Glucose Monitoring in Older Adults: How Much Is Too Much?

Wilcox_TanyaMy 90-year-old grandfather was the first person to teach me how to use a glucometer. He developed diabetes thirty years after his 3-vessel CABG, and the necessity of daily blood glucose checks seemed like an inevitable aspect of managing his new disease. As a diligent patient, he underwent the painful experience of pricking his finger and recording his measurements daily, and taught me how to help him as he lost dexterity with age. The experience left me questioning whether glucose monitoring is necessary for all patients with diabetes, especially older patients with late-onset, stable disease like my grandfather.

Diabetes mellitus is common disease among older adults; in the U.S., 1 in 4 persons over age 65 are affected. Cardiologists recognize diabetes management as integral to overall cardiovascular health. However in older adults, aggressive glycemic control can be burdensome and at times dangerous. Evidence from large randomized control trials including ADVANCE, ACCORD and VADT suggests that avoiding dangerously low blood sugars (hypoglycemia) may be more beneficial than achieving aggressively low hemoglobin a1c (HbA1c) targets. Based on available evidence, the American Geriatrics Society recommends higher Hba1c targets for older adults –  between 7-8.5% depending on comorbidity burden and prognosis. There remains, however, a lack of strong evidence on the optimal frequency of home glucose monitoring in this group of patients. An individualized discussion the benefits, risks and alternatives provides a framework for this discussion.

There is a clear need to avoid hypoglycemia, and self-glucose monitoring may provide a mechanism to screen for low blood sugars. Accordingly, the Endocrine Society indicates that glucose monitoring may benefit type 2 diabetics taking medications that put them at risk for hypoglycemia, including insulin or sulfonylureas. This may be especially important during medication initiation or uptitration. However, in patients with stable disease with no clear risk for hypoglycemia, the Endocrine Society and the Society of General Internal Medicine both recommend against routine multiple daily self-glucose monitoring. Home monitoring is nonetheless overprescribed; CDC health behavior data indicate that a majority (63%) of non-insulin dependent diabetics are checking finger sticks at home at least daily, and Veterans Affairs data found that test strips were prescribed to a large number of patients with stable non-insulin type-2 diabetes. Potential harms associated with daily self-monitoring of blood glucose monitoring include pain of needle sticks, cost, and general therapeutic burden, all of which can adversely influence quality of life. While needle-free glucose monitors are a potentially promising alternative, they remain under development.

In summary, in the absence of clear guidelines, decisions about initiation, frequency and discontinuation of self-monitoring of blood glucose in older adults with type 2 non-insulin dependent diabetes requires an informed discussion between clinician and patient, with particular attention to patient goals. For most older patients with cardiovascular disease, in whom sulfonylureas should be avoided, routine glucose monitoring is reasonable for a brief period during medication titration, and subsequent intermittent monitoring may be helpful to determine whether symptoms of hypoglycemia correlate with low blood glucose. However, for most patients with stable disease on oral agents, discontinuing routine (daily) home glucose checks can improve quality of life and reduce health care costs.

 

By: Tanya Wilcox, MD

Limited function, high costs, and the need for a better approach

dodson%20headshotA recent article in the New York Times described the “High Price of Failing America’s Costliest Patients.” The author highlights the disproportionate healthcare costs incurred by a small percentage of patients in the U.S. (for example, 5% of the population accounts for 50% of the costs). These costs are not simply attributable to traditional disease entities that we learn in medical school – for example, patients with a chronic illness plus functional limitation (inability to care for themselves or perform routine daily tasks) have four times higher medical costs, according to the Commonwealth Fund. With an aging U.S. population, these functional limitations, which complicate already difficult management decisions in patients with chronic illnesses, are going to become more common in clinical practice over the coming decades.

