JAMDA 14 (2013) 777e780
JAMDA journal homepage: www.jamda.com
Editorial
How to Manage Diabetes Mellitus in Older Persons in the 21st Century: Applying These Principles to Long Term Diabetes Care Alan Sinclair MSc, MD, FRCP a, b, John E. Morley MB, BCh c, * a
Bedfordshire and Hertfordshire Postgraduate Medical School, University of Bedfordshire, Bedfordshire, UK Institute of Diabetes for Older People (IDOP), Putteridge Bury Campus, Luton, Bedfordshire, UK c Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO b
For most of the past century, diabetologists pushed for tight control of glucose levels in those with diabetes with a minimum HbA1c of 7% (53 mmol/mol) and the feeling that closer to 6% (42 mmol/mol) was better. New guidelines have suggested that healthy older persons may be better served by having an HbA1C between 7.0% and 7.5% (53e59 mmol/mol) with frailer persons having an HbA1c of 7.5% to 8.0% (59e64 mmol/mol), particularly if they are using insulin, and disabled persons having an HbA1c between 8.0% and 8.5% ( 64e69 mmol/mol).1e3 In this issue of the Journal of the American Medical Directors Association, a guideline developed in Canada suggested that an HbA1c of 8% to 9% (64e75 mmol/mol) may be optimal for frail persons and even higher HbA1c would be acceptable for many disabled persons and those receiving palliative care.4 Unfortunately, available research data on nursing homes and optimum HbA1c levels is not available.5e14 A study of OnLok patients, who are equivalent to nursing home patients, found that an HbA1c level of 8% to 9% (64e75 mmol/mol) was associated with optimal outcomes.15 It would appear that a first step in managing nursing home residents with diabetes mellitus is to divide patients into groups that reflect levels of comorbidity, frailty, life expectancy, dependency, and overall functional status. In this article, we suggest 3 main categories: prefrail, frail, and severely disabled (including those with dementia or at the end of life). We recognize that some clinicians might prefer to separate those at the end of life into a separate category, but in our algorithm (Figure 1), we have not done this. Screening for frailty has been recommended for all persons older than 70 years.16,17 This can be done with the simple FRAIL scale (Table 1), which is now well validated,18e22 the Rapid Cognitive Screen (RCS) International Version (Table 2), or the 9-item Clinical Frailty Scale.23,24 Those who have functional impairment using the Activities of Daily Living (ADL) Scale, those who have endstage dementia,25e30 and those on hospice care31 would be clear candidates for an HbA1c higher than 8% (>64 mmol/mol). This new
The authors declare no conflicts of interest. * Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Boulevard, M823, St. Louis, MO 63104. E-mail address: [email protected] (J.E. Morley).
approach of separating all older patients into categories reflecting multiple factors, as in the preceding paragraph (independent and dependent categories), which in turn determine treatment is already being considered by the International Diabetes Federation (IDF), that is launching new international guidance for type 2 diabetes in older people at the end of this year. Alternatively, a simple guidelines document could be developed, such as was done by Benetos et al,32 to allow these guidelines to be implemented with minimal errors. Much data have supported the view that the primary treatment of persons with diabetes mellitus should be metformin in persons without renal failure.33e35 There is increasing evidence that dipeptidyl peptidase-IV (DDPIV) inhibitors are also suitable drugs for the management of diabetes, but at present they are much more expensive than metformin and require long-term study data to be evaluated.36e38 Pioglitazone can be used, but it causes edema and accelerates the development of osteoporosis and hip fractures.39 Alpha-1-glucosidase inhibitors, whose major effect is increasing glucagonlike peptide-I, also appear to be reasonable drugs in those who can tolerate their gastrointestinal side effects.40,41 Given new guidelines, the use of insulin should be limited to those with an HbA1c higher than 8% (64 mmol/mol). Although some have advocated the use of long-acting insulin analogs,42e45 neutral protamine Hagedorn (NPH) costs much less and there is little evidence that it is clinically inferior to the long-acting analogs.4 The use of insulin pen devices appears to be associated with more needle-stick injuries in long term care staff and the 3-mL vials appear to be more cost-effective for long term care.5 In general, the use of insulin sliding scales should be avoided in nursing home residents, particularly as glucose levels are often inappropriately checked after the person has eaten in long term care facilities.46 Therapeutic diabetic diets should not be used in nursing home residents.47e49 Exercise remains an important component of diabetes care in older persons.50 Exercise after meals seems a preferable approach.51 As diabetes accelerates sarcopenia,52,53 the exercise program should include resistance exercise.54e56 This appears also to be true in frail individuals.57,58 Polypharmacy remains a major problem in frail and disabled older persons.59e63 If available data are used to treat comorbidities in older
1525-8610/$ - see front matter Copyright Ó 2013 - American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2013.09.001
778
Editorial / JAMDA 14 (2013) 777e780
Fig. 1. Management of diabetes mellitus in nursing homes. BP, blood pressure.
