Diabetes in Late Life: Nadine Carter, Tamryn Gray, Alex Lee

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex Smith: This is Alex Smith.

Eric: And Alex, we’ve got a full house today.

Alex Smith: We have a full house. Today we are delighted to welcome from the East Coast, we have Nadine Carter, who’s a nurse practitioner who spent seven years in outpatient endocrinology and is now a hospice and palliative care fellow at Dartmouth Health and instructor at Dartmouth. Welcome to the GeriPal podcast, Nadine.

Nadine: Thank you, guys.

Alex Smith: And we’re delighted to welcome Tamryn Gray, who is an oncology and blood marrow transplant nurse by training and is a palliative care and caregiving researcher at Dana-Farber Cancer Institute, instructor in medicine at Harvard Medical School. Welcome to the GeriPal Podcast, Tamryn.

Tamryn: Thanks so much, Alex and Eric. Happy to be here.

Alex Smith: And we’re delighted to welcome back Alex Lee, who’s an epidemiologist and assistant professor at UCSF in the division of geriatrics. Very interested in diabetes and nursing homes and what we should be doing, hypoglycemia, hyperglycemia, continuous glucose monitoring. We’ll get into all of that. Welcome back, Alex.

Alex Lee: Thank you. Happy to be here.

Eric: And you can probably tell already, the topic at hand is diabetes management in late life. We’re going to be talking about in people with short life expectancies, hospice, SNFs, the whole works, including dementia. But before we do, who has a song request for Alex?

Nadine: I do.

Eric: Nadine, what is it?

Nadine: So I asked if you could play Sugar, Sugar by The Archies.

Eric: We won’t ask why. [laughter]

Alex Smith: (singing)

Very appropriate. Good choice. And also we did the other, what was it? Pour Some Sugar On Me in our last podcast-

Nadine: With Laura.

Alex Smith: … with Laura Petrillo-

Eric: The diabetes songs-

Alex Smith: … like, five years ago. So many good options.

Eric: Lips Like Sugar was another one that we were thinking about.

Alex Smith: Too much synthesizer there, though.

Tamryn: They’re just so sweet. What can we say?

Alex Smith: The Archies. 1969 was a good year for music.

Tamryn: Someone had to say it, Alex.

Nadine: Thanks, Tamryn.

Eric: Tamryn, I think you are the instigator for this podcast.

Tamryn: That would be correct, Eric. So I am not a diabetes expert by any means, but Nadine and I actually met a few months ago when there were a group of nurses who came together, PhDs and DNP prepared nurses. We came together here virtually in the New England area, and we were talking about research and talked about palliative care. And one of the things that Nadine mentioned is that she would love to talk more about her work. And one of the things that I know is that in nursing, we need to A, work together in terms of PhD and DNP nurses, so wanting to amplify our voices in the podcast, but also shed light on such a topic that I know very little about and I imagine many people do not know a lot about when it comes to diabetes and palliative care and diabetes and end-of-life care. So I was just really excited about her work and I did instigate this.

Eric: Let me ask you a question. If in your own work, your clinical work, is this something that you see people struggle with you, you see yourself struggle with?

Tamryn: Yes, 100%. So my background clinically is working with cancer patients and families and those who underwent bone marrow transplant, and a lot of times for their treatment regimen, it includes steroids. So a lot of my patients with cancer or blood disorders develop diabetes just as a result of their different treatments. So a lot of these patients that I care for are at risk for mortality or poor prognosis in general, and wanting to know how do we still provide them with quality care without giving them too many pricks, too many titrations when it comes to insulin. So I’m more familiar with patients who develop diabetes after treatment, but I’m really interested in learning about patients that Nadine cares for.

Eric: I also imagine that one of the challenges is that we often think about diabetes as an individual having to deal, take their diabetes medications, take their finger sticks, but it is in this caregiving environment where the families are often an important integral part and potentially something we should be thinking about even when we’re thinking about diabetes targets. What is the role of the family caregiver system, how they play a role? And I can only imagine that’s even more complicated in the cancer patient population, where we’re asking them to do so many other things as well. Is that your experience?

