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Introduction Taking a Step Back is the Best Approximately one-quarter of people over the age of 65 years have diabetes and one-half of older adults have prediabetes. People with diabetes often have other chronic diseases such as Way to Move Forward – hypertension, cardiovascular disease and renal disease, neurological complications and are at increased risk of some forms of cancer that also affect life expectancy. However, the increasing prevalence of type 2 diabetes in young people means that the hospice demographic will also A Review of Diabetes Management at End-of-Life change.

With the increasing prevalence of diabetes seen in the general population coupled with a large Christine Pham, Pharm.D., BCGP percentage of hospice patients admitted with comorbidities of cancer, cardiovascular disease, renal disease, and dementia, hospice clinicians should be prepared to be knowledgeable about the complexities involved in diabetes care at end-of-life.

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Objectives Diabetes in Older Adults • Identify the goals of diabetes care in the hospice setting and how they align with the overall goals of hospice care • Increases the risk of common geriatric syndromes • Review signs and symptoms of hypo/hyperglycemia and how to adjust the • Cognitive impairment diabetic medication regimen to avoid potential severe, life-threatening events • Depression • Coordinate a safe and individualized approach to managing diabetes based on • Injurious Falls patient prognosis • Polypharmacy • Review the recommendations in the 2021 American Diabetes Association • Persistent pain Standards of Medical Care in Diabetes, as they pertain to the end-of-life • Urinary incontinence hospice population • Difficulty adhering to complex self-care regimen • Identify patient concerns around deintensification of the diabetes regimen, • Hypoglycemic events can cause further cognitive decline and vice versa using that to effectively demonstrate the benefit for liberalization • Less likely to benefit from reducing risk of microvascular complications (seen long-term)

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American Diabetes Association - Older Adults: Goals of Diabetes Care at End-of Life Standards of Medical Care in Diabetes 2021 In a hospice patient, tight glycemic control not only has questionable benefit but has a clear potential to cause harm and significant morbidity. End of Life Care • Shift focus from prevention of long-term complications to patient comfort and individualized • “For patients receiving palliative care and end-of-life care, the focus should be to avoid goals of care. hypoglycemia and symptomatic hyperglycemia while reducing the burdens of glycemic • Avoid symptomatic hypo- and hyperglycemia and minimize the burdens of diabetes treatment management. Thus, when organ failure develops, several agents will have to be including frequent testing. deintensified or discontinued. For the dying patient, most agents for type 2 diabetes may • There is no role for hemoglobin A1C targets in the hospice patient population. Reduction in be removed.” HgA1C decreases the risk of long-term complications (years). HEDIS measures do not apply to • 12.20 - “Overall comfort, prevention of distressing symptoms, and preservation of quality hospice patients. of life and dignity are primary goals for diabetes management at the end of life.” • An acceptable fasting blood glucose level of 200-300 mg/dL is well tolerated without incurring symptoms of hypoglycemia or hyperglycemia.

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Symptoms of Hypoglycemia Symptoms of Hyperglycemia

• Cognitive impairment/confusion • Dry skin • Behavioral changes • Dehydration • Tremors/shakiness • Thirst/dry mouth • Seizure • Drowsiness • Palpitations/tachycardia • Blurred vision • Anxiety • Nausea • Sweating • Polyphagia • Hunger • Lethargy • Paresthesia • Coma • Coma

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What important changes occur in the hospice patient? Prognosis-Based Approach to Diabetes Care

• Advanced disease but relatively stable • Impaired cognition • Anticipated survival of several months • Loss of appetite and weight loss • Acute prevention of hypoglycemia and hyperglycemia • Erratic nutritional intake and hydration • Continue with regimen if demonstrated ability to recognize hypoglycemic symptoms • De-intensify diabetic regimen when N/V, decreased oral intake, or weight loss is observed • Impaired swallowing • Impending death or organ failure • Progressive renal/liver impairment • Anticipated survival of weeks • Complicated infections • Caregiver education of preventing hypoglycemia and taking appropriate action • De-intensify diabetic regimen – agents known to cause hypoglycemia should be considered for • Decreased activity level discontinuation • Decreased functional status • Actively dying, transition imminent • Medication changes • Patient is in final days of life • Focus on patient comfort • Discontinue all diabetic medications (unless Type 1 patient)

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Diabetes Medication Management Medications with Hypoglycemic Risk

James, June. “Dying Well with Diabetes.” Annals of Palliative Medicine vol. 8, no. 2, 2019

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Insulin Considerations Drug-Induced Hyperglycemia

• All insulins carry a risk of hypoglycemia • As patients approach the end-of-life, they may be prescribed medications necessary for patient comfort and symptom control that may increase blood • Patients with Type 1 diabetes will need to continue insulin indefinitely but dosing glucose levels should be reduced in presence of renal/hepatic failure and during active • Corticosteroids: prednisone, dexamethasone, (methyl)prednisolone, budesonide, etc. transition. • Atypical Antipsychotics: olanzapine, risperidone, quetiapine, etc. • • Patients with Type 2 diabetes may continue insulin if needed to maintain liberal Diuretics: Furosemide, torsemide, bumetanide, etc. • Beta2-agonists: Albuterol, levalbuterol, formoterol, salmeterol, etc. fasting blood glucose of 200-300 mg/dL or remain asymptomatic. Patients with organ dysfunction/failure will need to decrease insulin requirements. Insulin, and all diabetic medications, are stopped in Type 2 patients that are actively passing. • Any medication change (newly ordered or discontinued) should be evaluated to anticipate impact on glycemic control. The impact may not necessarily require adjustment in diabetic regimen if the patient is asymptomatic.

