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308 Diabetes Care Volume 39, February 2016

Medha N. Munshi,1 Hermes Florez,2

Management of Diabetes in Long- Elbert S. Huang,3 Rita R. Kalyani,4
Maria Mupanomunda,5
term Care and Skilled Nursing Naushira Pandya,6 Carrie S. Swift,7
Tracey H. Taveira,8 and Linda B. Haas9
Facilities: A Position Statement of
the American Diabetes Association
Diabetes Care 2016;39:308–318 | DOI: 10.2337/dc15-2512

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 Beth Israel Deaconess Medical Center and Joslin
diabetes management at end of life and in those receiving palliative and hospice Diabetes Center, Harvard Medical School, Bos-
ton, MA
care. The integration of diabetes management into LTC facilities is important and 2
Geriatric Research Education and Clinical Cen-
requires an interprofessional team approach. To facilitate this approach, accep- ters, Miami Veterans Affairs Healthcare System
tance by administrative personnel is needed, as are protocols and possibly system and University of Miami, Miami, FL
Section of General Internal Medicine, The Uni-
changes. It is important for clinicians to understand the characteristics, challenges,
versity of Chicago, Chicago, IL
and barriers related to the older population living in LTC facilities as well as the 4
Johns Hopkins University School of Medicine,
proper functioning of the facilities themselves. Once these challenges are identified, Baltimore, MD
individualized approaches can be designed to improve diabetes management while American Diabetes Association, Alexandria, VA
Department of Geriatrics, Nova Southeastern
lowering the risk of hypoglycemia and ultimately improving quality of life. University College of Osteopathic Medicine, Ft.
Lauderdale, FL
The epidemic growth of type 2 diabetes in the U.S. has disproportionately affected the Kadlec Regional Medical Center, Richland, WA
University of Rhode Island College of Pharmacy,
elderly. In 2012, the prevalence of diabetes among people aged $65 (25.9%) was more Providence, RI
than six times that of people aged 20–24 years (4.1%) (1). In the long-term care (LTC) 9
Private Consultant, Seattle, WA
population, the prevalence of diabetes ranges from 25% to 34% across multiple studies Corresponding author: Medha N. Munshi,
(2–4). The high prevalence of diabetes among older adults has contributed to the
unsustainable growth of health care costs in the U.S. The estimated total cost of The position statement was reviewed and ap-
diabetes in 2012 was $245 billion. Average medical expenditures for people with proved by the Professional Practice Committee
diagnosed diabetes were 2.3 times higher than among people without diabetes. LTC in November 2015 and approved by the Execu-
tive Committee of the Board of Directors in
costs for people with diabetes were estimated at $19.6 billion in 2012 (5).
November 2015.
The high prevalence of diabetes in older adults is due to age-related physiological
© 2016 by the American Diabetes Association.
changes, such as increased abdominal fat, sarcopenia, and chronic low-grade inflam- Readers may use this article as long as the work
mation, that lead to increased insulin resistance in peripheral tissues and relatively is properly cited, the use is educational and not
impaired pancreatic islet function (6). Diabetes increases the risk of cardiovascular and for profit, and the work is not altered. Munshi and Associates 309

microvascular complications but also in-

managing finances, housework).

ADL, activities of daily living (such as bathing, toileting, eating, dressing, transferring); IADL, instrumental activities of daily living (such as cooking, taking medications, traveling, using the telephone, shopping,

Major challenges

Diabetes self-care

Diabetes treatment
Diabetes self-care

Ability to perform ADL


Caregiver support

General characteristics

Table 1—Characteristics of older adults and their diabetes management based on living situation
creases the risk of common geriatric syn-

education needs


and/or IADL
dromes, including cognitive impairment,
depression, falls, polypharmacy, persis-
tent pain, and urinary incontinence (7,8).
The older diabetes population is highly
heterogeneous in terms of comorbid ill-
nesses and functional impairments. These

c Acute illnesses cause fluctuations in

c Best achievable without risk of

c Independent or adequate

characteristics have frequently been used

Medically stable
cognitive and/or physical status

Frequent education and reeducation


Usually independent



Independent living
Community-dwelling patients
to exclude older individuals from random-
ized clinical trials. The heterogeneity of
the population and the lack of clinical trial
data represent challenges to determining
standardized intervention strategies that
can work for all older adults with diabetes.
As the vast majority of the patients with
diabetes in LTC facilities have type 2 di-
abetes, most recommendations in this po-
sition statement are directed toward that

c Blood glucose monitoring and/or

c Based on comorbidities and

c Support of IADL

population. However, we have suggested
Inadequate diabetes education for
not provided
insulin injection assistance usually

Frequent education and reeducation


May need assistance

Partial dependence
Variable medication management

Partially ADL/IADL dependent

specific recommendations for patients
with type 1 diabetes when appropriate.

