Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association

Abstract

Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010

“…It will be of interest in future studies to determine whether this pattern changes with the adoption of current clinical guidelines recommending less stringent glycemic targets in NH residents, especially for those who are frail or with limited life expectancy. 7,9,36 Use of combination products containing two glucose-lowering medications in our NH sample was similar to that documented in studies of younger individuals in the community. 37 Our study has several limitations.…”

Cognitive Dysfunction in Older Adults With Diabetes: What a Clinician Needs to Know

“…These errors can lead to wide glucose excursions, which are more dangerous in the older population with a high risk of hypoglycemic unawareness. However, insulin can be used safely in appropriate settings, such as if caregivers are available or if the patient is in a supervised setting such as a longterm care facility (48).…”

Metformin Safety Warnings and Diabetes Drug Prescribing Patterns for Older Nursing Home Residents

“…5 We calculated the MDS Activities of Daily Living (MDS-ADL) score using seven ADLs (bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene), each ranging from 0 (total independence) to 4 (total dependence). 22 The sum of the seven items forms a 28-point scale, where higher scores indicate greater physical impairment.…”