loved one may have been harmed as a result of nursing home staff negligence, they may be well-served to contact a qualified attorney about filing a lawsuit.”
So are there a lot of lawsuits for nursing home abuse in diabetes treatment? Well, plenty are filed, probably as the result of families’ lack of awareness about the typically short lifespans following nursing home placement, but even poorly treated diabetes would be unlikely to kill anyone that quickly, especially in the type 2 arena. Still, how many of the cases are won in court? Not many, but a jury did find a nursing home negligent in the death of a type 2 in Texas just this year. He died a month after arriving. Of note, the staff didn’t address an infected toe until it turned black and had a foul odor (which led to a major amputation and ultimately his death). Their defense was that he was seriously ill on arrival with a wide variety of conditions requiring intervention, but they lost.
How many cases are settled out of court is unknown.
The Problem Parade
But gross negligence of the staff in a few cases aside, let’s be honest here: If you’re in a nursing home, you aren’t in the best of shape, now are you? Most diabetes patients in nursing homes have a host of other health issues, most have some level of physical disability, and many have cognitive problems as well. And in addition to all of that, as if it weren’t enough, not surprisingly, depression is a plague among nursing home residents.
So the patients are highly complex medically, and many are limited in their self-care ability. Meanwhile, nursing home doctors rarely actually see patients, and the line staff are over-worked, under-trained, and under-paid. And most facilities suffer from high staff turnover. All of this strains continuity of care, not to mention quality, and calls into question how well even the best guidelines might be deployed.
But given the short lifespans, does diabetes care in the closing chapters of life even matter?
Given all the challenges the ADA calls for a simple focus: Quality of life remaining. Simply doing whatever is necessary to make life as easy and comfortable as possible while it lasts. The ADA says the medical staffs of nursing homes should strive to improve management while ensuring lower hypo risk. In other words, try to walk a tight rope down the middle of glucose control. Or, quoting Charles Crecelius, MD, Phd, CMD, FACP, when it comes to blood sugar control in elderly patients in nursing homes, “Don’t be lazy, but don’t be crazy.”