Tamryn: That is absolutely my experience. When we think about the diabetic population in general, a lot of these patients self-manage. They watch their own glucose, they know what to do in response to certain symptoms. So sometimes caregivers are involved and sometimes it seems like they’re not just based on my own preparation for the podcast, but I’m curious about what Alex and Nadine think about the role of family because I imagine that when these patients get sick or families are taking on a whole other role, that could be often very unfamiliar to them. Or, if they’re used to such frequent monitoring and all of a sudden clinicians are like, “Let’s halt this. We don’t need to check sugars all the time,” that also is a shock for patients and families. So I’m curious so as to what you all think in terms of family and diabetes?

Nadine: I think for our geriatric friends that listen to the podcast, there’s a lot of discussion about de-intensifying management as people age. And I think some of that includes the transition of the caregiver, where maybe somebody’s been managing their diabetes their whole life and now their caregiver or their family member sometimes is trying to step in, help them manage their pumps, their medications, their testing, and don’t necessarily have the experience and the knowledge, so they’re trying to grapple with that.

And then the patient also, like you said, when you’re trying to de-prescribe and make things more simple, people have been poking their fingers and taking their insulins often for 30, 40+ years, and now we’re essentially telling them none of that matters. And so a lot of it’s the education for patients and their care partners, “This is why we’re doing the things we’re doing. The long-term repercussions aren’t as big of a deal anymore. The short-term symptoms and repercussions are more important, the quality of life.” And so there’s a lot of discussion going on about how you do all of that, especially when we start talking about really end of life, like less than six months to live.

Alex Lee: And I think another important aspect to just bring in here is the difference between Type 1 and Type 2 diabetes. In particular, people with Type 1, as you said, they’ve had it for 30, 40 years, it’s become a very integral part of their identity. And so it becomes very hard for them to suddenly say, “Nope, you don’t need to do that anymore.” In some cases, it really feels like it’s taking something that’s a part of them away from them, as opposed to Type 2, where you have the gamut of people who have only had it for three or four years, maybe they’re on one or two oral agents, and so for them, the intensification of, “Oh, you’re going to switch from this oral medication to this oral medication,” maybe it’s not as as much of a big deal. So I think there’s a huge difference in how we approach Type 1 and Type 2 differently, even though they might both be on short acting insulin and complex insulin regimes.

Nadine: I know we’ll talk more about it too, but when we start de-prescribing and thinking about what matters in those last days, weeks, months of life, that difference between types of diabetes and how long somebody’s had especially type two diabetes, it starts playing a role in whether or not they’re going to even need management at the end of life. And I know we can talk more about that, and that’s where some of my work has come in.

Tamryn: Nadine, will you give a sense for how many people in the US or proportion of people have diabetes?

Nadine: Yeah. So according to ADA, 29% of people over 65 have diabetes. Most of that’s Type 2, but more and more are also living longer with Type 1, so these people are aging into their seventies and eighties with type one diabetes, which is wonderful. There was also a statistic that half of older adults have pre-diabetes, whether they know it or not. And just with the aging population, baby boomers are going to be hitting 65. All of them are going to be over 65 by 2030, so if you figure a quarter of those have diabetes, I call it the silver tsunami that’s coming into the palliative care geriatrics world, so these are topics that are going to be really important to all of us.

Alex Lee: And I think there’s a dearth of information about what proportion of nursing home residents have diabetes. I think I’ve seen instances of a third of nursing home residents have diabetes, but again, this is data that’s quite old. And so again, with the aging population and more and more people having diabetes, I think it’s going to become more and more common and those sorts of issues are going to crop up more in the nursing home setting.

Eric: Alex, you’ve done a little bit of work in the dementia population too, right?

Alex Lee: Mm-hmm.

Eric: What do we know about diabetes in that particular population?

Alex Lee: Well, I would say it’s enormously complex and I think there’s a lot of literature focusing on how hypoglycemia is much more common among patients with dementia, and this is largely thought to be due to difficulties with diabetes. So people, especially those living alone who are still managing insulin, they might be forget a dose or then they take a dose and they forget to eat. All sorts of things can happen as people are losing track of their own activities throughout the day. And then I have some new research that’s coming out that’s looking within the VA nursing homes, and when we actually look at cognitive impairment within the nursing home, we don’t see an association with cognitive impairment.

Sorry, did I say that backwards? We don’t see an association with hypoglycemia, so the risk of hypoglycemia is the same whether you have intact cognition or severe cognitive impairment. And my hypothesis is that’s because it’s no longer the individual managing their own diabetes, it’s the nursing home staff managing their diabetes. And so once we take away that component where people are doing their own management, dementia is no longer associated with hypoglycemia. And so that’s another interesting aspect of all of this.

