Diabetes Management in New Brunswick Nursing Homes Prepared by Dr. Angela McGibbon March, 2016
As the population ages and with the rising incidence of diabetes, there are increasing numbers of people with diabetes living in LTC facilities. The current complex care of diabetes has made it difficult to transition to appropriate goals and targets in this population which may have multiple comorbidities. In nursing homes, people with diabetes may range from those with limited functional dependence to those who are at the end of their life with a goal of palliation and comfort. Aggressive management of diabetes to avoid long term complication is no longer relevant for some. This document is meant to provide suggestions for those who care for New Brunswick residents living in nursing homes with the following purpose: 1. To ensure resident safety and quality of life is balanced with optimal diabetes management requirements, 2. To allow individualized care plans based on current knowledge, best practices and guidelines, 3. To recognize and avoid symptomatic hypoglycemia, 4. To avoid symptomatic hyperglycemia, 5. To allow rational glucose monitoring protocols when stable and increased monitoring when appropriate, 6. To optimize diabetes medication choices and insulin management practices Preparation of this document is based on several national guidelines including the Canadian Diabetes Association Clinical Practice Guidelines (CPGs) (1), American Diabetes Association guidelines (2) and International Diabetes Federation guidelines (3). The differences of development and recommendations in these three documents have been outlined by Sherifeli et al (4). In addition, there have been several provincial documents including those from Nova Scotia, Prince Edward Island, Newfoundland and Ontario that have been used as guides. In addition, there may be individual programs or facilities with guidelines, such as the Best Practice guidelines developed for alternate level of care patients in Saint John Regional Hospital. The Canadian Diabetes Association CPGs have utilized the Clinical Frailty Scale (Appendix A) to help clinicians identify those who are elderly with significant functional impairment (Moderately Frail level 6, Severely Frail level 7 or Very Severely Frail level 8) and whom a higher A1c (and blood glucose) is not only acceptable, but desired. The higher A1c target is most relevant for those residents on insulin or sulphonylureas who may have unacceptable hypoglycemia risk with tighter control and, in whom, medications may need to be reduced or stopped. As a great many residents with diabetes are managed with lifestyle or Metformin, the main intervention to avoid hypoglycemia is to liberalize the diet for the frail elderly (1). A review of New Brunswick prescription drug program for nursing homes in 2013 showed over 4000 residents with diabetes in nursing homes with 50% on diet or oral agents only. Approximately 50% of nursing home residents with diabetes are on insulin alone (30%) or in combination with oral agent (20%) and between 25 and 30% of these have an A1c <7% (Stuart Halpine, personal communication). A survey of Anglophone nursing homes showed that >50% of nursing homes allow sliding scale insulin for treatment of diabetes, 32% have no facility standing orders for diabetes glucose monitoring and 70% feel that provincial recommendation would be useful (McGibbon and Nicholson, unpublished results). Osman et al (5) have identified nursing time and knowledge as barriers to achieving individualized targets and goals for these residents in the frail elderly. This document will briefly summarize the recommendations for glucose monitoring, A1c use and targets, hypoglycemia, blood pressure and lipids, and some suggestions for optimizing medications and insulin management. This is not a comprehensive clinical guide for diabetes in the elderly and does not take the place of clinical and individualized assessment. It is meant to provide the care team with resources to make decisions appropriate for individual residents. 2
1. Rational Glucose monitoring Blood glucose monitoring is a key component of self-management behaviours instructed to patients with diabetes. Rational glucose monitoring refers to monitoring or checking the blood glucose only when the information will aid in decision making; such as how much insulin to take, effects of certain diet choices, assessing hyper or hypoglycemia with symptoms and for decision around treatment effectiveness. A blood glucose in people without diabetes may range from 3.0 11.0 mmol/l. In those with diabetes, the expected or desired blood glucoses vary and will fluctuate depending illness, activity, pain, food intake, stress and other factors. Typically blood glucoses in the mid-teens can be associated with increased polyuria, the risk of dehydration and impaired wound healing. The suggested frequency of rational glucose monitoring has been reviewed by Canadian Association of Drugs and Therapeutics (CADTH) and the Canadian Diabetes Association. Suggested use of this information in the nursing home population (based on medical stability, clinical frailty index and treatment regimen) is summarized in Table 1. Suggestions for when to reassess the treatment schedule are offered. TABLE 1: Patient Description Clinical Frailty Scale >6 AND medically stable Clinical Frailty Scale > 6 and unwell/sick Clinical Frailty Scale 9 or active palliation/ end of life care Diabetes Management