Assisted living facilities

c Management of diabetes among
older adults residing in LTC facilities
is challenging due to heterogeneity
in this population. Careful evalua-
tion of comorbidities and overall
c Failure to switch to

health is needed before develop-
prehospitalization regimen at

Education prior to discharge

Optimal control for
Temporary assistance

Temporary dependence

Temporary supervision

Acutely ill
ing goals and treatment strategies

Hospitalized inpatients
for diabetes management. E
c Diabetes management in LTC pa-
tients (residents) requires differ-
ent approaches because of unique
challenges faced by this population
and the workings of LTC facilities. E

Need for Different Approaches for

LTC Population
c New or complex regimen c Inadequate diabetes

c Need to be able to perform c Erratic intake of food and

c Education prior to

c Variable with potential for

c Admitted for

The challenge of caring for older adults

home management
might be too difficult for

self-care after discharge


Optimal control for
Partial assistance


Full or partial
Probable home discharge

Skilled nursing facility

with diabetes arises not only from their

clinical heterogeneity but also from their
considerable variability in living arrange-
ments and social support, which signifi-
cantly impacts diabetes management.
Some older adults live independently,
some in assisted care facilities that pro-
vide partial support with medical man-

c Variation in practitioner

c Lack of diabetes-specific
c Time constraints
c Staff turnover

c Ongoing staff education at


Nursing facility (long-term)

Excessive use of SSI


education for staff

ADL dependence

all levels of care

Avoid severe hypo- and


Full or partial

Chronically ill

agement, and some in fully supervised

LTC facilities. As the challenges and
self-care responsibilities change in these
different environments, different recom-
mendations are needed for each setting
on how to manage diabetes in individual
patients (Table 1). The management
strategies for community-dwelling and
hospitalized patients with diabetes
310 Position Statement Diabetes Care Volume 39, February 2016

