“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.
About Joslin Diabetes Center
Founded in 1898, Joslin Diabetes Center is world-renowned for its deep expertise in diabetes treatment and research. Joslin is dedicated to finding a cure for diabetes and ensuring that people with diabetes live long, healthy lives. We develop and disseminate innovative patient therapies and scientific discoveries throughout the world. Joslin is an independent, non-profit institution affiliated with Harvard Medical School, and a federally-designated Diabetes Research Center.
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