New Guidance on Diabetes Care in Elderly Residential Facilities

Miriam E Tucker

February 02, 2016

New American Diabetes Association (ADA) guidelines addressing diabetes management in long-term care and skilled nursing facilities emphasize treatment simplification, avoidance of hypoglycemia, and the need to reassess therapeutic goals for patients who are nearing the end of life.

The guidelines were published in the February issue of Diabetes Care by Medha N Munshi, MD, director of the Joslin Geriatric Diabetes Program, Boston, Massachusetts, and colleagues.

Previous statements from the ADA have addressed care for the elderly in community settings and diabetes care among hospitalized patients, but this is the first to specifically address the unique needs of patients in long-term care settings, where the approach to diabetes management often needs to be dramatically altered from those in younger and healthier patients, Dr Munshi told Medscape Medical News.

"We've developed great protocols for looking at the numbers in managing diabetes. My fight in geriatric diabetes is we need to look at what the patient needs," she said.

Advice Tailored to Healthcare Providers

The guidelines are aimed at a variety of audiences. For endocrinologists and primary-care clinicians with expertise in diabetes, they provide additional information about the special considerations in institutionalized elderly patients. This includes guidance on the assessment of functional capacity and common comorbidities that may interfere with diabetes care and strategies for simplifying treatment regimens — the opposite of the usual practice of adding more medications.

"As a geriatrician, I see a lot of inappropriate care and things done to patients at the end of life, not because people aren't trying to help or aren't paying attention, but simply because they don't know what to do. When you have to withdraw something, it makes people very uncomfortable. We are hoping this will help [clinicians] to understand that it is okay to back off of some of these things," Dr Munshi commented.

And for nursing home directors, nurses, clinical pharmacologists, and others whose work centers on the elderly population, the document provides detailed diabetes-specific information and guidance, including minimization of hypoglycemia by replacing sliding-scale insulin-dosing regimens, and a medication roundup.

"It's not enough to just say the A1c needs to be different, but how you get to that A1c needs to be different. [Otherwise], you get a lot of hypoglycemia or complex regimens that can decrease quality of life," Dr Munshi noted.

She and her colleagues also point out that the vast majority of patients with diabetes in long-term care facilities have type 2 diabetes, so most recommendations in this position statement are directed toward that population. But specific recommendations for patients with type 1 diabetes are given, when appropriate.

Evaluation of Comorbidities

Careful evaluation of comorbidities that can affect diabetes management is advised prior to developing treatment goals and strategies.

Examples include cognitive dysfunction, depression, skin problems including infections and foot ulcers, hearing/vision problems, and oral health issues that may interfere with eating. These are all listed in a chart, along with their potential impact and possible strategies to manage diabetes in those situations.

"When we talk about diabetes, we're very good at understanding the micro- and microvascular complications, but for most providers [issues such as] depression, cognitive problems, and physical disabilities don't necessarily come to mind," Dr Munshi noted.

Avoidance of Hypoglycemia

The risk of hypoglycemia, Dr Munshi and colleagues write, "is the most important factor in determining glycemic goals due to the catastrophic consequences in this population."

Increasing evidence points to the risks of hypoglycemia in the elderly, while there is little to support the use of intensive glycemic control for that population.

"In younger patients the benefits of tight control are very well-defined, so the risks of hypoglycemia are to an extent understood to be well worth it. But as you get older, no studies have defined the benefits of tight control in this population, and hypoglycemia is a huge problem," Dr Munshi said.

Even less severe hypoglycemia can be "catastrophic" in the elderly, such as in patients with poor vision, neuropathy with unsteady gait, and those taking other medications. "Even if they just drop to 60 (mg/dL), that can add enough to cause a fall or mental confusion....You really have to be careful."

To that end, the guidelines advise simplified treatment regimens and avoidance of "sliding-scale" regimens that base insulin doses solely on current blood glucose levels without consideration for food or exercise. Such regimens have been shown to induce wide swings in blood glucose levels. Other guidelines have advised against sliding-scale regimens in hospital and long-term care settings, but this is the first that Dr Munshi is aware of that provides specific instructions for replacing them with alternative regimens, depending on the patient's current routine and clinical circumstances.

"It's really difficult to guide people....Whenever I see 'don't use sliding scale,' the question in my mind is 'so then what?' I've never seen any guidance on that."

Other hypoglycemia-avoidance advice includes liberalization of diet plans (also with the goals of avoiding unintentional weight loss and dehydration) and a detailed chart listing the advantages and disadvantages of each of the currently available glucose-lowering agents, including their hypoglycemia risk, as well as efficacy and cost.

The document also provides recommendations for transitions of care, advising that those times are particularly important for revisiting management goals and providing patient and caregiver education.

And for patients nearing the end of life, the guidelines advise respecting patients' wishes regarding the right to refuse treatment. At that phase, Dr Munshi advised, "Patients need to have whatever makes them comfortable."

Dr. Munshi is a consultant for Sanofi and Novo Nordisk. Disclosures for the coauthors are listed in the article.

Diabetes Care. 2016;39:309-318. Article

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