Clinical Context

Reports of severe hyperglycemia have been reported among patients with critical illness because of COVID-19, with very high requirements for insulin, but is this the case for patients with more moderate COVID-19? Sardu and colleagues sought an answer to this question and published their research in the May issue of Diabetes Care.

They followed 59 patients admitted with moderate COVID-19. At presentation, 57.6% of patients were normoglycemic and 42.4% had hyperglycemia; 72% of the patients with hyperglycemia had a preexisting diagnosis of diabetes before admission.

More than half (60%) of patients with hyperglycemia received insulin during admission, and the mean glycemic levels during hospitalization in the no insulin and insulin groups were 192 and 139 mg/dL, respectively. Levels of interleukin-6 and D-dimer were positively associated with hyperglycemia at presentation and during the hospitalization, and both the presence of preexisting diabetes and hyperglycemia were associated with a more severe disease course in a risk-adjusted regression analysis. Treating patients with insulin appeared to mitigate this risk.

The management of chronic diabetes is more challenging because of the COVID-19 pandemic, but maintaining good control of chronic disease remains important for long-term health and possibly for better outcomes of incident COVID-19. In an editorial summarized in "Study Highlights," Sy and Munshi provided pragmatic recommendations on the management of diabetes in older adults during the pandemic.

Synopsis and Perspective

Two experts in geriatric diabetes offered some contemporary practical recommendations for diabetes management in older adults during the COVID-19 pandemic.

JAMA Internal Medicine published the viewpoint titled "Caring for Older Adults With Diabetes During the COVID-19 Pandemic," by Medha N. Munshi, MD, director of the geriatrics program at the Joslin Diabetes Center, Boston, Massachusetts, and Sarah L. Sy, MD, a geriatrician in the same program.

Adults age 70 years and older with comorbidities such as diabetes are among persons at highest risk for adverse outcomes and mortality because of COVID-19.

At the same time, individuals who do not have the illness face major challenges in avoiding it, including disruptions in normal activities and barriers to receiving health care.

Although telemedicine has become much more widely adopted in diabetes management since the pandemic began, older adults may not be as tech-savvy, may not have computer or internet access, and/or may have cognitive dysfunction that precludes its use.

"These unprecedented times pose a great challenge to this heterogeneous population with varying levels of complexity, frailty, and multimorbidity," Munshi and Sy pointed out but noted that "clinicians can lessen the load by guiding, reassuring, and supporting them through this pandemic time."

Because the pandemic could last for several months longer, the authors offer the following advice for clinicians who care for older adults with diabetes:

Accessibility to health care -- When possible, use telemedicine, diabetes care apps, or platforms to obtain data from glucose meters, continuous glucose monitors, and/or insulin pumps. When use of technology isn't possible, schedule telephone appointments and have the patient or caregiver read the glucose values
Multicomplexity and geriatric syndromes -- Identify high-risk patients, such as persons with type 1 diabetes or recurrent hypoglycemia, and prioritize patient goals. If appropriate, simplify the diabetes treatment plan and reinforce with repeated education and instructions. Glucose goals may need to be liberalized. Advise patients to stay hydrated to minimize the risk for dehydration and falls. Take steps to avoid hypoglycemia, reduce polypharmacy, and consolidate medication doses
Burden of diabetes self-care -- Bloodwork for glycated hemoglobin can be delayed by a few months. Patients with type 2 diabetes can decrease the frequency of blood glucose checks if their glucose levels are generally within acceptable range. Encourage patients to eat healthily, with regular meals rather than optimizing the diet for glucose levels, and adjust medications for any changes in diet. Advise safe options for physical activity, such as walking inside the home or walking in place for 10 minutes, 3 times per day, and incorporating strength training, such as with resistance bands. Online exercise programs are another option
Psychological stress -- Check in with patients and encourage them to stay as connected as possible using technology (phone, video chat, text message), letters, or cards with family, friends, and/or religious communities. Screen for depression, using either the Geriatric Depression Scale or Patient Health Questionnaire-2, and refer to mental health colleagues if appropriate. Speak or email with caregivers to assess the patient's mental health state and offer local support resources, if needed
Medication and equipment issues -- Refill 90-day prescriptions and equipment, and request mail or home (contactless) delivery. Patients should also have backups in case of equipment failures, such as syringes and long-acting insulin in case of pump failure, and test strips/meter for continuous glucose monitor problems

Munshi and Sy concluded, "Many of the recommendations presented in this article are practical and will continue to be relevant after COVID-19. When this is all over, patients will remember how we made them feel, and how we kept them safe and healthy at home."

Munshi is a consultant for Lilly and Sanofi. Sy has reported no relevant financial relationships.

Study Highlights

Telemedicine visits are common now for the management of diabetes, and multiple electronic platforms can facilitate the transfer of data from patient to clinic.
Nevertheless, clinicians should bear in mind that many patients either will not have or cannot effectively use technology for remote visits; ≤ 44% of older adults with diabetes have some form of cognitive dysfunction.
These patients can be identified as part of previsit planning and given extra time to read their blood glucose values over the phone.
Missing a telehealth appointment is a potential red flag. Follow up to ensure that the patient is safe is warranted.
Families and loved ones should be informed of the care plan and, if possible, integrated into the care of diabetes among older adults.
The care plan can include liberalization of glycemic targets to avoid hypoglycemia and simplify the care plan. For example, many older adults can be shifted from basal-bolus insulin treatment to once-daily basal insulin augmented by oral drugs.
Healthcare providers should maximize the number of days’ supply and refills when prescribing chronic medications.
Nutrition may suffer because of a number of factors, including the economic recession and personal financial crisis. It is more important to eat regular meals with good nutrition than adhere to a strict and more expensive diet.
Physical activity can also be a challenge when patients are encouraged to stay home as much as possible. Walking inside or even in place for 10 minutes 3 times a day can be an alternative, and creative solutions to increase resistance training, such as using canned goods, are encouraged.
Multiple free online exercise programs, including programs for older adults, are available.
Regular monitoring of patients’ mental health is also recommended. The Geriatric Depression Scale and Patient Health Questionnaire-2 are useful tools in this regard.

Clinical Implications

In a previous study by Sardu and colleagues of patients with moderate COVID-19, most were normoglycemic at presentation. Nearly 30% of cases with hyperglycemia had no previous history of diabetes. Hyperglycemia was associated with higher levels of inflammatory biomarkers, but treatment with insulin appeared to reduce the severity of infection.
The current editorial by Sy and Munshi recommends a patient-centered and flexible approach to using technology in managing diabetes during the COVID-19 pandemic, as well as liberalization of glucose targets and simplification of diabetes treatment regimens. Patient and community circumstances may require a less than optimal diet, but exercise at home can be encouraged with as little as 30 min/d of walking.
Implications for the Healthcare Team: The healthcare team is critical for providing individualized care for patients with diabetes, particularly given the challenge of COVID-19. The team should work to their strengths across the different treatment goals for patients with diabetes.

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