persons, there are few data to support lowering systolic blood pressure below 145 mm Hg in healthy persons and no data to support treating systolic blood pressure until it is higher than 160 mm Hg in persons older than 80 years or frail older persons.64e66 There is little evidence to support lowering low-density lipoprotein cholesterol in older persons who are frail.67 Data suggest an increase in myositis in these individuals and some data suggest that statins can worsen dementia.68 Thus, using a logical approach to the management of comorbidities in persons with diabetes mellitus in long term care facilities should dramatically reduce polypharmacy by avoiding inappropriate and unnecessary medication.69 It should be recognized that hyperglycemia (>200 mg/dL) has its own set of side effects, including dehydration, zinc loss, increased infections, visual disturbance, cognitive problems, incontinence, and increased pain.48,50,70e74 The discerning physician needs to
Table 1 The Simple “FRAIL” Questionnaire Screening Tool (3e5 ¼ frail; 1e2 ¼ prefrail) Fatigue: Are you fatigued? Resistance: Cannot walk up 1 flight of stairs? Aerobic: Cannot walk 1 block? Illnesses: Do you have more than 5 illnesses? Loss of weight: Have you lost more than 5% of your weight in the past 6 months?
balance these quality-of-life issues against allowing glucose levels to remain at a high level. On the other hand, syncope is common in persons with diabetes mellitus75 and it appears that its genesis is in hypoglycemia triggering arrhythmias in persons with cardiac autonomic neuropathy.76 Figure 1 provides a logical and simple approach to the management of the key metabolic variables associated with diabetes in nursing homes. It should be remembered that an HbA1c less than 7% (
JAMDA journal homepage: www.jamda.com
Editorial
How to Manage Diabetes Mellitus in Older Persons in the 21st Century: Applying These Principles to Long Term Diabetes Care Alan Sinclair MSc, MD, FRCP a, b, John E. Morley MB, BCh c, * a
Bedfordshire and Hertfordshire Postgraduate Medical School, University of Bedfordshire, Bedfordshire, UK Institute of Diabetes for Older People (IDOP), Putteridge Bury Campus, Luton, Bedfordshire, UK c Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO b
For most of the past century, diabetologists pushed for tight control of glucose levels in those with diabetes with a minimum HbA1c of 7% (53 mmol/mol) and the feeling that closer to 6% (42 mmol/mol) was better. New guidelines have suggested that healthy older persons may be better served by having an HbA1C between 7.0% and 7.5% (53e59 mmol/mol) with frailer persons having an HbA1c of 7.5% to 8.0% (59e64 mmol/mol), particularly if they are using insulin, and disabled persons having an HbA1c between 8.0% and 8.5% ( 64e69 mmol/mol).1e3 In this issue of the Journal of the American Medical Directors Association, a guideline developed in Canada suggested that an HbA1c of 8% to 9% (64e75 mmol/mol) may be optimal for frail persons and even higher HbA1c would be acceptable for many disabled persons and those receiving palliative care.4 Unfortunately, available research data on nursing homes and optimum HbA1c levels is not available.5e14 A study of OnLok patients, who are equivalent to nursing home patients, found that an HbA1c level of 8% to 9% (64e75 mmol/mol) was associated with optimal outcomes.15 It would appear that a first step in managing nursing home residents with diabetes mellitus is to divide patients into groups that reflect levels of comorbidity, frailty, life expectancy, dependency, and overall functional status. In this article, we suggest 3 main categories: prefrail, frail, and severely disabled (including those with dementia or at the end of life). We recognize that some clinicians might prefer to separate those at the end of life into a separate category, but in our algorithm (Figure 1), we have not done this. Screening for frailty has been recommended for all persons older than 70 years.16,17 This can be done with the simple FRAIL scale (Table 1), which is now well validated,18e22 the Rapid Cognitive Screen (RCS) International Version (Table 2), or the 9-item Clinical Frailty Scale.23,24 Those who have functional impairment using the Activities of Daily Living (ADL) Scale, those who have endstage dementia,25e30 and those on hospice care31 would be clear candidates for an HbA1c higher than 8% (>64 mmol/mol). This new
The authors declare no conflicts of interest. * Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Boulevard, M823, St. Louis, MO 63104. E-mail address: [email protected] (J.E. Morley).
