The care of adults over age 65 with type 2 diabetes is a growing concern: the prevalence of diabetes is highest in this age group and is expected to grow as the U.S. population ages, with many needing care at long-term care (LTC) facilities. To ensure that this population receives proper care, the American Diabetes Association has issued its first position statement to address the management of diabetes in long-term care facilities, which include assisted living, skilled nursing and nursing facilities. The statement appears in the February 2016 issue of Diabetes Care.
"The differences in caring for older people with type 2 diabetes aren't well understood and haven't been the focus of guidelines for managing the disease. We wanted to give long-term care facilities very clear guidelines for caring for patients with diabetes that they can adapt into their care protocols," says statement lead author Medha N. Munshi, M.D., Director of the Joslin Diabetes Center Geriatric Diabetes Program and Assistant Professor at Harvard Medical School. The focus is type 2 diabetes, since the vast majority of patients at LTC facilities have this type of the disease but some recommendations are also included for type 1 diabetes.
Managing diabetes in older people presents unique challenges: the disease increases the risk of age-related conditions, such as cardiovascular disease, cognitive impairment, falls, persistent pain and urinary incontinence. Patients vary greatly in their comorbidities and health status. "Care of older patients with diabetes needs to be patient-centered and focused on individualized goals," says Dr. Munshi.
"Management of Diabetes in Long-term Care and Skilled Nursing Facilities" outlines the key differences in the management of diabetes in younger and older people, which include:
- Hypoglycemia risk is the most important factor in determining glycemic goals - older people are more prone to hypoglycemia which can have catastrophic consequences and is a major reason for hospitalizations in this population. Glycemic goals should balance the prevention of hypoglycemia while avoiding extreme hyperglycemia.
- Sole use of sliding scale insulin (SSL) should be avoided - it leads to wide variations in blood glucose levels, is a burden for patients, and requires more nursing time and resources.
- Liberal diet plans are preferable to therapeutic diets - more food choices benefit nutritional needs and glycemic control.
Strategies are offered for addressing the specific medical needs of the older diabetes population. The statement focuses on providing practical guidance, with information presented in convenient tables, taking into account how LTC facilities function and the strict government regulations they must follow.
Patients must often transition from one healthcare facility to another, such as from the hospital to a skilled nursing facility, which increases the risk for adverse events, especially in patients with complex comorbidities. The statement addresses the importance of communication among healthcare providers and the need for patient documentation to be transferred between facilities and offers strategies for ensuring safe transitions.
End-of-life care for diabetes patients, who may be receiving palliative or hospice care, is an area that has only recently begun to be addressed. ADA recommendations include relaxing glycemic targets, simplifying regimens and respecting the patient's right to refuse diabetes treatment.
As the first ADA statement to offer a comprehensive guide to managing older patients in long-term care, Dr. Munshi anticipates that it will be "widely used by LTC facilities" who will appreciate its focus on the practical. "It is also important to educate endocrinologists, who may not have experience with long-term care facilities, and geriatricians, who may lack a comprehensive understanding of diabetes care," she says.