Eric: If I remember too, correctly, from Laura Petrillo’s podcast and her paper, which we’ll have a link to on our show notes, hypoglycemia is super common in the nursing population too. One in nine patients in her cohort experienced hypoglycemia.

Alex Lee: Well, and that’s in hospice too. And when you look in the greater nursing home population, it’s more like one in three almost-

Eric: So it’s even worse.

Alex Lee: … particularly in on those insulin. And actually, in the VA, over 50% of people are on short-acting insulin in the nursing home who have diabetes, which is remarkable.

Alex Smith: So another way of phrasing your finding, Alex, is that people with dementia get just as much hypoglycemia as people without dementia, neither of which is good. It’s just as bad for people with dementia in the nursing home setting.

Alex Lee: Right.

Tamryn: But it also speaks to the heavy reliance that these patients have with the nursing home staff and potentially other surrogates who take on their care when they’re not able to cognitively be intact, and knowing how to self provide self-management themselves. And it has me thinking about how are we training clinicians who are diabetes experts or not about the proper ways of supporting these patients, especially when they’re facing poor prognosis? Are clinicians adequately trained and educated about signs and symptoms of that right balance of knowing when to change the whole medication regimen? Are clinicians being adequately educated and feel comfortable about having conversations with patients and families? And I don’t know where if we’re there yet.

Nadine: I think one of the good things that’s happening, at least through the ADA, is the guidelines over the last five or six years have really changed to start guiding people. For example, if people are over 65 and they’re healthy, maybe an A1C goal under 7 or 4.5 is fine. But if they have problems on top of problems, on top of problems, maybe we should shoot for under 8%. Or if they have really poor health and prognosis, stop paying attention to the A1C at all and start really managing symptoms.

Which is where I think it really starts folding into the whole palliative care, end-of-life world, is if people are having symptoms, then something is not being managed well and it needs to be changed. And maybe that means their glucoses are running higher, but they’re not having falls, they’re not having confusion. I think that’s the thing I would think about with especially our older population in nursing homes with hypoglycemia, is when people are falling all the time and they’re on sulfonylureas or they’re on insulin, it’s such an easy thing to rule out. And I don’t know if that’s a good time to talk about maybe how technology can play a role.

Eric: So wait, continuous glucose monitoring?

Alex Smith: Wouldn’t that make everything easier, if we just had knew at any given time point instantaneously what somebody’s blood sugar was?

Eric: Maybe everybody who gets admitted in a nursing home, just boom, CGM.

Nadine: I would argue, insurance doesn’t agree, that anyone with diabetes should be on a CGM at least initially for behavior modification. But I think when you start talking about the risk of hypoglycemia in people who’ve had Type 2 for a long time, everyone who has Type 1, I would argue that the cost of especially some of the newer two-week wear CGMs are way less money than admissions for falls and for complications.

Eric: Can you describe for our audience what is a CGM, a continuous glucose monitor, and tell us more about these two-week wearable things.

Nadine: I’m not sure where the rules are on brands, but there’s essentially three different CGMs on the market in the United States. There’s a two-week wear that’s called Freestyle Libre is the brand, there’s several models. There’s the Dexcom, several models, that is now a 10 or a 14-day depending on the model, and then there’s Eversense, which is implantable, that’s I still think only three months in the US. But these devices are measuring a chemical reaction that’s happening under the skin either every minute or every five minutes, and they’re giving you the equivalent of a glucose. So not only do they give you a number, they give you trends. And so where this becomes-

Eric: And no poking and prodding with these.

Nadine: No poking and prodding. This hasn’t floated into our hospital systems yet, but at least in the real world, people are using these to make insulin dosing decisions without needing to poke their fingers. So my tagline, I haven’t trademarked it yet, but is, “Data at your fingertips without the expense of your fingertips.”

Tamryn: I love it.

Alex Lee: Nice.

Alex Smith: I have two friends in Type 1 diabetes who are on continuous glucose monitoring and they say it’s been a game changer for them. Alex, do you study this?