approach of separating all older patients into categories reflecting multiple factors, as in the preceding paragraph (independent and dependent categories), which in turn determine treatment is already being considered by the International Diabetes Federation (IDF), that is launching new international guidance for type 2 diabetes in older people at the end of this year. Alternatively, a simple guidelines document could be developed, such as was done by Benetos et al,32 to allow these guidelines to be implemented with minimal errors. Much data have supported the view that the primary treatment of persons with diabetes mellitus should be metformin in persons without renal failure.33e35 There is increasing evidence that dipeptidyl peptidase-IV (DDPIV) inhibitors are also suitable drugs for the management of diabetes, but at present they are much more expensive than metformin and require long-term study data to be evaluated.36e38 Pioglitazone can be used, but it causes edema and accelerates the development of osteoporosis and hip fractures.39 Alpha-1-glucosidase inhibitors, whose major effect is increasing glucagonlike peptide-I, also appear to be reasonable drugs in those who can tolerate their gastrointestinal side effects.40,41 Given new guidelines, the use of insulin should be limited to those with an HbA1c higher than 8% (64 mmol/mol). Although some have advocated the use of long-acting insulin analogs,42e45 neutral protamine Hagedorn (NPH) costs much less and there is little evidence that it is clinically inferior to the long-acting analogs.4 The use of insulin pen devices appears to be associated with more needle-stick injuries in long term care staff and the 3-mL vials appear to be more cost-effective for long term care.5 In general, the use of insulin sliding scales should be avoided in nursing home residents, particularly as glucose levels are often inappropriately checked after the person has eaten in long term care facilities.46 Therapeutic diabetic diets should not be used in nursing home residents.47e49 Exercise remains an important component of diabetes care in older persons.50 Exercise after meals seems a preferable approach.51 As diabetes accelerates sarcopenia,52,53 the exercise program should include resistance exercise.54e56 This appears also to be true in frail individuals.57,58 Polypharmacy remains a major problem in frail and disabled older persons.59e63 If available data are used to treat comorbidities in older
1525-8610/$ - see front matter Copyright Ó 2013 - American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2013.09.001
778
Editorial / JAMDA 14 (2013) 777e780
Fig. 1. Management of diabetes mellitus in nursing homes. BP, blood pressure.
persons, there are few data to support lowering systolic blood pressure below 145 mm Hg in healthy persons and no data to support treating systolic blood pressure until it is higher than 160 mm Hg in persons older than 80 years or frail older persons.64e66 There is little evidence to support lowering low-density lipoprotein cholesterol in older persons who are frail.67 Data suggest an increase in myositis in these individuals and some data suggest that statins can worsen dementia.68 Thus, using a logical approach to the management of comorbidities in persons with diabetes mellitus in long term care facilities should dramatically reduce polypharmacy by avoiding inappropriate and unnecessary medication.69 It should be recognized that hyperglycemia (>200 mg/dL) has its own set of side effects, including dehydration, zinc loss, increased infections, visual disturbance, cognitive problems, incontinence, and increased pain.48,50,70e74 The discerning physician needs to
Table 1 The Simple “FRAIL” Questionnaire Screening Tool (3e5 ¼ frail; 1e2 ¼ prefrail) Fatigue: Are you fatigued? Resistance: Cannot walk up 1 flight of stairs? Aerobic: Cannot walk 1 block? Illnesses: Do you have more than 5 illnesses? Loss of weight: Have you lost more than 5% of your weight in the past 6 months?
balance these quality-of-life issues against allowing glucose levels to remain at a high level. On the other hand, syncope is common in persons with diabetes mellitus75 and it appears that its genesis is in hypoglycemia triggering arrhythmias in persons with cardiac autonomic neuropathy.76 Figure 1 provides a logical and simple approach to the management of the key metabolic variables associated with diabetes in nursing homes. It should be remembered that an HbA1c less than 7% (