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Management Strategies

• Oral medications to manage diabetes are preferred, as are simplified insulin Dialogue with Patients regimens with low risk for hypoglycemia (No SSI) • Discontinue diabetes medications that carry risk of hypoglycemia (except for insulin in type 1 diabetics) • Discontinue diabetes medications that commonly cause nausea • Rapid-acting insulin may benefit patients who have erratic appetites or miss meals due to episodes of nausea or vomiting. Can be given after patient starts a meal. • Long-acting insulin may benefit patients with stable, daily nutritional intake. Adjust dose if food intake decreases or patient experiences weight loss.

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Patient Perception and Concerns Overall Strategy and Clinician Approach

• For some patients and families, careful attention to diabetes management may • Prepare yourselves – These conversations will be difficult, emotionally charged, be one of the few health-related activities they can maintain control over. and lengthy. • Patients have been educated about the importance of monitoring and strict • Upon enrollment into hospice, providers should discuss goals of care with glycemic control for years. patients and their families and the likely trajectory of glycemic treatment. • Suggestions to stop diabetes medications or blood glucose checks can be seen as • Frame these discussions therapeutically, clarifying that stopping or adjusting lack of concern or hastening the disease process. medications is being done to prevent harm and promote patient well-being. • Patient may become anxious about the effects of uncontrolled blood glucose and • Educate about the burdens and risks of tight diabetes management. These hyperglycemic events. discussions should dispel fears of abandonment. Recommendations to liberalize • Concerns about uncontrolled diabetes leading to blindness, amputations, diabetes control are designed to improve quality of remaining life. neuropathy.

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Conclusion Overall Strategy and Clinician Approach ✓Diabetes is (and will increasingly become) a prevalent co-morbidity in the hospice patient • Reference ADA guidelines as support for population ✓ the changes at end-of-life. Build trust, understand the It is important for clinicians to understand the characteristics, challenges, and physiological changes that present in the hospice patient and how they affect diabetes care • Recognize their knowledge and hard work patient’s concerns, inform of ✓ in managing their diabetes care for many the guidance from evidence- Identifying when therapy de-escalation is warranted can prevent negative outcomes and improve patient quality of life. years. based medicine, listen to the ✓ • Explain that the focus of care is now patient’s goals and Maintaining function and quality of life, as defined by the patient, becomes more important than maintaining glucose and HgA1C goals. changing from tightly controlled blood expectations, develop and ✓ sugars to alleviating other symptoms – agree on a plan collaboratively. When communicated effectively, less aggressive glycemic treatment can allow patients to dyspnea, pain, and other comfort reduce pill burden, painful fingersticks and laboratory monitoring, and give patients measures. permission to focus on enjoying what time they have left, rather than disease management.

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Questions? References

1. American Diabetes Association. 12. Older adults: Standards of Medical Care in Diabetesd2021. Diabetes Care 2021;44(Suppl. 1):S168–S179 | https://doi.org/10.2337/dc21-s012 2. Angelo, Mark, et al. “An Approach to Diabetes Mellitus in Hospice and Palliative Medicine.” Journal of Palliative Medicine, vol. 14, no. 1, 2011, pp. 83–87., doi:10.1089/jpm.2010.0191. Christine Pham, PharmD, BCGP 3. Lee, Sei J., et al. “Improving Diabetes Care for Hospice Patients.” American Journal of Hospice and Palliative Medicine®, vol. [email protected] 33, no. 6, 2015, pp. 517–519., doi:10.1177/1049909115578386. 4. Scheufler, Janice M., and Maryjo Prince-Paul. “The Diabetic Hospice Patient.” Journal of Hospice & Palliative Nursing, tel: 855.806.1765 vol. 13, no. 6, 2011, pp. 356–365., doi:10.1097/njh.0b013e3182330edc. 5. James, June. “Dying Well with Diabetes.” Annals of Palliative Medicine, vol. 8, no. 2, 2019, pp. 178–189., doi:10.21037/apm.2018.12.10. 6. Dunning, Trisha, and Peter Martin. “Palliative and End of Life Care of People with Diabetes: Issues, Challenges and Strategies.” Diabetes Research and Clinical Practice, vol. 143, 2018, pp. 454–463., doi:10.1016/j.diabres.2017.09.018.

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