Skip to main content

Advertisement

SpringerLink
Log in

Inpatient Management of T2DM and Hyperglycemia in Older Adults

  • Hospital Management of Diabetes (A Wallia and JJ Seley, Section Editors)
  • Published:
Current Diabetes Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This review aims to provide a summary of the evaluation and treatment of older adults (≥ 65 years) with type 2 diabetes and/or hyperglycemia in the hospital.

Recent Findings

Caring for these older adults requires special considerations. Diabetes is a risk factor for hospitalization and hyperglycemia in the hospital is associated with increased complications and mortality. Treatment plans for hospitalized older adults with diabetes should include a comprehensive geriatric assessment. This team-based approach aims to develop an individualized care plan, with consideration of the patients’ personal goals, comorbidities, functional status, life expectancy, and hypoglycemia risk. Studies from hospitalized middle age and older adults with hyperglycemia can help guide diabetes treatment goals and management in older adults.

Summary

Further studies, examining both glucose targets and care management assessments and treatment plan specifically targeting older adults in the hospital setting, are needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, et al. IDF diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018;138:271–81. https://doi.org/10.1016/j.diabres.2018.02.023.

    Article  CAS  PubMed  Google Scholar 

  2. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA. 2015;314(10):1021–9. https://doi.org/10.1001/jama.2015.10029.

    Article  CAS  PubMed  Google Scholar 

  3. Proposed working definition of an older person in Africa for the MDS Project In: Healt statistics and information systems. World Health Survey. World Health Organization 2002. https://www.who.int/healthinfo/survey/ageingdefnolder/en/ - .XLEMyTWR1fU.email. Accessed April 12th, 2019 2019.

  4. Older People Projected to Outnumber Children for First Time in U.S. History. 2017 National Population Projections. United States Census Bureau U.S. Department of Commerce 2018. https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html. Accessed 03/18/2019 2019.

  5. National Diabetes Statistics Report. Centers for Disease Control and Prevention. Atlanta: US Department of Health and Human Services; 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed 3/5/2019 2019

    Google Scholar 

  6. Falciglia M, Freyberg RW, Almenoff PL, D’Alessio DA, Render ML. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009;37(12):3001–9. https://doi.org/10.1097/CCM.0b013e3181b083f7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Healthy People 2020. Clinical Preventive Services. . In: Poor glycemic control (D-5.1) 200 Independence Avenue, S.W., Washington, DC 20201. https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Clinical-Preventive-Services/data - D-5.1. Accessed June 4th, 2019 2019.

  8. Sleiman I, Morandi A, Sabatini T, Ranhoff A, Ricci A, Rozzini R, et al. Hyperglycemia as a predictor of in-hospital mortality in elderly patients without diabetes mellitus admitted to a sub-intensive care unit. J Am Geriatr Soc. 2008;56(6):1106–10. https://doi.org/10.1111/j.1532-5415.2008.01729.x.

    Article  PubMed  Google Scholar 

  9. Halter JB, Musi N, McFarland Horne F, Crandall JP, Goldberg A, Harkless L, et al. Diabetes and cardiovascular disease in older adults: current status and future directions. Diabetes. 2014;63(8):2578–89. https://doi.org/10.2337/db14-0020.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033–46. https://doi.org/10.2337/dc12-2625.

  11. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978–82. https://doi.org/10.1210/jcem.87.3.8341.

    Article  CAS  PubMed  Google Scholar 

  12. Sinclair AJ, Abdelhafiz AH, Forbes A, Munshi M. Evidence-based diabetes care for older people with type 2 diabetes: a critical review. Diabet Med. 2018;36:399–413. https://doi.org/10.1111/dme.13859.

    Article  PubMed  Google Scholar 

  13. Lee PG, Halter JB. The pathophysiology of hyperglycemia in older adults: clinical considerations. Diabetes Care. 2017;40(4):444–52. https://doi.org/10.2337/dc16-1732.

    Article  PubMed  Google Scholar 

  14. McDonnell ME, Umpierrez GE. Insulin therapy for the management of hyperglycemia in hospitalized patients. Endocrinol Metab Clin N Am. 2012;41(1):175–201. https://doi.org/10.1016/j.ecl.2012.01.001.

    Article  CAS  Google Scholar 

  15. Sinclair A, Dunning T, Rodriguez-Manas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes Endocrinol. 2015;3(4):275–85. https://doi.org/10.1016/s2213-8587(14)70176-7.

