American Society of Consultant Pharmacists (ASCP) Spring Conference and Exhibition 2012

Anaheim, CA; May 21-23, 2012
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Sessions

Challenges of Caring for Elderly Long-Term Care Residents With Diabetes

Older people with diabetes are often the sickest people in long-term care (LTC) facilities, as they tend to have more comborbidites and are likely to experience numerous diabetes-related complications, such as increased susceptibility to infection, recurrent congestive heart failure, urinary retention, urinary track infections, and weight loss. As such, caring for these patients presents many challenges and requires use of measures beyond glycemic control.

Speaking at the ASCP conference, Naushira Pandya, MD, CMD, professor and chair, Department of Geriatrics, and director, Geriatrics Education Center, Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL, outlined four main challenges of managing diabetes in LTC residents that need to be considered to ensure that these patients receive the best care.

The first challenge is recognizing that diabetes is a complex disease in elders due to the many confounding factors that make this disease a moving target. Among the factors that caregivers need to keep in mind and be agile in managing is the greater potential for adverse effects and drug interactions, increased risk of hypoglycemia, high rate of irregular meal consumption, high prevalence of cognitive dysfunction and depression, propensity for psychological insulin resistance, high rate of impaired vision and manual dexterity, and the high prevalence of terminal illnesses. Pandya also emphasized paying attention to oral and foot complications, as they can be signs of other serious diseases.

The second challenge relates to LTC facilities themselves, as numerous challenges are encountered in this setting, including a high rate of staff turnover, Pandya said. Additionally, many LTC facilities do not have adequate review of glucose logs, lack facility-specific diabetes treatment algorithms, and lack established blood glucose parameters for physician or provider notification. Another problem is restricted dietary practices, which, she said, is changing as people recognize that older persons may fare better on a liberalized diet.

A third challenge is the often outdated practices used by staff and practitioners. She stressed that the care of older persons with diabetes should focus on adequate glycemic control rather than tight control. Among the problems Pandya highlighted are knowledge deficits among staff about the disease, its associated complications, and therapy modifications. For example, she said that often there is confusion between insulin brands (eg, regular vs rapid-acting analogs). The biggest problem she sees, however, is withholding administration of a long-acting basal analog because the morning blood glucose level was slightly low.

The final challenge is medical management. Pandya noted that medical management can be confusing given the multiple and continually changing treatment approaches.

To manage these challenges, Pandya emphasized the need to establish a systematic facility-wide approach to disease management that employs a team strategy in which consultant pharmacists play a key role. She noted that drugs are the mainstay of treatment of diabetes in LTC facilities and that they need to be changed regularly. She stressed that diet is not the appropriate way to manage diabetes in the elderly and that dietary restrictions should be avoided.

In terms of managing glycemic control, she said that the first task is to fix the fasting glucose levels to aim for <130 mg/dL and then attend to meal-time glucose levels. She walked the audience through a way of advancing therapy through a basal-bolus treatment strategy with rapid-acting and long-acting insulin analogs.

Pandya also emphasized the importance of treating hypoglycemia with what she called the “Rule of 15,” which is to give 15 grams of glucose or carbohydrate (ie, equivalent to a half cup of juice or apple sauce, 1 cup of milk, 1 tube of glucose gel, or 3 glucose tablets) and then wait 15 minutes and check blood glucose levels again. If glucose levels are still below target, then another 15 grams of glucose or carbohydrate need to be given and the possible causes of hypoglycemia must be assessed for and documented. She highlighted that the most difficult part of this protocol is waiting 15 minutes to recheck the resident’s glucose levels, but emphasized that this step is critical.

Pandya also discussed system issues in LTC facilities that can be addressed to improve diabetes management. Along with proposing a new design for glucose logs that make it easier to follow glucose trends by mealtimes, she emphasized the importance of using clinical judgment and ongoing clinical assessments for making day-to-day decisions regarding treatment of hyperglycemia, rather than excessive reliance on sliding scale insulin, which she noted had been voted as a suboptimal treatment option by the American Diabetes Association. Despite this, she said that use of sliding scale insulin persists in LTC facilities.

A final issue she discussed is when to call the practitioner. Citing a 2008 consensus statement by the American Medical Directors Association (https://guidelines.gov), Pandya said that a practitioner should be called as soon as possible when a patient has two or more blood glucose values of >250 mg/dL with change of condition and no treatment; with blood glucose values of >300 mg/dL during all or part of 2 consecutive days; or if the patient has not eaten well or not had sufficient fluids for 2 or more days and has abdominal pain, fever, hypotension, lethargy or confusion, and/or respiratory distress.—Mary Beth Nierengarten

Product Theaters

Potential Benefit of Combined Therapy to Treat Mixed Dyslipidemia

For select patients with mixed dyslipidemia, treatment aimed at raising high-density lipoprotein (HDL) along with lowering low-density lipoprotein (LDL) may be more effective in reducing the risk of coronary artery disease (CAD) than solely targeting LDL in these patients. Although population-based studies show that an HDL of >60 mg/dL poses a negative risk of developing CAD, there is not yet evidence showing that raising HDL reduces the risk of CAD events. Emphasizing repeatedly that the evidence is lacking on whether to target HDL when treating patients who have mixed dyslipidemia, Paul Rosenblit, MD, PhD, clinical professor of medicine, Division of Endocrinology, Diabetes, Metabolism, University of California, Irvine School of Medicine, spoke to clinical pharmacists at the ASCP conference on the rationale for combination therapy aimed at both lowering LDL and raising HDL to more effectively treat these patients.

In his presentation during a product theater sponsored by Abbott Laboratories, Rosenblit talked about treatment recommendations in the current 2004 National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) that indicate non-HDL (total cholesterol minus HDL) as a secondary target of therapy after LDL for patients with triglycerides of >200 mg/dL. For these patients, the guidelines (www.nhlbi.nih.gov/guidelines/cholesterol/atp3xsum.pdf) recommend either intensifying therapy with an LDL-lowering drug or adding a nicotinic acid or fibrate to the statin if used with appropriate caution. In addition, the guidelines say that if triglycerides are <200 mg/dL (isolated low HDL cholesterol), drugs for raising HDL with fibrates or nicotinic acid can be considered, although this should be reserved primarily for persons with CAD or CAD risk equivalents.

Rosenblit walked the audience through the results of studies on two drugs, Niaspan and Simcor, which combine a statin with a niacin agent. Both drugs, he said, have been shown to be beneficial in lowering LDL and non-HDL levels, as well as raising HDL. One limitation of using the drugs, he said, is that no incremental benefit to morbidity or mortality has been found over single-agent therapy. A trial designed to compare single-agent versus combined therapy, called the AIM-HIGH clinical trial, was terminated early because of the lack of benefit seen with the combination therapy.

Rosenblit stressed a number of contraindications of the drugs (eg, active liver disease, pregnancy). He also discussed their most common side effect, which is flushing from the niacin agent.—Mary Beth Nierengarten

This product theater was sponsored by Abbott Laboratories.

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Use of MDS 3.0 Brief Interview for Mental Status in the Management of Alzheimer’s Disease in Long-Term Care Residents

With a growing aging population and an increasing number of people receiving an Alzheimer’s disease or dementia diagnosis, early detection and better treatment is taking on a more urgent focus. Consultant pharmacists who work in long-term care (LTC) facilities are in a good position to get involved in the early detection and treatment plan of residents who live in these facilities or for short-stay residents who eventually return to their homes in the community.

One key way pharmacists can get more closely involved is to help educate nurses on the value of incorporating a new, simple screening tool into the initial assessment of LTC residents, according to Frederick Wendt, RPh, president, FLW Consulting Services, Dallas, TX, during a product theater sponsored by Forest Pharmaceuticals at the ASCP conference. Introduced in the Minimum Data Set, Version 3 (MDS 3.0), the Brief Interview for Mental Status, which is more commonly referred to as BIMS, is a very simple assessment tool to evaluate for cognitive impairment. Wendt emphasized that BIMS is not a diagnostic tool, but only a screening tool that is most valuable as a first assessment tool or as an additional assessment tool to correlate and compare findings when used with other assessment scales.

Along with educating nurses, Wendt encouraged consultant pharmacists to conduct the BIMS themselves, which will enable them to work directly with residents and get more actively involved in the care planning for the residents as needed. In this way, consultant pharmacists will add value to the team in LTC facilities.

Reiterating that the MDS 3.0 BIMS is only a screening tool that can provide additional information to a larger diagnostic work-up, James E. Galvin, MD, MPH, associate director and education core leader, Alzheimer’s Disease Center, New York University Langone School of Medicine, discussed the application of MDS 3.0 BIMS in the real-world setting.

He emphasized that there are an increasing number of people residing in LTC settings, with currently one in eight persons aged ≥65 years and one in two persons aged ≥85 years living in these facilities. Among these individuals, 50% have Alzheimer’s disease or dementia, and he said that many of these residents will not receive the diagnosis when they enter the LTC facility. This is where MDS 3.0 BIMS can be used as the first standardized assessment of patients, he said.

For people with Alzheimer’s disease, the diagnosis is often made when the disease is at the moderate stage. For these patients, he said data support the use of combination donepezil and memantine, as reported in a study published in 2004 by Tariot and colleagues (JAMA. 2004;291[3]:317-324).

In that study, participants with moderate to severe Alzheimer’s disease treated with stable doses of donepezil were randomized to receive memantine or placebo. At 24 weeks, the study found that participants treated with the donepezil and memantine combination had significant improvement in measures of cognition, activities of daily living, global outcome, and behavior compared with the donepezil- and placebo-treated participants.

Galvin emphasized the importance of delaying or slowing down the functional decline in these patients to help them maintain their quality of life. At what point do you stop treatment was a question raised by a participant in the session that initiated a discussion on when the risk of treatment outweighs the benefits.

Galvin suggested that if a resident is still engaged with the community in the LTC facility then that is reason enough to continue medications. For bedridden patients, he emphasized the importance of discussing discontinuation of treatment. Overall, he emphasized that the goal of treatment is to maintain activity because once it is lost, it will not be regained. —Mary Beth Nierengarten

This product theater was sponsored by Forest Pharmaceuticals.