We clearly need better models of care for functionally limited, complex older patients including those with cardiovascular disease. The Times article highlights several models already underway – including a Medicare Advantage Plan which spends more upfront time on team-based care (including physicians, nurse practitioners, and social workers) to achieve the aim of reduced downstream costs. These models are most likely to be successful if they focus on the “whole patient” rather than a single disease. For example, hospital readmissions in older patients (which are a major driver of healthcare costs) are usually for something other than the index condition, including in patients with heart failure (where fewer than half of 30-day readmissions are for heart failure). Efforts focused on a single disease entity (for example, diuretic management for heart failure) therefore may miss the larger picture. Another innovative approach to management involves incorporating patient goals into care plans, which moves beyond traditional disease-based management, and may be especially relevant in the setting of functional limitations. Ongoing work by Mary Tinetti, Caroline Blaum, and others is helping to incorporate goal elicitation, and alignment of treatment plans with these goals, into routine clinical care.

In my opinion there’s unlikely to be a “one size fits all” approach that solves the challenge of improving care in older patients with functional limitations. However I think the general principle of working beyond our silos, both by participating in teams with other clinicians and by directly eliciting goals from patients, will make a difference.

 

By: John Dodson, MD, MPH

A Healthy Old Age

karen-alexanderMaintaining a healthy lifestyle in our 30s, 40s or 50s is an important determinant of how we will age. New information confirms this association between lifestyle and healthy aging has no expiration date. Healthier lifestyles in our 70s and beyond continue to yield benefits as demonstrated by the Three Cities Study. In 2010, the American Heart Association released Life’s Simple 7, which is a 7-step list of ideal lifestyle modification goals that target improved cardiovascular health. AHA Life’s Simple 7 are a mix of behavioral (healthy diet, nonsmoking, moderate to vigorous physical activity more than 150 min/week) and biological (total cholesterol <200 mg/dl, blood pressure <120/80 mm Hg, fasting glucose <100 mg/dl, and body mass index <25 kg/m2) targets, with each goal having levels of ideal, intermediate, and poor attainment. Attainment of Life’s Simple 7 goals is associated with better cardiovascular health, better general health, less cancer, depression, cognitive impairment, diabetes, frailty, and all-cause mortality.

Better attainment of the American Heart Association’s Life’s Simple 7 goals among 9,294 men and women from France (mean age of 73.8 years) was associated with better health outcomes a decade later. Older adults who met at least 5 of 7 ideal goals at baseline had a 35% lower risk of all-cause mortality. Adults who met 3 to 5 ideal goals (intermediate health) had a 17% lower risk of all-cause mortality. Even better news is that outcomes improved with each goal attained; even intermediate goal attainment had a beneficial association with outcomes. Now for the bad (if predictable) news: only 1 participant met all 7 goals at ideal status, 5% met at least 5 of 7, and 15% met all behavioral goals. This attainment is comparable to similarly low rates in much younger populations around the US and world. Even though aging biology impacts non-attainment of ideal status on some measures (e.g. blood pressure and cholesterol), healthier behaviors were more likely among longer lived adults. Since healthy behaviors may prevent cognitive impairment and frailty, better goal attainment in older populations is important for optimizing survival and quality of life, while limiting time spent with illness and disability. This article has emboldened me to push my older patients to continue to shoot for Life’s Simple 7, giving few a “pass” based solely on age. Even more relevant for the older population, working to achieve these goals is likely to yield benefits before attaining ideal status. A favorite Tibetan proverb applies to those age 70 and beyond: “The secret to living well and longer is to eat half, walk double, laugh triple, and love without measure.”

 

By: Karen Alexander, MD

The Emerging Field of Palliative Nephrology

Jen Schere“To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science.”

-Albert Einstein

Mrs. RS is an 83 year old female with coronary artery disease, congestive heart failure (EF=30%), and chronic kidney disease stage IV-V. She was referred to my kidney palliative care outpatient clinical program named Kidney CARES (Comprehensive Advance kidney disease and End stage kidney disease Support) to manage her kidney disease. She lives on her own and walks with a cane. Unfortunately, she had two recent admissions to the hospital for heart failure. With each admission, her kidney disease has worsened, as has her functional status. Mrs. RS is cognitively intact and willing to take an active role in her care. On her first visit, she reports living with constant arthritic pain and anxiety about her disease burden. She shares with me that maintaining her independence is her current most important life goal. She would never want to use machines to keep her alive.

