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Diabetes and COVID-19 as Obstacles to Returining to Normal

      Mr. G is an 87-year-old White male who was recently transferred to a nursing home within a continuing care retirement community where he lives with his wife. He was treated in an acute care setting for an exacerbation of congestive heart failure, and he now requires skilled care for deconditioning and medical management. Per state regulations, upon admission he was quarantined in the COVID-19 unit.
      His other diagnoses include hypothyroidism, hypertension, diabetes, sleep apnea, chronic obstructive pulmonary disease (COPD), gout, iron deficiency anemia and anemia of chronic disease, chronic kidney disease, atrial fibrillation, and hypercholesteremia. His current medications include levothyroxine at 100 μg daily, febuxostat at 40 mg by mouth daily, Eliquis at 2.5 mg twice a day, budesonide ER at 3 mg daily, clopidogrel at 75 mg daily, ferrous sulfate at 325 mg daily, famotidine at 20 mg daily, linagliptin at 5 mg daily, carvedilol at 3.125 mg twice a day, furosemide at 20 mg by mouth daily, atorvastatin at 80 mg daily, and trazadone at 100 mg daily. He is on sliding-scale Novolin insulin with fingersticks twice a day. Since admission, his blood sugar has ranged between 200 and 400 mg/dL, and he generally needs coverage at 4:00 p.m. with 4 units of insulin.
      Mr. G participated in therapy, and he progressed with ambulating short distances with his walker. Before his hospitalization, he had enjoyed using his computer and sharing meals with his wife, which included a drink and television at dinner. Before the pandemic, his life was more active, with regular bridge games with friends and visits with his daughter. Now he reports life is not worth living in this current state of pandemic isolation. He wants to go home, but he worries that may not happen given the difficulties with insulin management, and he fears his wife is adjusting to life without him. Aside from participating in therapy, Mr. G sits and stares out the window or watches television.
      Medically, Mr. G is unstable, given that his weight fluctuates between 154 lbs and a dry weight of 146 lbs, with Lasix doses alternating between 20 and 40 mg. He really did not want to take insulin because he was concerned about being able to manage it at home. When he was at home Mr. G had refused to wear his CPAP (continuous positive airway pressure) device; in the nursing home, he has been helped to do so by nursing. During his last hospitalization continuing with CPAP was strongly recommended.
      The interdisciplinary team (IDT) is concerned Mr. G will not be able to return to independent living or be able to achieve optimal medical management in that setting. How might the IDT optimize his quality of life during the COVID-19 pandemic and balance it against the restrictions of the nursing home setting?

      Attending Physician

      Melvin Hector, MD, FAAFP, CAQ Geriatrics, CMD
      Dr. Hector is a Tucson-based physician with over 30 years of medical director experience.
      As Mr. G’s attending physician and after a first review of his medications, I see several concerns that need to be addressed. A side effect of febuxostat is a higher cardiovascular death rate than with allopurinol, so it should only be used if allopurinol cannot be and/or if gout is a true issue. Mr. G is taking budesonide without a clear indication; presumably, if he is taking it orally, it is for treating an inflammatory bowel condition. The indications for budesonide should be determined and justified because steroids can impact his glucose control and his mood, and also contribute to depression.
      Mr. G is taking a furosemide regimen for edema and fluctuating weight; however, the linagliptin he is taking for diabetes has frequent side effects of congestive heart failure and fluid retention. Given that linagliptin counters the effect of furosemide, the linagliptin should be discontinued.
      His iron replacement can be enhanced if vitamin C is added. His poorly controlled diabetes is contributing to his high cholesterol, and a regimen of long-acting insulin in a single dose might suffice to lower his blood sugar and allow him to take a lower dose of atorvastatin. Statins can also contribute to confusion and forgetfulness, so a lower dose of atorvastatin might be beneficial for that reason.
      Screening for depression and early dementia, given his apathy and concern about his “wife adjusting to life without him” is certainly in order. A behavioral health evaluation could be immensely helpful. Given Mr. G’s familiarity with computers, the IDT should be able to enhance his communication with his family and encourage his interests via a video or audio bridge over the internet with just a little effort.
      Mr. G needs assurance that many of his issues can be remedied here, and that everyone’s goal is to get him back safely home as soon as possible.