Alex Lee: Yeah. I think it’s pretty much standard of care for Type 1, but it’s definitely not there for Type 2. I think for people on insulin, especially short-acting insulin, Type 2 should be on it. And I think the other aspect that’s interesting to me about CGMs in the nursing home is then you’re talking about a lot of nursing home time that they’re not spending poking people’s fingers. And also, for the nursing home in terms of liability, it’s a real risk management system. If you could put every person who has diabetes on a continuous glucose monitor and have some sort of dashboard that’s either monitored in-house or elsewhere and you can look at people’s trends and have alerts when the trends are going down, if they’re going 70, 50, 60, 55, then it can go,” Hey, nurse, go give them some apple juice,” or whatever it is.

I think there’s a huge amount of potential, and it’s only I think at the idea stage with all of us here, realizing that this is a remarkable opportunity. And I think it’s interesting when I talk to geriatricians sometimes that they say, “What? Continuous glucose monitors? We don’t want more intensive monitoring.” And it’s only that gut reaction of, “We don’t want to be too doing too much for these patients,” but when you actually recognize that it’s going to be better for the individual, better for the caregiving system, potentially better for the caregivers, the family members, so it might be easier for them to trust and acknowledge that it’s being monitored even though they don’t have to do the finger sticks anymore, I think there’s a huge amount of potential.

Eric: Just to push back, in the Type 2 diabetics who are on oral agents, let’s say they’re on Metformin, maybe they’re on something else like an SGL inhibitor, the risk of hypoglycemia in those individuals is small. Overwhelming people with just a lot of data is big. You have to create systems and processes to manage the data too, so somebody has to be monitoring this. And ultimately, do we have any outcome data that this actually improves care, in particular Type 2 diabetics, versus that person’s on Metformin, they probably shouldn’t be getting finger sticks?

Nadine: I’m going to go back to behavior change. What’s the number one thing that makes a difference to somebody with early onset Type 2? It has to do with movement and food in a lot of ways-

Tamryn: Physical activity, nutrition, dietary changes. Absolutely.

Nadine: And I think we are an instant gratification society. Somebody telling somebody to make themselves bleed and hurt many times a day to get data just doesn’t happen. And I would argue for nursing homes as well, slapping a two-week device on somebody one time is going to give you more data than months and months worth of finger sticks. So say you have somebody new diagnosis, you’ve just put them on Metformin and something else, and you slap a CGM on them and they can see it. I’m not a fan anymore of blinded, now that they’re so readily available.

But you send somebody home with this device and say, “Scan it before you eat, scan it after you eat. Scan it as many times as you want,” or if it’s a Dexcom, it’s real time. And what happens is people go home, and they’ve had dieticians help them and they eat something they would normally eat and they see their blood sugars spike over 200, and then it comes back down because they still have insulin production. And then they eat something a little maybe smaller portioned or something that’s a little healthier, and then they see their blood sugars only go up to 180 and they go, “Oh man. Maybe if I eat half a sandwich, my blood sugar won’t go over 200. Maybe if I have a salad with chicken instead of having a cheeseburger, maybe my blood sugar won’t go over 200.” And I think people make very quick relationships between those things, and so they can see the fruits of their labor pretty quickly, even though they’re not having lows, that’s not necessarily concern.

And they also start to equate the symptoms of hyperglycemia, which happen often over 180, maybe over 200 for newer diagnosis folk with those high blood sugars. “Wow, I’m really sleepy and grumpy and I can’t focus when my blood sugar’s 250,” then there’s more motivation to not be there in the first place. But once again, insurance won’t agree with me, but I do my best to prescribe as many as possible, even for that population. Going back to the nursing home quickly, I’ve actually used this in a patient in a geriatric environment. A patient who was insulin-dependent was taken off all treatments because of severe lows and then was in a memory unit, having a lot of behaviors and wetting the bed and incontinence, it was causing falls, all these problems. And I said, “Well, we’re not checking blood sugar. She used to be insulin-dependent.”

So we got a Freestyle Libre, the two-week version, slapped it on her and after a couple days of data, I had to teach the provider how to use it of course, and get access to it, blood sugars were in the four to 500s. It maxes out. And so we were able to show this data to the family, who is the activated DPOA, and say, “I know this patient had the severe reaction and had a low blood sugar, but now they’re having all these symptoms because of high blood sugars. They need to be back on insulin.” We are able to initiate basal insulin, titrate it with that information, and then after about four weeks, blood sugars were down in the 200. Symptoms were improving, behaviors were improving. Still couldn’t convince him to go back on anything rapid-acting, but for this patient whose prognosis is indeterminate, six months at more than a year, we were able to really improve her quality of life just by a few weeks of gathering that data with a CGM.