Categories Diet alone Metformin or DPP4 i.e. (Glucophage, Glumetza, Januvia, Onglyza, Trajenta ) Sulfonylureas i.e. Gliclazide (Diamicron ), Glimepiride (Amaryl ) Repaglanide (Gluconorm ) Insulin Once or twice daily injections Insulin - Multiple daily dose injections (not sliding scale) ANY ANY Recommendations for Blood Glucose Monitoring No blood glucose monitoring required unless symptomatic of hypoglycemia or hyperglycemia No blood glucose monitoring required unless symptomatic Once daily at alternating times initially and less frequently if stable. +Once or * twice daily at alternating times when stable. May require TID or QID monitoring when insulin adjustments are being made. *Twice daily alternating times, before meals. May require TID or QID monitoring when insulin adjustments are being made. Increase glucose monitoring to twice a day for 48 hours to rule out hyperglycemia or hypoglycemia. No glucose monitoring unless symptomatic (ex: shaking and tremulous, or thirsty and unusual urinary incontinence) Reassess when: glucose > 18 mmol/l More than one hypoglycemia event or persistent blood glucose > 18 mmol/l Example of: + Once daily alternating times = Day 1 before breakfast Day 2 before lunch Day 3 before supper Day 4 at bedtime 3
* Twice daily alternating times = Day 1 before breakfast and before supper Day 2 before lunch and at bedtime 2. A1c Use and Targets The A1c is not reliable in the older population for several reasons including renal dysfunction, a change in red blood cell turnover and other metabolic factors. A1c monitoring is generally not useful for those who meet a clinical frailty score of >8 or 9 or who have a very short life expectancy as the A1c is used primarily as predictor of long term complications. A low A1c in the elderly patient on diet alone is likely not clinically relevant (especially if the diet has been liberalized) and may signify declining renal or liver function if hypoglycemia is present. In those elderly residents who are on metformin, a low A1c (< 7-8%) is usually acceptable unless there are episodes of hypoglycemia or GI upset in which case the metformin should be reduced or discontinued. Given the potential for serious or prolonged hypoglycemia in elderly on sulphonylureas or insulin, the A1c target is most appropriately higher to avoid hypoglycemia. For those in whom an A1c is being used to assess glycemic control, the recommended A1c is approximately 8.5% (1, 2, 3). A higher A1c is acceptable in order to avoid hypoglycemia. For those on medications or insulin, consider liberalizing diet and reducing or stopping some medications or insulin when the A1c is < 8.0, particularly when there has been hypoglycemia symptoms. The optimal frequency of A1c monitoring is not known in LTC residents. In the absence of symptoms or changing treatment regimens, A1c monitoring may be done once every 6 months or even annually if stable. In some cases (very severely frail or terminally ill patients) the A1c will add little to the patients care and does not need to be tested. 3. Hypoglycemia Hypoglycemia is an important complication of diabetes management and must be avoided in nursing home residents. Hypoglycemia is defined as a blood glucose <4.0 in most people with diabetes but for some, symptoms occur at a higher blood glucose and should also be avoided. In nursing home residents on sulphonylureas or insulin, a blood glucose <5.0 may represent hypoglycemia. Residents on sulphonylureas may have prolonged hypoglycemia, particularly when there is declining renal function. Hypoglycemia is difficult to recognize in the elderly person, particularly those with cognitive impairment. Common symptoms of hypoglycemia are diaphoresis, trembling/shaking and confusion. Any change in resident behaviour may indicate abnormal blood glucose. A poster developed by CADTH and Western Health in Newfoundland to help recognize hypoglycemia is found in Appendix B. LTC facilities ideally have a hypoglycemia protocol for blood glucose less than 5.0 mmol/l. This does not apply to residents treated with lifestyle or diet treatment, however if these residents have frequent hypoglycemia, they should have a medical review. An example of a protocol for hypoglycemia is: Hypoglycemia protocol for residents with blood glucose <5.0 mmol/l with symptoms: For conscious patient who is able to take treatment orally: 20 g fast-acting carbohydrate (i.e. 250 ml unsweetened apple juice) Retest blood glucose in 15 minutes, If less than 5 mmol/l, treat with 20 g fast acting carbohydrate again Repeat every 15 minutes until blood glucose is greater than 5 mmol/l 4
Give protein and carbohydrate snack (2 tablespoons peanut butter or 1 ounce (30g) cheese or meat/fish along with 7 crackers or 1 slice of bread or 1 small muffin) if meal is greater than 30 minutes away For unconscious patient or patient unable to treatment orally: Give glucagon 1 mg subcutaneous x 1, check glucose in 15 minutes, repeat if necessary Notify physician if hypoglycemia persists 4. Blood Pressure and Lipids Nursing Home residents with diabetes have higher cardiovascular risk profiles and may benefit from treatment for hypertension however this must be balanced with the adverse events associated with drops in blood pressure including falls. The recommended blood pressure target for most frail elderly is <150/90. Statins should be considered if there is likely benefit from prevention of complications from dyslipidemia, particularly in regard to secondary prevention with a target LDL < 2.0 mg/dl (or 50% reduction from original LDL). In residents with dementia, lipid-lowering therapy may not be appropriate, especially if dementia is non-vascular in nature. 