      Behavioral Health

      Lori Nisson, MSW, LCSW
      Ms. Nisson is Family & Community Services Director at Banner Alzheimer’s Institute/Banner Sun Health Research Institute. She has spent more than 20 years specializing in clinical and leadership positions, serving the needs of patients and families coping with emotional, neurological, and behavioral problems.
      It appears Mr. G may be experiencing an adjustment reaction or depressive episode. It may be beneficial for the social worker to use the Patient Health Questionnaire (PHQ-9) to assess his mood and to initiate counseling, either face to face or via telehealth, to help him deal with his current circumstances and losses. Further interventions such as engaging him in activities like online bridge and televideo family visits may help provide positive engagement and give him something to look forward to each day.

      Pharmacists

      Nicole Brandt, PharmD, MBA, and Amy Chen
      Dr. Brandt is a professor and the executive director of the Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy. Ms. Chen is a fourth-year pharmacy student.
      Given Mr. G’s worries about not being able to go home due to difficulties with insulin management, a closer look at his diabetes regimen is warranted. His high blood sugar readings suggest suboptimal control, which can be attributed to his sliding-scale insulin regimen. Sliding-scale insulin is not recommended for older adults such as Mr. G due to its higher risk of hypoglycemia without improvement in hyperglycemia management. Given his limited life expectancy, the high risk of hypoglycemia associated with the insulin and the fact that he was not taking insulin before his admission indicate that insulin is not an appropriate choice for him.
      With respect to the stroke and systemic embolism prophylaxis for his atrial fibrillation, the dose of Eliquis may or may not be appropriate. Mr. G is ≥80 years old and weighs >60 kg, so the recommended dose depends on his serum creatinine value. If his serum creatinine is ≥1.5 mg/dL, the recommended dose is 2.5 mg twice daily; otherwise, the dose will be 5 mg twice daily. In addition, his use of Eliquis and clopidogrel together increases the risk of bleeding. Since his CHA₂DS₂-VASc score is 5 (≥2 in men), oral anticoagulants such as Eliquis are recommended. (Antiplatelets such as clopidogrel are more appropriate in the setting of atrial fibrillation complicated by acute coronary syndrome, which does not apply to Mr. G.)
      With respect to the treatment of his cardiovascular conditions, the current dosage of carvedilol at 3.125 mg twice daily is suboptimal. The addition of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) may be beneficial. In addition, given that Mr. G is >75 years old with diabetes but without atherosclerotic cardiovascular disease, the dose of atorvastatin (80 mg) may be too high; a moderate-intensity statin such as atorvastatin at 20 mg is more appropriate.
      With respect to the treatment of his sleep apnea and COPD, Mr. G is currently not taking any medications for those conditions. If left untreated, they could increase his risk for severe illness from COVID-19. In addition, Mr. G is on oral budesonide, for which the indication is unclear in his case.

      Community Life Coordinator

      Diane Mockbee, BS, AC-BC
      Ms. Mockbee is an activity consultant, educator, and trainer.
      The goal of a community life interventions would be to help address Mr G’s depression and feelings of isolation. If possible, the facility can provide him with an iPad or computer and encourage Mr. G. to engage in Facetime visits with his wife, daughter, and other family members. Bridge games could be downloaded for him to play, or he could be encouraged to play bridge by himself. From a social perspective, adding an alcoholic beverage to his dinner meal may normalize his routine. A nonalcoholic, sugar-free drink may also be considered if necessary.

      Social Worker

      Paige Hector, LMSW
      Ms. Hector has over 25 years’ experience in post-acute and long-term care settings as a social worker and clinical educator.
      The focus from the social work perspective would be to validate Mr. G’s concerns about the changes in his life due to the pandemic and his medical condition, and his worries about not being able to return home. Let him know his concerns are heard and normalize them. Next, complete a comprehensive biopsychosocial assessment to learn about his prior level of functioning, his emotional and psychological well-being, and the financial and cultural aspects that impact his situation.
      I would focus on a strengths perspective to look for coping strategies and examples of resilience that can inform his current situation. It can be helpful to incorporate his life experiences and work history, which likely includes crises and successes. Some possible questions to ask include: Could you describe a time when you lived through a period of uncertainty? Have you experienced any silver lining in the disruption?
      Although the PHQ-9 was completed with the first Minimum Data Set, I would readminister this screening tool outside of the regularly scheduled MDS dates and evaluate the scores across time. I would also talk with his wife and daughter to determine whether they share his concerns around medical management at home, and explore solutions. Mr. G also should be screened for trauma using the PC-PTSD-5 (https://www.ptsd.va.gov/professional/assessment/documents/pc-ptsd5-screen.pdf) and the information gained should be incorporated into a care plan based on Mr. G’s goals and hopes.
      Likewise, contributing to a capacity assessment would be helpful to determine his ability to make his health care decisions. The discussion around his health care preferences needs to include several elements and also be documented in the medical record: conversations about risks and benefits, attempts to make the situation more agreeable for Mr. G, all efforts at education and interventions implemented, and the care and services Mr. G accepts.

