Diabetes at the End of Life

Dr David Kerr MDBournemouth Diabetes and Endocrine Centre

www.b-dec.co.uk

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09“A good way to live longer is to move to the eastern part of the English county of

Dorset and take up the game of golf”

Lancet 2008; 371: 2158

“old age is not so bad when you consider the alternative”

Maurice Chevalier

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09Diabetes at the end of life“Surely this is a non subject? The only thing one can say is that if you are dying, the important thing is to be as

comfortable as possible. In other words avoid diabetic symptoms and hypoglycaemia and keep finger pricking to a minimum. I don't know of any literature on the subject and

very much doubt that there is any”

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09“a good death”• To know when death is coming and to understand what can be expected • To be able to retain control of what happens • To be afforded dignity and privacy • To have control over pain relief and other symptoms • To have choice and control over where death occurs • To have access to spiritual and emotional support• To have access to hospice care• To have control over who is present and who shares the end • To be able to issue advance directives • To have time to say goodbye and control over other aspects of timing • To be able to leave when it is time to go

• To die with glucose levels that are not too high nor too low….

Br Ger Soc Feb 2009

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09End of life care for older people

• Dying patients frequently do not receive basic nursing care • Staff may focus on physical needs at the expense of psychological and spiritual care • Older people are less likely to receive appropriate pain control than their younger counterparts, especially for patients with dementia.• Older people are less likely to receive hospice care • In care homes end of life care may be impeded by inadequate staff training, poor symptom control and lack of psychological and emotional support • Comorbidity and drug reactions make symptom control more difficult• Diabetes is perceived to be “difficult”

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09Diabetes at the end of life• Pre-existing diabetes• Secondary diabetes• Drug-induced

diabetes

• Poor nutrition• Defective counter-regulation• Kidney/liver disease

Hyperglycaemia

Hypoglycaemia

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09Diabetes care at the end of life

• When is death expected?• Glucose control problem?• Non-glucose control problem?• Patient problem?• Health care professional

problem?

05

1015202530354045

<5 5 to 10 11 to 15 <20 Unsure

Last weeks

Last days

Target glucose (mmol/l)

% HCP’s

J Pain Symptom Management 2006; 32:275

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09Hyperglycaemia• Agitation:

– tense, irritable, restless, poor concentration

• Osmotic: – thirst, dry mouth, polyuria

• Neurological: – dizziness, blurred vision, weakness

• Malaise: – headache, nausea

• Threshold for symptoms: 15 mmol/l

(Diab Metab Res Rev 2003; 19: 408-14)

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09

0.0

5.0

10.0

15.0

20.0

25.0

0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00

Time

Sen

so

r valu

e (

mm

ol/

l)Living and dying with Diabetes

Hypoglycaemic symptoms

Osmotic symptoms

MalaiseLethargyFrustration

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09Terminal Care (1)

• Type 1 Diabetes• Once daily basal insulin• Reduce by 50%• Test once daily• Watch for hypoglycaemia• Do not die of DKA

• Type 2 Diabetes• Stop oral agents• Stop monitoring• Watch for hypoglycaemia• Watch for hyperglycaemia*• Do not die of HONK

Palliative Med 2006; 20: 197-203

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09Terminal Care (2)• Give permission to run high glucose levels• Give permission to miss meals• Do not withold Rx for fear of upsetting

diabetes• Testing may be expected• Steroids increase glucose levels and

appetite• Illness causes insulin resistance• Glimepiride, Lantus and Actrapid

0800 2400Time

Glucose

Steroid

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09Steroids and Glucose tolerance

0

0.5

11.5

22.5

33.5

4

Pre24 hours7 days

Glucose Disappearance kTTT (%.min)

•10 healthy volunteers•Short insulin tolerance test•Caudal epidural•80 mg Triamcinolone