Alex Smith: That’s a compelling clinical argument…

Tamryn: It is.

Alex Smith: … just by saying, “I tell geriatricians about this and they poo poo the continuous glucose monitoring right away,” but we got to rethink it. I’m hearing some compelling arguments here. I think part of the reason is that we feel kind of burned by this idea of home blood pressure monitoring and getting reams of data from patients. It’s just overwhelming, and there’s no studies based on getting blood pressure measurements multiple times a day from patients at home. They’re all based on measurements in the office setting. So as a clinician, when you hear continuous glucose monitor, you’re envisioning, “What am I going to do with these reams of blood sugar data? I don’t want to sort through that. Just summarize it for me.”

Nadine: The reports have been standardized and summarized. So there’s a snapshot, they call it an AGP report that they all produce, all the three CGMs put out the same report and it’s very straightforward. You see the low, you see the high threshold, you can see where the blood sugars average, and that way it’s very quick to be able to see they’re having low blood sugars 10% of the time, let’s change something. Maybe it’s stopping something, maybe it’s adjusting, but it actually is pretty simple. It’s like a 10-minute orientation maybe.

Alex Smith: That’s great.

Alex Lee: And I would say the research is coming along on this. Obviously, CGMs, they’ve been around for at least a decade now, but the research is still kind of in progress. And I think there’s a tension between what is a good research metric and what is best for patients in the sense of maybe time and range is a really good metric for researchers, it’s pretty good for patients, but how high are you above 250 compared to how are long are you above 180, and how much variability? How do you capture whether people are going up and down a lot during the day or if they’re just going down up like this? Those sorts of things are all really important to the patient experience, and they can be a little bit more complex to gather and figure out how to analyze.

Eric: Is there data in Type 2 diabetics that it improves other hard outcomes?

Alex Lee: I’m not sure about hard outcomes yet, but it definitely, and Nadine, correct me if I’m wrong, I believe it improves A1C, I believe it improves time and range. And based on extrapolation, we would expect therefore that it would improve hard outcomes.

Eric: I’m guessing probably mostly people who are on insulin, those studies.

Alex Lee: Yes.

Nadine: Especially where Medicare generally won’t cover that population on CGMs unless they’re on insulin.

Eric: I got a different question. Nadine, you work in also inpatient palliative care and hospice unit. Is that right?

Nadine: Yep.

Eric: What does that look like from a diabetes control perspective, now moving away from the SNF?

Nadine: The reason this all came into my life, I thought maybe I had pseudo left diabetes behind and changed professions to palliative care in hospice-

Eric: Because you were working in endocrinology, right?

Nadine: In Idaho. Moved across the country, settled in New England and became a fellow, which as a nurse practitioner, fellowships are unheard of, and it’s an amazing program. But I found an opportunity I couldn’t turn off my diabetes brain. And so we have a inpatient end-of-life unit, not hospice per se, but it looks very much hospice-y, and we mostly get patients from hospice at home who can’t have their symptoms managed at home, but the majority of our patients come from our hospital and transfer over across the street to our inpatient end-of-life unit. And historically, the length of stay was averaging like, 72 hours, and so they really came there for intensive symptom management at end of life, usually needing IV medication for pain and delirium, things like that.

As we started supporting the hospital by taking longer prognoses, we started having patients who were living weeks and months who’d have their diabetes management decreased or stopped in the hospital, and then were having hyperglycemia problems at our unit. And my first response was, “Why was their insulin stopped?” And this is where it all started from. So learning more about how to inform providers on how to make decisions about de-prescribing based on prognosis, based on diabetes type, based on their oral intake and their goals. So essentially, what just went live two weeks ago is working with our pharmacist at our end-of-life unit and our diabetes inpatient team, we created an insulin order set specific for our unit, but also anticipatory guidance for our providers because it doesn’t happen often that this needs to be done on how to decide who to de-prescribe coming over to our unit.

So how often we should check their blood sugars and how often we should be giving them insulin. Also, we have a very liberalized diet plan. We have a chef who will cook our patients anything they want for comfort feeding end of life, and this means no carb counting, and our staff and our nurses aren’t trained to manage insulin related to food. And so we really had to be very mindful of making it as simple as possible, so what we ended up doing is basically creating an order set and a plan to either adjust their current insulin plan, increase it, decrease it, stop it. We also have-

Eric: Can you give us the general sense of what this looks like? I’m sure all of our listeners are wanting to see it. And here, can you walk us through the key components?

