Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association.

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.

Special Considerations for Older Adults With Diabetes Residing in Skilled Nursing Facilities.

About 25% of all residents of skilled nursing facilities (SNFs) have diabetes, and that proportion is expected to increase. SNF residents with diabetes have special needs related to nutrition, hydration, physical activity, and medical therapy. Vigilant assessment and maintenance of safety is also crucial for such patients, including but not limited to issues such as hyper- and hypoglycemia, polypharmacy, falls, lower-extremity problems, and transitions of care. Interventions to provide stable glycemic control; ensure adequate nutrition, hydration, and physical activity; decrease polypharmacy; prevent falls; facilitate transitions of care; and improve the diabetes-related knowledge of SNF staff can help to meet these needs. Although this article focuses on SNFs, many of the topics covered also apply to elderly people with diabetes in other long-term care settings.

Optimizing insulin use in type 2 diabetes: role of basal and prandial insulin in long-term care facilities.

Approximately 25% of patients in nursing homes have diabetes, and it is the primary reason for 12% of nursing home admissions among residents 45 to 75 years of age. Glycemic control is important to reduce the risk of diabetic complications in this patient population. Management of diabetes in the long-term care setting is complicated, because many residents already have diabetic complications and other comorbidities. Data from several studies suggest that a significant number of nursing home residents receive suboptimal diabetes care. This review is intended to provide guidance for optimizing glycemic control in patients with type 2 diabetes in long-term care facilities. Oral antidiabetic drugs (OADs) represent first-line pharmacotherapy for diabetes. However, because of the progressive nature of type 2 diabetes, most patients will eventually require insulin. Adding a basal insulin analog, such as insulin glargine or insulin detemir, to an OAD is a simple, safe, and effective strategy for introducing insulin therapy. These long-acting insulin analogs provide effective glycemic control with a lower risk of hypoglycemia, a particular concern in the elderly, compared with NPH insulin. In patients whose insulin requirements have increased as a result of increases in post-prandial glucose excursions, prandial insulin should be added following a stepwise approach to therapy. Overall patient care and optimizing treatment of type 2 diabetes and its associated complications are vital services provided by the nursing staff at long-term care facilities.

Improving inpatient diabetes care: nursing issues.

As the epidemic of diabetes continues to escalate, the number of patients with diabetes who are hospitalized also will grow. Current evidence shows the value of good glycemic control in reducing morbidity and mortality in patients with diabetes. Nurses will increasingly be called on to provide the majority of the hospitalized care for these patients, and to implement care strategies that are safe, efficient, and effective. This article lists barriers faced by nurses in the inpatient setting when providing care to patients with diabetes and hyperglycemia, describes certain strategies that have successfully overcome these barriers, and suggests other strategies for testing.

Diabetes in nonveterans, veterans, and veterans receiving Department of Veterans Affairs health care.

OBJECTIVE: To compare behavioral risk factors and health and disease characteristics among three groups of adults with diabetes: nonveterans, veterans not receiving Department of Veterans Affairs (VA) health care, and veterans using VA services. RESEARCH DESIGN AND METHODS: Two data sources were used to describe the veteran population. First, the 2000 Behavioral Risk Factor Surveillance System (BRFSS) characterized the U.S. adult population by preventive health practices and risk behaviors linked to chronic and preventable diseases. New to the 2000 survey were questions on veteran status, which were administered in all states. Second, VA administrative and veterans benefits data were analyzed to describe comorbidity, education services, and veterans benefits. RESULTS: The estimated prevalence of diabetes in male veterans receiving VA care was 16%. Male veterans with diabetes using VA care were more likely to be nonwhite, not employed, have lower income, lower health status, and more activity limitations than male veterans not using these services. Computerized records indicate VA users with diabetes also had high concurrent comorbidity. Frequency of VA diabetes and preventive care services, as measured by selected quality indicators, was equivalent to or higher than the levels reported by veterans not receiving VA care and nonveterans. In addition to health care, nearly one-fourth of veterans with diabetes also received monthly awards for compensation and pension. CONCLUSIONS: Males receiving VA care with self-reported diabetes indicated receiving preventive care services at equivalent or higher levels than their counterparts receiving care outside the VA and nonveterans.

The relationship between provider coordination and diabetes-related foot outcomes.

OBJECTIVE: To investigate the relationship between provider coordination and amputations in patients with diabetes. RESEARCH DESIGN AND METHODS: The study design was a cross-sectional, descriptive study of process and outcomes for diabetes-related foot care at 10 Department of Veterans Affairs (VA) medical centers representing different geographic regions, population densities, patient populations, and amputation rates. The subjects included all providers of diabetes foot care and a random sample of primary care providers at each medical center. The main outcome measures were the Foot Systems Assessment Tool (FootSAT), nontraumatic lower extremity amputation rates, and investigators' ordinal ranking of site effectiveness based on site visits. RESULTS: The survey response rate was 48%. Scale reliability, as measured by Cronbach's alpha, ranged from 0.73 to 0.93. The scale scores for programming coordination (i.e., electronic medical record, policies, reminders, protocols, and educational seminars) and feedback coordination (i.e., discharge planning, quality of care meetings, and curbside consultations) were negatively associated with amputation rates, suggesting centers with higher levels of coordination had lower amputation rates. Statistically significant associations were found for programming coordination with minor amputations (P = 0.02) and total amputations (P = 0.04). CONCLUSIONS: The FootSAT demonstrated a stronger association with amputation rates than site visit rankings. Among these 10 VA facilities, those with higher levels of programming and feedback coordination had significantly lower amputation rates.