Rheumatology 2002; 41: 68-71

•28 COPD•Non-diabetic•Acute hospital admission•30-40 mg Prednisolone

0

2

4

6

8

10

12

Admission +24 hrs +48 hrs +72 hrs

FastPeak

Glucose (mmol/l)

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09Steroids - Practical AspectsType 2 diabetes

No history of diabetes

<15 mmol/l

Starting steroidsTry once daily

Test BG at 1800 hours

>15 mmol/l

No action

Glimperide 2 mg at 1200 hoursTitrate dose

>15 mmol/lafter 5 days

Start once dailyLantus 10 units

In morning

GlipizideIf severe renal impairment

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09

No Carbohydrates

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09

0

2

4

6

8

10

12

14

16

1 2 3 4 5 6 7

Glucose (mmol/l)•22 hr continuous feeds with i.v. insulin + basal Glargine/Isophane•Change after 48-72 hrs to:•3 feeds each day with•Soluble/analogue insulin at start of feed

Diabetic Med 2002; 19: 1006-8

PEG feeding and diabetes control

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09Admitted with hyperglycaemia• 40 consecutive patients over 2

months with admission glucose between 11 and 17 mmol/l

• 10 patients without known diabetes

• 55% treated – glucose 13.4 mmol/l

• 45% untreated – glucose 13.7 mmol/l

Rx n Admissionglucose (mmol/l)

Day 1glucose (mmol/l

i.v. insulin 7

5

9

18

15.1 9.0

s.c. insulin

14.0 8.0

Oral Rx 13.0 11.1

No Rx 14.0 N/A

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09Insulin and meals in hospital

0

5

10

15

20

25

31-60 min 11-30 min 5-10 min 0 min +30 min +60min

%

Time of injections relative to meals

(Diabetic Med 2006; 23 (Suppl): P164)

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09Diabetes Treatment in Older People

• Requires understanding

• Requires training • Requires knowledge• Requires review

00.20.40.60.8

11.21.4

70-74 75-79 80-84 85+

No DMTablet RxInsulin Rx

Falls (person/year)

Diabetes Care 2002; 25: 1749-54

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09Hypoglycaemia and the brain

• Characteristic symptoms• Idiosyncratic symptoms• Negativism and denial• Automatism• Seizures• Coma• Death

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09Hypoglycaemia Unawareness

Symptoms Recognition Action

Failure to:• develop warning symptoms• recognise warning symptoms• take appropriate action despite warning symptoms

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09Glucose counter-regulation

Glucose (mmol/l)4.0

3.0

2.0

Release of hormones

Warning symptoms

Cognitive impairment

Increased brain blood flow

Glucose ProductionMuscle glucose uptake

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09Risk factors for hypoglycaemiaat the end of life

• Insulin/SU -too much, wrong time

• ↓ Exogenous glucose - anorexia

• ↓ Endogenous glucose - glycogen depletion

• ↑ Insulin sensitivity - sleep,

• ↓ Insulin clearance- renal

• Hypoglycaemia

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09Insomnia and Diabetes

• Hypoglycaemia• Fear of hypoglycaemia• Painful neuropathy• Restless leg syndrome• Hyperglycaemia• Sleep apnoea• Cognitive impairment• Sleep disorders• Pain• Medications

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09

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09Diabetes at the end of life“Surely this is a non subject (it’s not!)? The only thing one can say is that if you are dying, the important thing is to be as comfortable as possible. In other words avoid diabetic symptoms (<15 mmol/l) and hypoglycaemia (>4 mmol/l) and keep finger pricking to a minimum. I don't know of any literature on the subject and very much doubt that there is any but if in doubt ask the diabetes team”

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09Diabetes at the End of Life

Dr David Kerr MDBournemouth Diabetes and Endocrine Centre

www.b-dec.co.uk

• There is no evidence• Aim for > 4 and < 15 mmol/l• Testing may be necessary/expected• Once daily basal insulin/SU• Avoid Metformin