    Article  PubMed  Google Scholar 

  16. Huang ES, Laiteerapong N, Liu JY, John PM, Moffet HH, Karter AJ. Rates of complications and mortality in older patients with diabetes mellitus: the diabetes and aging study. JAMA Intern Med. 2014;174(2):251–8. https://doi.org/10.1001/jamainternmed.2013.12956.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Umpierrez GE, Pasquel FJ. Management of inpatient hyperglycemia and diabetes in older adults. Diabetes Care. 2017;40(4):509–17. https://doi.org/10.2337/dc16-0989.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Soe K, Sacerdote A, Karam J, Bahtiyar G. Management of type 2 diabetes mellitus in the elderly. Maturitas. 2011;70(2):151–9. https://doi.org/10.1016/j.maturitas.2011.07.006.

    Article  CAS  PubMed  Google Scholar 

  19. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–12. https://doi.org/10.1056/NEJMsa1103053.

    Article  CAS  PubMed  Google Scholar 

  20. Lipska KJ, Ross JS, Wang Y, Inzucchi SE, Minges K, Karter AJ, et al. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med. 2014;174(7):1116–24. https://doi.org/10.1001/jamainternmed.2014.1824.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60(12):2342–56. https://doi.org/10.1111/jgs.12035.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Sinclair AJ, Abdelhafiz A, Dunning T, Izquierdo M, Rodriguez Manas L, Bourdel-Marchasson I, et al. An international position statement on the management of frailty in diabetes mellitus: summary of recommendations 2017. J Frailty Aging. 2018;7(1):10–20. https://doi.org/10.14283/jfa.2017.39.

    Article  CAS  PubMed  Google Scholar 

  23. Medicare Learning Network Booklet. Annual wellness visit. . In: Services USCfMaM, editor. Website. . 7500 Security Boulevard, Baltimore, MD 21244: American Medical Association 2018. p. 1–16.

  24. •• Le Roith D, Biessels GJ, Braithwaite SS, Casanueva FF, Draznin B, Halter JB, et al. Treatment of diabetes in older adults: an Endocrine Society* clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1520–74. https://doi.org/10.1210/jc.2019-00198 The Endocrine Society 2019 clinical practice guidelines include the prevalence, pathophysiology, assessment, and management considerations in older adults with DM. These guidelines outline the approach to inpatient and outpatient therapy with special considerations for the aging adult population with DM.

    Article  Google Scholar 

  25. 12. Older adults: standards of medical care in diabetes-2019. Diabetes Care 2019;42(Suppl 1):S139-s47. https://doi.org/10.2337/dc19-S012.

  26. Moreno G, Mangione CM, Kimbro L, Vaisberg E. Guidelines abstracted from the American Geriatrics Society guidelines for improving the care of older adults with diabetes mellitus: 2013 update. J Am Geriatr Soc. 2013;61(11):2020–6. https://doi.org/10.1111/jgs.12514.

    Article  PubMed  Google Scholar 

  27. Pilotto A, Cella A, Pilotto A, Daragjati J, Veronese N, Musacchio C, et al. Three decades of comprehensive geriatric assessment: evidence coming from different healthcare settings and specific clinical conditions. J Am Med Dir Assoc. 2017;18(2):192.e1–e11. https://doi.org/10.1016/j.jamda.2016.11.004.

    Article  Google Scholar 

  28. Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9:Cd006211. https://doi.org/10.1002/14651858.CD006211.pub3.

    Article  PubMed  Google Scholar 

  29. Munshi MN. Cognitive dysfunction in older adults with diabetes: what a clinician needs to know. Diabetes Care. 2017;40(4):461–7. https://doi.org/10.2337/dc16-1229.

    Article  CAS  PubMed  Google Scholar 

  30. Munshi MN, Slyne C, Segal AR, Saul N, Lyons C, Weinger K. Simplification of insulin regimen in older adults and risk of hypoglycemia. JAMA Intern Med. 2016;176(7):1023–5. https://doi.org/10.1001/jamainternmed.2016.2288.

    Article  PubMed  Google Scholar 

  31. • Van Craen K, Braes T, Wellens N, Denhaerynck K, Flamaing J, Moons P, et al. The effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis. J Am Geriatr Soc. 2010;58(1):83–92. https://doi.org/10.1111/j.1532-5415.2009.02621.x In this meta-analysis of studies performed in a hospital ward focused on the care of older adults (GEMU), components of the CGA were employed with a team-based approach to develop an individualized care plan, including a focus on rehabilitation, discharge planning, and early post-hospital follow-up. This study found the GEMU approach effective in two distinct areas: less functional decline at discharge (relative risk [RR] = 0.87, P = 0.04) and a lower rate of institutionalization 1 year post discharge (RR = 0.78, P = 0.003).

