Diabetes is more common in older adults due to age-related physiological changes, such as increased abdominal fat, sarcopenia, and chronic low-grade inflammation that can lead to increased insulin resistance in peripheral tissues.  In the elderly, the diabetes guidelines recommend less aggressive glycemic control.  This is due to the fact that hyperglycemia generally does not cause any acute issues.  Hyperglycemia is harmful over time for the kidneys, heart, arteries, nerves, and eyes.  As patients get older and life expectancy decreases, those long-term risks are not as significant or applicable.

Typical goals for diabetes management at the end-of-life are to promote comfort, control symptoms (including pain, and symptoms caused by hypoglycemia and hyperglycemia), decrease complexity of treatment, relax target glucose levels, and reduce or discontinue monitoring.

Hypoglycemia is very low blood sugar, usually <72mg/dl.  Some symptoms include shakiness, dizziness, sweating, and anxiety. Terminal patients have a higher risk of hypoglycemia with reduced oral intake.  Hyperglycemia is very high blood sugar, defined by some sources as >270mg/dl.  Some symptoms include increased thirst, fatigue, blurred vision, and weight loss.  However, since symptoms are typically more prevalent with hypoglycemia, this is more of a concern while on hospice than hyperglycemia.

The following are some general tips for management of diabetes in end-of-life.

Type 1 Diabetes: The body cannot make its own insulin. This is an autoimmune disorder typically with an early (often childhood) onset. Thus, this is also called “insulin-dependent” diabetes (not to be confused with type 2 diabetes patients that are using insulin to manage their glucose).

  • There is not enough evidence to support discontinuation of insulin

  • Simplify current insulin regimen

  • Sole use of sliding scale should be avoided

Type 2 Diabetes: The body either resists the effects of insulin, or does not make enough insulin to manage glucose levels appropriately. This used to be called “adult-onset diabetes”, but today more children are being diagnosed with the disorder due to the rise in childhood obesity.

  • If diet is controlled, no routine blood glucose checks required

  • Reduce or stop oral diabetic medications and monitor for symptoms

  • May use once daily long-acting insulin, or twice daily intermediate-acting (NPH) insulin – conservative dosing recommended, with goal to avoid unnecessarily high glucose levels

  • Addition of sliding scale or post-prandial regimens using rapid-acting or short-acting insulins may be considered if tighter control desired

  • Non-fasting levels of up to 300 mg/dL are often acceptable on hospice, as long as the patient remains asymptomatic

 Steroid-Induced Diabetes

  • Steroids will most likely be reduced or discontinued in terminal phase and blood sugars should normalize

  • No need for routine blood glucose monitoring

 

Written by:  Madeline Vallejo, Pharm. D.


 References:

  1. Diaz Rodriguez JJ. “Perspective and general approach of diabetes in palliative care” Hos Pal Med Int Jnl. 2018;2(3): 197-202.
  2. SJ Lee, MA Jacobson, and CB Johnston. “Improving Diabetes Care for Hospice Patients” American Journal of Hospice and Palliative medicine. 2016;33(6): 517-519.
  3. MN Munshi, H Florez, ES Huang, et al. “Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association” Diabetes Care. 2016;39:308-318.
  4. K Quinn, P Hudson, and T Dunning. “Diabetes Management in Patients Receiving Palliative Care” J Pain Symptom Manage 2006;32:275-286.