Treatment of Diabetes in Long-Term Care Facilities: A Primary Care Approach

Abstract

IN BRIEF The epidemic of type 2 diabetes now affects 190 million people globally,with numbers continuing to grow. In long-term care facilities, ∼ 25% of residents have diabetes, a great majority with type 2 diabetes. Appropriate guidelines and medication use are examined for members of this population,accounting for their unique needs and comorbidities.

Managing Special Populations Among Patients with Type 2 Diabetes Mellitus

“…8 In addition, metformin is not recommended in patients with hepatic dysfunction, chronic heart failure (CHF), metabolic acidosis, dehydration, or alcoholism due to the risk of lactic acidosis, which is a rare but potentially fatal complication. 3,8,9 The incidence of lactic acidosis in patients taking metformin is low (~3 cases/100,000 patient-yrs); however, it is fatal in half of all cases. 10 Lactic acidosis has occurred primarily in patients with type 2 diabetes who have significant renal impairment, including renal hypoperfusion and renal disease.…”

“…1 Due to their low cost, sulfonylureas are commonly prescribed to elderly patients; however, these drugs should be used cautiously in this population due to declining renal and hepatic function, and reduced effectiveness of these drugs with age. 3,9 In addition, the use of sulfonylureas is associated with weight gain and hypoglycemia, which can be prolonged and life-threatening. 1,3 Hypoglycemia can be more pronounced with the use of first-generation sulfonylureas, such as glyburide, than with second-generation sulfonylureas; therefore, second-generation sulfonylureas are preferable.…”

“…These agents must be used carefully, and patients should be closely monitored. 9 Thiazolidinediones Thiazolidinediones are insulin-sensitizing agents in muscle and fat, and are used as monotherapy or as add-on therapy with metformin. Although hypoglycemia with thiazolidinediones is fairly rare, patients may experience other adverse reactions.…”

“…5,6 Common comorbidities, including poor renal function, declining cognitive function, hypoglycemia, and dementia, must be considered when determining appropriate therapy regimens in this population. 9 However, because age-related changes can alter the presentation of diabetes, it can be difficult to determine which symptoms result from diabetes and which are associated with the normal aging process. 39 The criteria used to determine resident treatment goals are based on life expectancy, cognition, and their drug therapy for comorbid conditions.…”

“…In a study of 62 nonterminal, long-term care residents with diabetes, 89% achieved an A1C less than 7%, 84% had a blood pressure lower than 130/80 mm Hg, and 89% had an LDL less than 100 mg/dl. 9…”