    Article  PubMed  Google Scholar 

  32. Halter J, Ouslander JG, Studenski S, High KP, Asthana S, Supiano MA, et al. Hazzard’s geriatric medicine and gerontology, seventh edition chapter 16: Acute hospital care. New York, NY: McGraw-Hill; 2017.

    Google Scholar 

  33. Jover N, Traissac T, Pinganaud G, Moras JB, Rainfray M, Bourdel-Marchasson I. Varying insulin use in older hospitalized patients with diabetes. J Nutr Health Aging. 2009;13(5):456–9.

    Article  CAS  PubMed  Google Scholar 

  34. Aliberti MJR, Apolinario D, Suemoto CK, Melo JA, Fortes-Filho SQ, Saraiva MD, et al. Targeted geriatric assessment for fast-paced healthcare settings: development, validity, and reliability. J Am Geriatr Soc. 2018;66(4):748–54. https://doi.org/10.1111/jgs.15303.

    Article  PubMed  Google Scholar 

  35. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–4.

    Article  PubMed  Google Scholar 

  36. Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, et al. Assessing psychosocial distress in diabetes: development of the diabetes distress scale. Diabetes Care. 2005;28(3):626–31.

    Article  PubMed  Google Scholar 

  37. Patel A, Parikh R, Howell EH, Hsich E, Landers SH, Gorodeski EZ. Mini-cog performance: novel marker of post discharge risk among patients hospitalized for heart failure. Circ Heart Fail. 2015;8(1):8–16. https://doi.org/10.1161/circheartfailure.114.001438.

    Article  PubMed  Google Scholar 

  38. Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008;6(3):246–52. https://doi.org/10.1370/afm.842.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 14. Diabetes care in the hospital: standards of medical care in diabetes-2018. Diabetes care. 2018;41(Suppl 1):S144-s51. https://doi.org/10.2337/dc18-S014.

  40. 15. Diabetes care in the hospital: standards of medical care in diabetes-2019. Diabetes care. 2019;42(Suppl 1):S173-s81. https://doi.org/10.2337/dc19-S015.

  41. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67. https://doi.org/10.1056/NEJMoa011300.

    Article  PubMed  Google Scholar 

  42. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354(5):449–61. https://doi.org/10.1056/NEJMoa052521.

    Article  PubMed  Google Scholar 

  43. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97. https://doi.org/10.1056/NEJMoa0810625.

    Article  PubMed  Google Scholar 

  44. Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125–39. https://doi.org/10.1056/NEJMoa070716.

    Article  CAS  PubMed  Google Scholar 

  45. Jacobi J, Bircher N, Krinsley J, Agus M, Braithwaite SS, Deutschman C, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40(12):3251–76. https://doi.org/10.1097/CCM.0b013e3182653269.

    Article  PubMed  Google Scholar 

  46. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353–69. https://doi.org/10.4158/ep09102.Ra.

    Article  PubMed  Google Scholar 

  47. Umpierrez GE, Smiley D, Zisman A, Prieto LM, Palacio A, Ceron M, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):2181–6. https://doi.org/10.2337/dc07-0295.

    Article  CAS  PubMed  Google Scholar 

  48. Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011;34(2):256–61. https://doi.org/10.2337/dc10-1407.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169–74. https://doi.org/10.2337/dc12-1988.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Lansang MC, Umpierrez GE. Inpatient hyperglycemia management: a practical review for primary medical and surgical teams. Cleve Clin J Med. 2016;83(5 Suppl 1):S34–43. https://doi.org/10.3949/ccjm.83.s1.06.

    Article  PubMed  Google Scholar 

  51. • Franchin A, Maran A, Bruttomesso D, Corradin ML, Rossi F, Zanatta F, et al. The GesTIO protocol experience: safety of a standardized order set for subcutaneous insulin regimen in elderly hospitalized patients. Aging Clin Exp Res. 2017;29(6):1087–93. https://doi.org/10.1007/s40520-017-0728-5 This retrospective, observational study of older hospitalized adults with T2DM evaluated the safety, efficacy, and benefit of a standard order protocol for SQ insulin therapy in the hospital. In frail adults (mean age 82 ± 7), total daily (TDD) insulin requirement was adjusted (decreased) to avoid hypoglycemia; 9.1% experienced mild hypoglycemia, no severe hypoglycemia was reported, and mean blood glucose improved (P < 0.005).