Nadine: Yeah. The first part for me was just literature review. And to Tamryn’s point, I had a really hard time finding good guidelines of any kind related to end of life, especially in an inpatient hospice unit. And so I felt like gosh, I want to have this be research-based, and there’s not much out there other than some expert opinions, and so we kind of wanted to create our own with the information that was out there. And so some of the things that were very clear is patient and family goals matter. If somebody, especially with Type 2 says, “I don’t want to take insulin, I don’t want you poking my finger and I want to eat whatever I want,” great. As long as they understand the repercussions of potential hyperglycemia, then that’s their choice.

Prognosis matters a lot. And so I created some flowcharts and some tables for different learning types in the anticipatory guidance to help people decide what the providers help to decide what’s the best way, and prognosis is probably the most important thing. We’re looking at hours to days, days to weeks, weeks to months. And so really, with people who have weeks to live, then loosening the expectations and the plan from finger sticks and insulin dosing is okay, but there’s no reason to discontinue it. If their blood sugars are still running in the three, 400s, then we still need to be doing something.

Eric: And honestly, my aim is, usually in that population, 150 to 250 is a reasonable target.

Nadine: We have a loose goal of 150 to 300, so fasting under 200, random under 300.

Eric: And that’s because over 300, you’re starting to get potentially symptoms as far as increased urination, maybe headaches.

Tamryn: Confusion.

Alex Lee: Although I will say-

Nadine: You can actually start having symptoms in the 200s. Go ahead.

Alex Lee: I was going to say, there’s very little data on when symptoms actually occur at what glucose levels, and this is something-

Nadine: Especially in Type 2.

Alex Lee: And this is something I’m really interested in looking into in my research and understanding when do those symptoms start, and is it different for different patients? I think there’s a lot of evidence at a more molecular level that suggests it’s not just the average or the peak or the low, it’s where they sit and again, back to the fluctuation. And so if someone’s sitting high all the time, they might not have that many symptoms. If they just go from 300 to 350, that might not bother them. Whereas someone who’s sitting at 250 all the time and then they hit 350 or 400, then they’re going to suddenly have a lot of symptoms. So I think it’s quite complex and we really don’t have a good understanding of it.

Tamryn: I definitely agree. To Alex’s point, every individual is so different in terms of their needs, in terms of their baseline, and I think one of the key takeaways from this podcast should be that we need to have a good assessment on prior medication use and prior self-management practices for individual patients before we make any substantial changes when they’re really sick or approaching end-of-life care. I also think there’s a balance that we need to have when it comes to giving them and maintaining a sense of autonomy and control, but also making sure that they’re safe in the process, the patients are safe in terms of not getting too high or too low. And I think because these patients are unique in that aspect, they’re not always necessarily in the hospital like say cancer patients are. They know how to manage a lot of these back at home and in the community, so giving them that sense of control even towards the end is I think hugely important.

Eric: And Tamryn, let me ask you this, is that I can say from a provider’s perspective, historically we were very focused on the risks of hyperglycemia while largely ignoring the risks of hypoglycemia. I think that’s changing, and certainly changing in guidelines. What do you think of from a family caregiver perspective? Is it still a lot of focus on the risk of hyperglycemia or do people understand in general the risks of hypoglycemia and the reason that we’ve become a little bit more liberal as morbidities add up, prognosis worsens?

Tamryn: I think a lot of families would be really worried about stopping insulin doses too quickly because what does that mean for the patient? I think a lot of them, there is still very much a fear of too many drastic changes because they’re so used to such tight glycemic control. But I think when it comes to active listening with the patient and family, remembering where the patient is in that given moment in terms of how they’re eating, how they’re behaving, what symptoms they have, by each given day, it’s important to consider before freaking out over their glucose levels. And also, I just want to reiterate, I think families should focus less on the numbers, both glucose and A1C, and more on the symptoms and what’s in front of them. And Nadine, you’re cheering.

Nadine: Yeah. I feel like we spend so much time educating family about, “Well, are you going to check their oxygen saturations when we’re weaning O2 with COPD?” And it’s like, “Do they look short of breath? Are they gasping?” Educating family on helping recognize symptoms over actual signs or numbers, and if somebody looks uncomfortable, let’s do something. If they don’t look uncomfortable, even if their oxygen says it’s 60, they’re probably okay at the end of life. So that’s why I’m cheersing that. I feel like we need to spend much more time focusing on symptoms and how people are feeling and not so much on the numbers, and that’s one of the things that we do a lot at our end-of-life center.

