title: Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association.
abstract: Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.
authors.affiliation: Beth Israel Deaconess Medical Center and Joslin Diabetes Center, Harvard Medical School, Boston, MA mmunshi@bidmc.harvard.edu.
authors.forename: Medha N
authors.initials: MN
authors.lastname: Munshi
authors.affiliation: Geriatric Research Education and Clinical Centers, Miami Veterans Affairs Healthcare System and University of Miami, Miami, FL.
authors.forename: Hermes
authors.initials: H
authors.lastname: Florez
authors.affiliation: Section of General Internal Medicine, The University of Chicago, Chicago, IL.
authors.forename: Elbert S
authors.initials: ES
authors.lastname: Huang
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Rita R
authors.initials: RR
authors.lastname: Kalyani
authors.affiliation: American Diabetes Association, Alexandria, VA.
authors.forename: Maria
authors.initials: M
authors.lastname: Mupanomunda
authors.affiliation: Department of Geriatrics, Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, FL.
authors.forename: Naushira
authors.initials: N
authors.lastname: Pandya
authors.affiliation: Kadlec Regional Medical Center, Richland, WA.
authors.forename: Carrie S
authors.initials: CS
authors.lastname: Swift
authors.affiliation: University of Rhode Island College of Pharmacy, Providence, RI.
authors.forename: Tracey H
authors.initials: TH
authors.lastname: Taveira
authors.affiliation: Private Consultant, Seattle, WA.
authors.forename: Linda B
authors.initials: LB
authors.lastname: Haas
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose; D015897:Comorbidity; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000188:drug therapy* / Q000451:nursing*; D019468:Disease Management; D006801:Humans; D007003:Hypoglycemia / Q000209:etiology; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008134:Long-Term Care; D008875:Middle Aged; D015995:Prevalence; D011788:Quality of Life; D012866:Skilled Nursing Facilities; D014481:United States
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin