Miriam E. Tucker
July 14, 2020
The viewpoint, entitled, "Caring for Older Adults With Diabetes During the COVID-19 Pandemic," was published online in JAMA Internal Medicine 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 aged 70 years and older with comorbidities such as diabetes are among those at highest risk for adverse outcomes and mortality due to COVID-19.
At the same time, those who don't 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 point out, noting 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 those 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 of dehydration and falls. Take steps to avoid hypoglycemia, reduce polypharmacy, and consolidate medication doses.
- Burden of diabetes self-care: Bloodwork for A1c 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, three 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 conclude: "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 Sanofi and Lilly. Sy has reported no relevant financial relationships.