A recent position statement from the American Diabetes Association (ADA) addresses the management of diabetes in older adults in long-term care (LTC) and skilled nursing facilities (SNF), focusing on the unique needs of this diverse population.1 The statement, published in the February issue of Diabetes Care, provides clear and practical guidance, often in tabular form, that LTC and facilities can incorporate into their diabetes protocols. It emphasizes the prevention of hypoglycemia, the consideration of patient comorbidities in tailoring goals and strategies, and the adjustment of treatment for individuals at the end of life.1
The position statement addresses more specifically some of the issues discussed broadly in a 2012 ADA/American Geriatrics Society statement on diabetes in older adults, explained Hermes Florez, MD, PhD, professor of public health and medicine at the University of Miami and director of the Geriatric Research, Education, and Clinical Center at the Miami VA Healthcare System, who co-authored the 2016 statement.
“There is a growing concern about how to care for older patients with diabetes who have experienced significant functional decline and consequently need admission to assisted living, skilled nursing, and nursing facilities,” he stated. The recent position statement addresses this concern.
Focus on Serious Risks
Of primary importance is the avoidance of hypoglycemia, which can have “catastrophic consequences leading to emergency room (ER) visits and acute hospitalizations in this population,” Dr Florez explained. The ADA recommends that clinicians admitting patients to LTC facilities — which include assisted living, skilled nursing, and nursing facilities — assess risk for hypoglycemia and take it into account when determining glycemic goals on admission.
As the statement points out, older adults are more prone to hypoglycemia than younger adults for many reasons, including irregular food intake, impaired renal function, slowed hormonal regulation and counterregulation, slowed intestinal absorption, cognitive dysfunction, and reduced hepatic enzyme activity. Other factors contributing to hypoglycemic risk are polypharmacy and recent hospitalization. Persistent sliding scale insulin (SSI), a customary practice in many health care settings, may also contribute to hypoglycemia, as it can lead to wide variations in blood glucose levels.1
In a study conducted by Daniel S. Budnitz, MD, MPH, of the Centers for Disease Control and Prevention, and colleagues published in 2011, insulin was the No. 2 reason for emergency hospitalizations due to adverse drug reactions in US adults aged 65 years and older. Of the 99 628 hospitalizations that occurred from 2007 through 2009, insulin was implicated in 13 854 (13.9%) and oral hypoglycemic agents were involved in 10 656 (10.7%).2
The ADA recommends that clinicians avoid using SSI as the sole method of blood glucose control and offers practical strategies for converting from SSI to other regimens. Regarding oral antihyperglycemic drugs, the statement notes that sulfonylureas are associated with a higher risk for hypoglycemia than other oral agents. Glyburide carries the highest risk and should be avoided in the LTC population, according to the statement, and other sulfonylureas should be avoided in patients with inconsistent nutritional intake.1
While recommending that severe hyperglycemia be prevented in all patients, the position statement provides a framework for determining glycemic goals based on setting: Although optimal glycemic control is necessary for community-dwelling patients who require a short-term, SNF stay after an acute illness, glycemic control offers no benefit in end-of-life settings except to prevent symptomatic hyperglycemia. In LTC facilities, intensive glucose control has limited benefits, and other factors, such as quality of life, risk for hypoglycemia, and life expectancy, should also be considered.1
Importance of Flexibility
The ADA statement also recommends the liberalization of restrictive diets to include more food choices.1 Restrictive therapeutic diets can lead to dehydration and unintended weight loss and should therefore be avoided. Flexible meal plans, on the other hand, have been associated with improved food and fluid intake.3 “No concentrated sweets” and “no sugar” diet orders are ineffective and not recommended. Nutritional needs may be better met, and glycemic control more easily maintained, with a “general diet,” meaning a “consistent carbohydrate meal plan that allows for a variety of appropriate choices,” the guidelines state.1