Decisions about diabetes care can
become harder as people age, and that may be especially true for
those needing hospice care.
A new US study has found that, among people getting
hospice care in a nursing home, diabetes care may lead to higher
rates of dangerous low blood glucose episodes, known as
That finding came from the researchers' analysis of data
on nearly 20,000 people with type 2 diabetes, all in nursing homes
and receiving hospice care.
In 180 days, the time period covered by
the study, about one in nine people experienced low blood
glucose episodes. But, among those treated with insulin, about one
in three had low blood glucose episodes, according to the study's
lead author, Dr. Laura Petrillo, an instructor in medicine at
Harvard Medical School.
Low blood glucose can cause weakness, sweating, confusion,
shakiness and dizziness, which can cause suffering and reduced
quality of life. The researchers defined low blood glucose episodes
as blood glucose levels under 3.9 mmol/L (millimole per
"Hospice is care focused on maximizing comfort at the
end-of-life, and usually includes stopping treatments that are
unlikely to have short-term benefits," Petrillo said. "Patients
with type 2 diabetes were experiencing hypoglycemia, which would be
an indication that there was room for improvement in their diabetes
The study also looked at high blood glucose episodes,
defined as blood glucose levels over 22.2 mmol/L. High glucose --
hyperglycemia -- can cause excessive thirst and a need to urinate
more frequently. During the 180 days, 38 per cent of patients
treated with insulin had low blood glucose, 18 per cent had severe
low blood glucose and 35 per cent had high blood
Blood glucose levels were checked an average of 1.7 times
a day for people on insulin and 0.6 times a day for those who
weren't given insulin, according to the report.
People in the study were receiving end-of-life care at
Veterans Affairs nursing homes between 2006 and 2015. All were 65
or older, and nearly all -- 98 per cent -- were men. About 83 per
cent died before 100 days.
The study findings bring up an important issue -- the need
for more specific guidelines for diabetes management in nursing
home and hospice patients, according to Dr. Joel Zonszein, director
of the Clinical Diabetes Center at Montefiore Medical Center in New
Those institutions often "export guidelines for
hospitalised patients, and end up continuing to use a lot of
medications that cause hypoglycemia," he said.
Zonszein noted that insulin isn't the only medication that
can cause low blood glucose levels. Some oral diabetes medications
also can cause blood glucose levels to drop too low.
In addition to causing people to feel terrible, low blood
glucose levels can also increase the likelihood of falls -- a
concern in hospice facilities and in nursing homes, he
"If medications are not improving quality of life in
hospice, it doesn't make sense to use them," Zonszein said. "There
are many newer medications that don't cause lows and control the
highs. They cost more, but you don't have to monitor patients as
much," so ultimately they're likely cost-saving, he
Matt Petersen, managing director of medical information
for the American Diabetes Association, said that the study adds to
the understanding of end-of-life care for people with
"Hypoglycemia is to be avoided for safety and quality of
life, but severe hyperglycemia is also to be avoided for the same
reasons -- left to go too high, glucose levels can lead to
catastrophic (and very unpleasant) metabolic crisis," Petersen
said. "In patients that may not be eating well, estimating insulin
dosing to match food intake can be challenging."
Petersen said it appears from the information provided
that patients in the study were receiving individualized care based
on their health condition, which is what the American Diabetes
Association recommends for care.
"Care should involve a comprehensive consideration of what
will ensure the best circumstances for the patient," he
The study authors pointed out that about one-quarter of
people in the United States die in a nursing home, making this a
problem many people might face.
What, then, can people do to ensure they or a loved one
receives the right care for them in a nursing home, particularly as
they near the end-of-life?
"Advocate for your loved ones," Petrillo advised. "Ask for
a medication review, and make sure that medications are geared
toward providing comfort and that they're not receiving anything
that doesn't have a short-term benefit."
The study was published as a research letter in the Dec.
26 online edition of
JAMA Internal Medicine.
By Serena Gordon