Although current guidelines emphasize that hypoglycemia should be avoided in people in hospice care with diabetes, hypoglycemia occurs in 1 in 9 nursing home patients with type 2 diabetes, and 1 in 20 experience severe hypoglycemia, according to an article published in JAMA Internal Medicine.
The American Diabetes Association currently recommends relaxing glycemic control for patients with diabetes and advanced disease and recommends discontinuation of medication as a patient nears death to avoid hypoglycemia. To determine whether these guidelines are being followed in patients in hospice care, Laura A. Petrillo, MD, of the department of medicine, Massachusetts General Hospital, Boston, Massachusetts, and colleagues conducted a retrospective cohort study of 20,329 patients older than 65 years with type 2 diabetes who were admitted to Veterans Affairs nursing homes between January 1, 2006, and June 30, 2015. The cumulative incidence of hypoglycemia, severe hypoglycemia, hyperglycemia, and the competing risk for death among all those in hospice care and among patients treated with insulin vs those not treated with insulin were analyzed.
The 100-day mortality rate was 83% and the median length of stay was 10 days. Mean baseline glycated hemoglobin levels were higher among patients receiving insulin (n=1687) compared with patients who were not treated with insulin (7.4% vs 6.8%; P<.001). In addition, the mortality rate at 100 days was lower among those who were treated with insulin vs those not treated with insulin (61% vs 85%; P <.001).
Patients treated with insulin had more frequent glucose tests compared with those who were not treated with insulin (mean 1.7 glucose tests/day vs 0.6 glucose tests/day; P <.001). At 180 days, the cumulative incidence of hypoglycemia (glucose <70 mg/dL) among all patients, accounting for the competing risk for death, was 12%, whereas the incidence for severe hypoglycemia (glucose <50 mg/dL) was 5%. However, by 180 days, among insulin-treated patients, 38% had experienced hypoglycemia and 18% had experienced severe hypoglycemia. Patients were most likely to experience hypoglycemia within the first 20 days of admission. Hyperglycemia (glucose >400 mg/dL) had occurred in 9% of all patients and 35% of those treated with insulin by 180 days.
The authors note that hypoglycemia is not consistent with a goal of comfort in those receiving hospice care and add that these data demonstrate suboptimal care in people in hospice who have type 2 diabetes.
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 [published online December 26, 2017]. JAMA Intern Med. doi: 10.1001/jamainternmed.2017.7744