Eric: Can I ask for this diabetes order set and teaching of providers, where do all these orals come in? SGLT2s-

Nadine: Great question

Eric: … and metformin and everything, because we’re running these, while they may cause less hypoglycemia, they certainly have their own risk, especially with people with worsening organ function, renal disease, eating less-

Tamryn: Appetite.

Eric: Is that part of your algorithm too?

Nadine: So generally, people that are already in the hospital have already been taken off their injectables as far as GLP-1 agonists and oral GLP-1 agonists before they ever come to us, so we don’t reinitiate those in our center. Something that we definitely pay attention to is things like metformin, sulfonylureas, those are about the only two classes I can think of, and SGLT2 inhibitors, that are continued in the hospital.

I think to some degree, if people are able to take pills and they’re still providing a benefit at the end of life, we’ll continue them, and some of that is patient goal aligned. But the thing we do worry about with SGLT2 inhibitors even in Type 2 diabetes is that if people are not eating or they’re in a starvation or fasting state, they can actually end up ketotic just like somebody with Type 1 diabetes, and so those medications may not be helpful. I think there’s the extreme of stopping everything and not stopping enough, and we are trying to be in the middle-

Eric: Like Goldilocks.

Nadine: … when it comes to this order set. I know. Laura brought that up in her podcast too, the Goldilocks phenomenon. So with our order set, generally if people with Type 2 diabetes are no longer eating and drinking consistently, we discontinue all orals for sure. If they’re still eating and drinking intermittently, basically the most anybody will have a blood sugar test with our order set is 8:00 AM and 6:00 PM, so fasting and evening, and the only amount of insulin they’ll ever get is twice a day at most, basal and sliding scale insulin if they’re trending over 300. But the orals generally, we aren’t going to be continuing those at our center because the prognosis is generally under weeks and in that population, there’s not really an indication to continue orals. The Type 1 population, obviously we’re continuing their insulins until end of life.

Tamryn: And can I just say, we know from the literature that patients and families, when they’re faced with a difficult situation, they like to feel like they’re doing something, fixing something, they’re hands on, physical monitoring. And I just wonder where that plays into the mindset of the shift in care where you don’t need all those glucose checks, but what about patients and families when they have that sense of, “Oh, I need to do something with my hands. I’m so used to doing something,” even during this period of time? How do you have a conversation about that? I don’t know, Alex, have you seen any of that in nursing home practice, where people just want to feel like they’re doing something with their hands?

Alex Lee: I can’t say I’m the best one to answer that one since I’m not a clinician, but I think that it’s a great point and I think it’s something that it’s hard to get at from a very direct standpoint when you’re just looking at the medications and the side effects and stuff like that. So I think there needs to be a lot more studies around caregivers and their experience of this as well.

Nadine: I would say one other thing that Laura brought up in the 2018 podcast was whether or not we should be switching to some of these more expensive medications that are maybe less of a burden for patients and their caregivers, things like GLP-1 agonists and SGLT2 inhibitors that have such an in significant impact on glucose without the risk of low blood sugars. And I’d like to think that these medications have become so popular in the last four or five years that as our population ages, more of them will be on these medications, less of them will be reliant on insulin or as much insulin. And so maybe it’s going to come to that conversation where we have to start thinking about when do we de-prescribe these medications? Because they’re working really well without any harm. And GLP-1 agonists are safe with non-existent renal function, and so I think that there’s a lot of research and maybe even retrospective research that’s going to come from people being on those medications as they age into Medicare.

Tamryn: Yeah. That’s a good point. Go ahead, Alex.

Alex Lee: I do think the one thing we have to be pay attention to is the SGLT2s can increase urinary tract infections, and so that particularly among people with dementia is something we have to keep an eye on.

Eric: Because it mainly works by peeing out the glucose.

Alex Lee: Exactly.

Tamryn: That’s right.

Eric: So the renal function also doesn’t work.

Nadine: It does work at lower renal functions, but anytime you have glucose uria, which is anything really over 180 or 200, you’re going to have to worry about infections, especially with women. I’m a huge fan of education, and so for women, I would put these medications on, tell them ahead of time and just tell them to buy wet wipes and really clean things out after every urination. And for guys, my tagline for that would be dab, don’t drip, because I’ve had men with penial fungal infections.

