BOSTON—Clinical guidelines recommend relaxing glycemic control target levels for patients with diabetes and advanced disease and eventual discontinuation of medications as patients near death to avoid hypoglycemia. A new study published in JAMA Internal Medicine sought to determine if that was occurring in VA long-term care facilities.1
The issue, according to the Massachusetts General Hospital-led researchers, is that hypoglycemia causes symptoms of weakness, diaphoresis, confusion, shakiness and dizziness and is a potentially preventable cause of suffering among hospice patients. They pointed out that past research has little effect on whether nursing home patients with Type 2 diabetes in hospice are assessed for dysglycemia, receive insulin or oral hypoglycemic medications or experience hypoglycemia and hyperglycemia.
To remedy that, they conducted a retrospective cohort study of patients older than 65 years with Type 2 diabetes admitted to VA nursing homes between Jan.1, 2006, and June 30, 2015, using linked laboratory, pharmacy and administrative data. The study cohort ultimately included 20,329 hospice patients, nearly all of whom were male. Study authors report that the hospice patients had an 83% 100-day mortality rate, with 16,791 deaths, and a median length of stay of 10 days.
Results indicated that 8% of patients in the cohort received insulin, and that mean baseline glycated hemoglobin levels were higher than patients not treated with insulin—7.4% vs. 6.8%—while the mortality rate at 100 days was lower (61% vs. 85%; P < .001).
In addition, patients treated with insulin had more frequent glucose tests—mean 1.7 glucose tests/d, vs. 0.6 glucose tests/d among patients not treated with insulin; P < .001. The cumulative incidence of hypoglycemia, defined as glucose less than 70 mg/dL, among all patients, accounting for the competing risk of death, was 12% at 180 days, and that of severe hypoglycemia—glucose less than 50 mg/dL, was 5%.
Overall, among patients treated with insulin, 38% experienced hypoglycemia, and 18% experienced severe hypoglycemia at 180 days. The highest risk of hypoglycemia occurred in the first 20 days of admission, the study pointed out.
Researchers reported that the cumulative incidence of hyperglycemia (glucose greater than 400 mg/dL) at 180 days was 9% in all patients, but higher in the group treated with insulin at 35%.
“Despite guidelines that stress avoiding hypoglycemia in hospice patients with diabetes, we found that one in nine nursing home patients with type 2 diabetes experienced hypoglycemia (glucose <70 mg/dL) while one in 20 experienced severe hypoglycemia (glucose <50 mg/dL) while on hospice,” study authors wrote. “The risk of hypoglycemia was highest among patients treated with insulin, one-third of whom experienced hypoglycemia. Patients treated with insulin lived longer and experienced more hyperglycemia than patients not treated with insulin, which suggests that clinicians may be choosing to continue insulin for those hospice patients with a longer life expectancy and more severe diabetes at hospice admission.
“Nevertheless,” they concluded, “hypoglycemia is not consistent with a goal of comfort, and these data demonstrate suboptimal avoidance of dysglycemia among patients with type 2 diabetes on hospice in nursing homes. Further research is needed to establish optimal timing of diabetes medication titration and cessation and characterize the effect of hypoglycemia and hyperglycemia on the symptom burden of patients with diabetes on hospice.”
- Petrillo LA, Gan S, Jing B, Lang-Brown S, Boscardin WJ, Lee SJ. Hypoglycemia in Hospice Patients With Type 2 Diabetes in a National Sample of Nursing Homes. JAMA Intern Med. 2017 Dec 26. doi: 10.1001/jamainternmed.2017.7744. [Epub ahead of print] PubMed PMID: 29279891.
About 5% of the United States population has been diagnosed with type 1 diabetes, and the great majority are diagnosed before age 25. Since a diabetes diagnosis prevents enlistment in the military, relatively few veterans have the condition compared to type 2 diabetes, which affects about a fourth of VHA patients.
VA patients dying of cancer are far less likely to receive excessive and unnecessary end-of-life interventions than those treated by Medicare.