February 11, 2016

Guidelines for Diabetes Care in LTC Facilities

The new American Diabetes Association(ADA) guidelines for diabetes management in long-term care (LTC) and skilled nursing facilities (SNF) is needed and may be a good start. For now the emphasis is on treatment simplification, avoidance of hypoglycemia, and the need to reassess therapeutic goals for patients near 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. The ADA has not addressed this topic in prior guidelines, just the care for the elderly in community settings and diabetes care among hospitalized patients.

Dr. Munshi said, "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."

Most of the guidelines are written for doctors and nursing home directors, nurses, clinical pharmacologists, and others whose work centers on the elderly population. The guidelines provide additional information about the special considerations in institutionalized elderly patients. They did not forget the core of caring for the elderly, the assessment of functional capacity and common comorbidities that may interfere with diabetes care and strategies for simplifying treatment regimens and not adding more medications.

Dr Munshi commented, "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."

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.

I like the next discussion, 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.

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.

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.

If you are nearing this point in life or your parents are at this point, carefully read the guidelines at the link above to be aware of them and discuss them with the care facility.

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