      Director of Nursing

      Robyn Eaglen, RN, BSN, LNHA
      Ms. Eaglen has worked in a variety of nursing roles for the past 24 years and is currently working as a Director of Nursing at a post-acute and long-term care facility outside Tucson, AZ.
      From a nursing perspective, it would be helpful to teach Mr. G about the benefits of long-acting insulin and assess whether he is able to check his own blood sugar and self-administer a preset dose of insulin. To optimize his quality of life, nursing should encourage the family to bring his computer from home as well as other items he might find useful and comforting. Further, the increased use of video or phone chats with his family could be encouraged and facilitated, as well virtual games online with friends.

      Physical Therapist

      Jim Patten, PT
      Mr. Patten is a graduate of the University of Vermont (1990) and has enjoyed 30 years of geriatric care in the acute and subacute rehabilitation settings. He currently works in a post-acute and long-term care facility outside Tucson, AZ.
      Physical therapy would focus on improving Mr. G’s functional activity tolerance, supported by appropriate use of energy conservation techniques to facilitate a more consistent level of performance. Coordination of the therapy schedule with the care team would help eliminate his prolonged periods without positive social interaction.
      Use of communication technology between scheduled therapy or care requirements would permit visits with his spouse and family and provide a way for him to update the family on his progress. He could also use the computer for participation in self-identified leisurely activities and to pursue personal interests and educational opportunities.
      When discussing his options for the discharge plan, the therapy goal will be to minimize functional mobility deficits and the amount of physical assistance required to manage fall risk.

      Nutritionist

      Rebecca Myrowitz, MHS, RDN, LDN, CSOWM, CPH
      Ms. Myrowitz is a clinical dietitian nutritionist who serves in a leadership role in the CCRC Roland Park Place.
      In caring for Mr. G, we need to optimize his nutrition-related quality of life given the restrictions of the nursing home during COVID-19, especially since his feeling of isolation can lead to a decreased appetite. When he was in independent living, his evening meal was more of a social activity involving an alcoholic beverage as well as company. It would be helpful to mimic that as much as possible in the nursing home. An example would be a video dinner date with his wife or daughter. If Mr. G is medically allowed, the team may request an order from the medical provider to add a drink with his dinner.
      To optimize Mr. G’s intake, we need to update his food preferences regularly. His family may consider ordering food for him from his favorite restaurant as an occasional treat. Furthermore, he may want to have some of his favorite spices at his bedside so he can add them to his meal to increase its palatability. If he tolerates juicier foods better than dry foods, ordering dark meat and stews may help as well as having gravy, sauce, or condiments to add as needed. It also may be helpful to have him eat in areas outside of his room, if possible. Enjoyable supplements can be offered such as Glucerna as well as some preferred sweets in reasonable portion sizes.
      Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. She is also a member of the Editorial Advisory Board for Caring for the Ages.
      Ms. Hector is a clinical educator and professional speaker specializing in clinical operations for the interdisciplinary team and other topics. She is a member of the Editorial Advisory Board for Caring for the Ages. She is passionate about nursing homes and supporting staff to care for the most vulnerable people in their communities.
      The interdisciplinary approach was important in combining each discipline’s unique (and sometimes overlapping) perspective in a balanced set of recommendations:
      • The team was consistent about addressing some of the pharmacologic issues and options and about using internet-based resources to connect him with his family and to provide entertainment and social interactions.
      • The team offered recommendations to assess his decision-making capacity for care preferences, to honor his choices, and to help him achieve his goals.
      • The physician and pharmacy providers recommended changes to his medication regimen. The results of these changes should be observed before his discharge. Further, the differences in approach between the two in recommendations need to be discussed first with each other and then with Mr. G to explore changes and alternatives.