Tamryn: Nadine, this is your other talent.

Nadine: I know, taglines for diabetes advice.

Eric: Practical advice. This is great.

Tamryn: And we’re not doing enough in this area in the United States. There’s this great article and I’ll send it to you all, it’s called End-of-Life Care Requires Caution With Use of Continuous Glucose Monitoring, JPM, from 2020. And so I’ll send you that link. But a lot of these studies, the very dearth amount of studies that we have about diabetes and palliative care and diabetes end of life are in other countries. And from a research standpoint, maybe we should think about more cohort studies. I’m also a epidemiologist trained as well, and thinking about larger populations from diverse backgrounds, and how are those outcomes similar or different when we think about quality care, and also those hard outcomes that we talked about earlier. I think that is important to consider just going forward.

Eric: And I got two quick questions too for you, Nadine. Do you ever prescribe sulfonylureas anymore?

Nadine: Not in my current profession.

Eric: Do you think there’s still a role for them?

Nadine: In the palliative care, we usually see people who have a prognosis under two years in our outpatient environment. I think if somebody had heart failure or somebody had diabetes that was generally well-controlled and I think their cognition was good, I think they are wonderful medications because it’s an easy pill to take to manage prandial blood sugar variation, which is food-related. I think the cost would be the thing to argue for a lot of insurers, and the safety profile because there are lots and lots of people with Type 2 who’ve ended up in the hospital because they’ve gotten sick or they had a procedure or they were dehydrated. So I think with people with impaired cognition, I’d be more worried about those medications because they wouldn’t necessarily be aware enough to stop them when needed.

Eric: Last question for you, because I also think about Tamryn working in a oncology practice in dementia patients, especially with the GLP-1s, right? People use it for weight loss, anorexia, delayed gastric emptying is an issue with them. These are all things that we see in the cancer patients. How do you think about the GLP-1s as people in late life, and obviously in hospice it sounds like you’re stopping them, but even in the cancer population, we’re also worried about weight loss and the side effects from that, kind of the opposite is what we’re usually thinking about for diabetes, is weight loss is a good thing.

Nadine: I actually had a patient in her eighties, she had Type 2, was on basal insulin, I think it was maybe Ozempic or Trulicity, one of them, and we were really trying to get prandial control by upping her GLP-1 agonist, but she kept losing weight too much, and so we had to back off and make other adjustments. So I think that is a huge concern in our cancer population and our older population. We don’t want them to lose weight, that increases their frailty, and so those may be medications that are not appropriate if they’re causing weight loss. What I’ve seen with those medications is generally once a dose is set, they still have appetite suppression from that delayed gastric emptying, but they don’t tend to actively continue to lose weight. It’s hard. Every time you titrate a dose, people tend to lose more weight, and so that’s where you have to be really careful. If they’ve been on it for years and it’s been working and it’s limiting their insulin needs, which also is limiting their hypoglycemia risk, then it might be a good one to continue.

Tamryn: Yeah. I 100% agree. These populations are so vulnerable, especially when we think about that coupled with other comorbidities. We have to really think about the trade-offs, the pros and cons. Any slight titration and change that we make to diabetes medications is going to have a ripple effect to some of the other organs. And also, it makes us to reconsider what treatments they need to be on for their other comorbidities. So it is a ripple effect, and I think it just depends on the individual patient and how they’re responding to treatment.

Eric: Well, I want to thank all three of you for being on this podcast. Tamryn, a big thank you for pushing this podcast through. Alex, always great to have you. And Nadine, is there a way that people who are interested in this algorithm, did you write this up somewhere or are you planning to, are you willing to share it?

Nadine: In process. We just went live two weeks ago, and so we’re just in the beginning process of writing it up. It is very specific to our unit, but we hope that the process to get there will be shareable. And so when we finally do write it up, I’ll send it to you guys and maybe you can pass it along.

Eric: Great.

Nadine: Stay tuned.

Eric: Well, how about we get a little bit more of Sugar, Sugar before we end?

Alex Smith: (singing)

Eric: Nadine, Alex, Tamryn, thank you for joining us on the GeriPal podcast.

Tamryn: Thank you for having me.

Alex Lee: Thank you. It was fun.

Nadine: Thank you guys.

Eric: And thank you to all of our listeners.