As a geriatric patient living with both heart and kidney disease, Mrs. RS is a common referral to a nephrologist. The prevalence of cardiovascular disease (CVD) in older patients with CKD is nearly twice that of those without CKD (68.8% versus 34.1%). Additionally, co-diagnosis of CKD and CVD worsens survival prognosis. Clinically, Mrs. RS represents many patients I have seen throughout my seven years of practice as an attending nephrologist. However, now I was meeting Mrs. RS after completing a palliative care fellowship and a shared clinical focus of both specialties.

Palliative care is specialized medical care delivered by an interdisciplinary team, that focuses on quality of life and living well with serious illness. Specific skills of palliative care include physical and emotional symptom management, spiritual support, assistance with shared-decision making, and facilitation of advance care planning. It can be delivered while a patient is pursing curative care. Palliative care has gained importance in current health care policy given the transition to patient-centered care that is called for in the Affordable Care Act.

How can palliative care be integrated into the care of Mrs. RS? This starts with identification of her goals. Mrs. RS would like to live the remainder of her life at home, independent, and symptom free if possible. Although these are relatively simple, the unfortunate reality of current practice is that the goals of patients are often not met in clinical care plans. Rather than a person-centered discussion in the context of their individual prognosis, a CKD stage V patient is commonly faced with disease focused discussions of dialysis initiation, the level of phosphorous and potassium in their diets, and fluid status. For Mrs. RS, best practice calls for a discussion that asks the following questions: What does she understand about her illness? What does she expect in the future? What brings her life joy? How can we support her family throughout her illness? Is dialysis the right choice for her? What is most important to her now that she understands her prognosis? How can we treat her symptoms?

This patient centered approach to care does not detract from disease focused treatment, but rather enhances the existing paradigm. For example, randomized controlled trials for patients with lung cancer have shown that integrated palliative care, delivered alongside standard oncology care and introduced early in the treatment process significantly improves the quality of life of patients, while also extending survival. Unfortunately, we have no comparable data for patients in the U.S. living with kidney disease. There is observational data from the United Kingdom and Australia suggesting that conservative management (non-dialysis) and integrated palliative care can improve quality of life. Importantly, some evidence suggests that for older adults living with heart disease, dialysis initiation does not necessarily lead to a survival advantage. It is time to ask these questions to similar patients living in the US.

To our knowledge, Kidney CARES is the only outpatient interdisciplinary kidney palliative care program in the U.S. It is modeled after a similar care delivery model in Australia. We hope that rigorous study of the implementation and clinical outcomes of our care delivery model can answer questions that directly impact the care of patients similar to Mrs. RS. It is her story that illustrates the value of new approaches to care, one that puts the patients’ goals at the center.

 

By: Jennifer Scherer, MD

Patient-directed Advance Care Planning

dodson%20headshotSeveral weeks ago, the American Geriatrics Society (AGS) held its annual scientific sessions in San Antonio, TX. This meeting attracts geriatricians and other professionals dedicated to caring for older adults. As a geriatric cardiologist I attend AGS regularly, and in recent years I have seen interest from other subspecialists continue to grow.

One of the most interesting abstracts presented at AGS this year was by Dr. Rebecca Sudore (UCSF), who discussed a randomized clinical trial aimed at improving advance care planning (ACP). Essentially, Dr. Sudore and colleagues created an interactive, patient-centered advance care planning website. They then assigned half of participants to review this website, and the other half to receive usual care. After 9 months, documentation of ACP improved significantly in the group assigned to the website. They published these findings concurrently in JAMA Internal Medicine.

One of the true innovations of this study is that they targeted patients without requiring intervention on part of the clinical team or health system. This helped to overcome some of the barriers we face in our busy practices with regards to ACP; we all know it’s important, but are often busy with more acute medical issues and long-term planning is therefore overlooked. I am interested in seeing whether Dr. Sudore’s work can be scaled to other healthcare settings in the coming years.

 

By: John Dodson, MD