5. Optimizing Medications and insulin management Medication choices for the elderly available through the NB drug program coverage are: Medications Insulin Covered Metformin (Glucophage) Glyburide (Diabeta) Gliclazide (Diamicron and Diamicron MR) Glimepiride (Amaryl) Acarbose (Prandase) (*chlorpropamide, tolbutamide) Regular insulin Intermediate Acting insulin Premixed (30/70, 40/60 and 50/50) With Special Authorization Combination Metformin and Sitagliptin (Janumet) Sitagliptin (Januvia) Repaglanide (Gluconorm) Canaglifozin (Invokana) (**rosiglitazone and pioglitazone) Rapid acting insulin Basal analogues *Chlorpropamide and Tolbutamide older sulphonylures with a very high risk of hypoglycemia which should not be used in the LTC population. Glyburide is associated with a higher hypoglycemia risk than the other choices. **Rosiglitazone and Pioglitazone may be associated with weight gain, fluid retention, heart failure and other adverse effects. Generally not used except in younger patients with early diabetes. Metformin is first line therapy, but may cause nausea, GI upset or diarrhea. It should not be used in the setting of heart failure or renal disease (elevated creatinine) but does not cause hypoglycemia. Metformin doses may be reduced or stopped in the resident who has GI symptoms or changes in renal function. Gliclazide, Glimepiride and Repaglanide are sulphonylureas or insulin secretagogues which may cause hypoglycemia in residents with advanced renal failure or impaired oral intake. Acarbose can result in a small glucose reduction but is poorly tolerated. 5
Newer classes of oral medications may be approved with special authorization and the DPP4 class (such as Sitagliptin) has some potential benefits as the risk of hypoglycemia is low and there are generally few limiting side effects. The SGLT2 class (such as Canagliflozin) has not been well studied in the elderly person and may cause hypotension including postural hypotension; it would not be recommended for most residents in nursing homes. Many residents with type 2 diabetes (>95% of those with diabetes in LTC) and a consistent schedule can be well managed on the older regular and intermediate acting insulins. There may be some advantages to the simple twice daily schedule of premixed insulins; however, these are unlikely to result in glucose management that would meet targets for the healthy elderly. With special authorization, insulin analogues (humulog, novorapid, apridra, lantus and detemir ) may be considered, but the advantages in the elderly, clinically frail population are not clear (1). Proper insulin injection technique and regular site rotations are an important part of managing diabetes with insulin. Sliding scale insulin is not recommended for nursing home residents as a primary means of glucose management. There may be situations where a corrective dose of short acting insulin is appropriate for some residents who are otherwise well, have type 1 diabetes, or are having their blood glucose monitored regularly in order to make decisions about insulin dosing or during illness. The decision regarding the most appropriate medication or insulin treatments for the resident with diabetes in nursing homes can be difficult and is typically based on hypoglycemia risk, coverage, side effect profile and renal function. Residents with Type 1 diabetes, or insulin dependent diabetes, will always need some basal or long acting insulin even if the resident is not eating well. Residents with type 2 diabetes who refuse or skip meals may need to have sulphonylureas and insulin held or reduced temporarily or long term if there is a major decline in appetite or intake. Likewise, declining renal function often requires adjustment in medications (6). Metformin should be used with caution and at a reduced dose when CrCl is less than 60 and discontinued when Cr Cl is less than 30. Glyburide is used with caution at Cr Cl < 50 and should be discontinued when Cr Cl is less than 30 (see Appendix C). 6. Summary The goals and management strategies for residents in nursing homes with diabetes will be different than for the healthy elderly population. On or before admission, each resident should ideally be reviewed by a diabetes educator, physician or specialist with knowledge of the special considerations of diabetes in this population to determine if medication or insulin changes are required (such as stopping sliding scale insulin or switching glyburide to glyclazide for hypoglycemia risk reduction etc), and to determine a rationale glucose monitoring schedule for each resident and A1c target. Standing orders for hypoglycemia are encouraged for all facilities as well as a mechanism for ensuring medication adjustments are prompted when unacceptable hypoglycemia or hyperglycemia are experienced. Nursing Home staff should receive appropriate education that allows them to confidently assess and treat hypo and hyperglycemia in addition to knowing proper insulin injection techniques. For most nursing home residents, there is no benefit to maintaining dietary restrictions. Individualized management is ideal and many need to be adjusted over time. For many residents who are at the end of life, consideration can be given to discontinuing the diabetic regimen. 6
APPENDIX A: 7