    Article  PubMed  Google Scholar 

  52. Kagansky N, Levy S, Rimon E, Cojocaru L, Fridman A, Ozer Z, et al. Hypoglycemia as a predictor of mortality in hospitalized elderly patients. Arch Intern Med. 2003;163(15):1825–9. https://doi.org/10.1001/archinte.163.15.1825.

    Article  PubMed  Google Scholar 

  53. Lee AK, Lee CJ, Huang ES, Sharrett AR, Coresh J, Selvin E. Risk factors for severe hypoglycemia in Black and White adults with diabetes: the Atherosclerosis Risk in Communities (ARIC) Study. Diabetes Care. 2017;40(12):1661–7. https://doi.org/10.2337/dc17-0819.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Boucai L, Southern WN, Zonszein J. Hypoglycemia-associated mortality is not drug-associated but linked to comorbidities. Am J Med. 2011;124(11):1028–35. https://doi.org/10.1016/j.amjmed.2011.07.011.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Ena J, Gaviria AZ, Romero-Sanchez M, Carretero-Gomez J, Carrasco-Sanchez FJ, Segura-Heras JV, et al. Derivation and validation model for hospital hypoglycemia. Eur J Intern Med. 2018;47:43–8. https://doi.org/10.1016/j.ejim.2017.08.024.

    Article  CAS  PubMed  Google Scholar 

  56. Sinha Gregory N, Seley JJ, Gerber LM, Tang C, Brillon D. Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting. Hosp Pract (1995). 2016;44(5):260–5. https://doi.org/10.1080/21548331.2016.1250603.

    Article  Google Scholar 

  57. Sinha Gregory N, Seley JJ, Ukena J, Shah S, Fred MR, Dargar SK, et al. Decreased rates of inpatient hypoglycemia following implementation of an automated tool in the electronic medical record for identifying root causes. J Diabetes Sci Technol. 2018;12(1):63–8. https://doi.org/10.1177/1932296817744808.

    Article  PubMed  Google Scholar 

  58. Baldwin D, Apel J. Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes. Curr Diab Rep. 2013;13(1):114–20. https://doi.org/10.1007/s11892-012-0339-7.

    Article  CAS  PubMed  Google Scholar 

  59. Wexler DJ, Beauharnais CC, Regan S, Nathan DM, Cagliero E, Larkin ME. Impact of inpatient diabetes management, education, and improved discharge transition on glycemic control 12 months after discharge. Diabetes Res Clin Pract. 2012;98(2):249–56. https://doi.org/10.1016/j.diabres.2012.09.016.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care. 2013;36(10):2960–7. https://doi.org/10.2337/dc13-0108.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Bahrmann A, Abel A, Zeyfang A, Petrak F, Kubiak T, Hummel J, et al. Psychological insulin resistance in geriatric patients with diabetes mellitus. Patient Educ Couns. 2014;94(3):417–22. https://doi.org/10.1016/j.pec.2013.11.010.

    Article  PubMed  Google Scholar 

  62. Munshi MN, Segal AR, Suhl E, Ryan C, Sternthal A, Giusti J, et al. Assessment of barriers to improve diabetes management in older adults: a randomized controlled study. Diabetes Care. 2013;36(3):543–9. https://doi.org/10.2337/dc12-1303.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Umpierrez GE, Reyes D, Smiley D, Hermayer K, Khan A, Olson DE, et al. Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care. 2014;37(11):2934–9. https://doi.org/10.2337/dc14-0479.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Blaum C, Cigolle CT, Boyd C, Wolff JL, Tian Z, Langa KM, et al. Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care. 2010;48(4):327–34.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Medicare and home health care In: Services USDoHaH, editor. 7500 Security Blvd., Baltimore, MD 21244–1850: Centers for Medicare and Medicais Services 2017. p. 1–32.

  66. Linekin PL. Home health care and diabetes assessment, care, and education. Diabetes Spectr. 2003;16(4):217–22.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave., Suite 530, Chicago, IL, 60611, USA

    Kristen DeCarlo & Amisha Wallia

Authors
  1. Kristen DeCarlo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amisha Wallia
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Amisha Wallia.

Ethics declarations

Conflict of Interest

Kristen DeCarlo declares no conflict of interest. Amisha Wallia receives grants from Novo Nordisk and serves as research investigator for studies for United Health Group and Eli Lilly.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Hospital Management of Diabetes

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

DeCarlo, K., Wallia, A. Inpatient Management of T2DM and Hyperglycemia in Older Adults. Curr Diab Rep 19, 104 (2019). https://doi.org/10.1007/s11892-019-1209-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11892-019-1209-3

Keywords

Search

Navigation