have been previously described by the Other Guidelines leading limiting factor in the glycemic
American Diabetes Association (ADA) Along with the AMDA guidelines, guide- management of type 1 and insulin-treated
(9,10). lines from the ADA, the International As- type 2 diabetes (14–16). Multiple fac-
sociation of Gerontology and Geriatrics tors increase the risk of hypoglycemia in
Current Literature in Management of (IAGG), and the European Diabetes Work- older adults, including impaired renal
Diabetes in LTC Patients ing Party for Older People (EDWPOP) function, slowed hormonal regulation
Several organizations have developed have provided selective guidance for LTC and counterregulation, variable appetite
diabetes guidelines for patients living populations. The ADA consensus panel and nutritional intake, polypharmacy, and
in LTC settings. Almost all of these identified the challenges of caring for pa- slowed intestinal absorption (17). The
guidelines emphasize the need to indi- tients in LTC facilities, such as irregular strongest predictors of severe hypoglyce-
vidualize care goals and treatments re- and unpredictable meal consumption, in- mia have been found to be advanced age,
lated to diabetes, the need to avoid adequate staffing, and frequent transitions recent hospitalization, and polypharmacy
sliding scale insulin (SSI) as a primary in care (9). Additionally, the IAGG and (18,19), all of which are common in the
means of regulating blood glucose, EDWPOP have called to reduce the preva- LTC population.
and the importance of providing ade- lence and burden of pressure ulcers (13). Advanced age is associated with higher
quate training and protocols to LTC staff Building on a core set of principles from rates of cognitive dysfunction, causing
who may be operating without the these guidelines, this position statement difficulty in carrying out complex care ac-
presence of a practitioner for prolonged elaborates on unique features of diabetes tivities such as glucose monitoring and
periods. management in patients in LTC facilities adjustment of insulin doses. Impaired re-
The American Medical Directors and provides practical strategies to the nal function and reduced hepatic enzyme
Association Guidelines clinical staff caring for them. activity may interfere with the metabo-
The most extensive guideline available was lism of sulfonylureas and insulin, thereby
developed by the American Medical Direc- potentiating their hypoglycemic effects.
tors Association (AMDA) (11). These guide- Recommendations Age-related decrease in b-adrenergic re-
lines include a 12-step program for LTC c Hypoglycemia risk is the most im- ceptor function and defective glucose
staff that comprises all phases of diabetes portant factor in determining glyce- counterregulatory hormone responses
care from diabetes detection to institu- mic goals due to the catastrophic increase the vulnerability of older adults
tional quality assessment. The glucose- consequences in this population. B to severe hypoglycemia (6). The present-
lowering steps advocated by the AMDA c Simplified treatment regimens are ing symptoms of hypoglycemia in older
are consistent with those published in the preferred and better tolerated. E adults can be primarily neuroglycopenic
ADA position statement on patient- c Sole use of SSI should be avoided. C (confusion, delirium, dizziness) rather
centered individualized approaches to c Liberal diet plans have been asso- than adrenergic (palpitation, sweating,
glucose lowering in adults with diabetes ciated with improvement in food tremors) (20). The presence of cognitive
(12). In terms of A1C goals, the AMDA and beverage intake in this popu- impairment coupled with hypoglycemia
guidelines are also consistent with those lation. To avoid dehydration and unawareness puts some older adults
recommended in the 2012 ADA consen- unintentional weight loss, restric- with diabetes in LTC facilities at increased
sus report (9). To achieve goals, it is ac- tive therapeutic diets should be risk because they may not recognize
knowledged that the notion of a “diabetic minimized. B and/or fail to communicate hypoglycemia
diet” is outdated and that a more liberal c Physical activity and exercise are to their caregivers. Additionally, caregivers
diet may be appropriate among LTC important in all patients and should may not recognize that symptoms such
patients. The guidelines are fairly nonspe- depend on the current level of the as confusion, delirium, and dizziness may
cific with regard to choice of glucose- patient’s functional abilities. C be related to hypoglycemia.
lowering agents but advise practitioners
to avoid the use of SSI and to transition to Establishing the goals of care and man- Hyperglycemia
scheduled basal insulin (and prandial as agement strategies for an individual in Although much attention is rightly fo-
required) shortly after admission. Beyond the LTC setting requires an acknowledg- cused on hypoglycemia, persistent
these long-term goals of care, the AMDA ment of heterogeneity in terms of stage hyperglycemia increases the risk of de-
guidelines provide recommendations to of disease, complications, comorbidities, hydration, electrolyte abnormalities,
LTC staff regarding when to call a practi- self-care ability, life expectancy, and risk urinary incontinence, dizziness, falls, and
tioner (11). The guidelines recommend of adverse drug events (2–4). The most hyperglycemic hyperosmolar syndrome.
that LTC facilities develop their own important aspects of developing goals The 2012 ADA consensus report states
facility-specific policies and procedures and strategies for a patient residing in that goals that minimize severe hypergly-
for hypoglycemia treatment. These LTC are described below. cemia are indicated for all patients (9).
guidelines emphasize that frail patients Thus, glycemic goals for patients in LTC
with cognitive impairment may present Hypoglycemia are guided by preventing hypoglycemia
with atypical symptoms, mainly neuro- Care goals should be established at the while avoiding extreme hyperglycemia.
glycopenic or behavioral in nature. The time of admission to the LTC facility for Table 2 provides a framework for consid-
unique needs of patients with diabetes all chronic conditions. Glycemic goals in ering treatment goals for patients living in
who are terminally ill or have limited life particular are dependent on the patient’s different settings, facing distinct clinical
expectancy are also discussed. risk of hypoglycemia. Hypoglycemia is the circumstances. Munshi and Associates 311

Table 2—Framework for considering diabetes management goals

Fasting and
premeal blood
Special considerations Rationale A1C glucose targets Glucose monitoring
Community-dwelling c Rehabilitation c Need optimal glycemic c Avoid relying on c 100–200 mg/dL c Monitoring frequency
patients at skilled potential control after recent A1C due to based on complexity of
nursing facility for c Goal to discharge acute illness recent acute regimen
short rehabilitation home illness
c Follow current
glucose trends
Patients residing c Limited life expectancy c Limited benefits of c ,8.5% c 100–200 mg/dL c Monitoring frequency
in LTC c Frequent changes intensive glycemic (69 mmol/mol) based on complexity of
in health impacting control c Use caution in regimen and risk
glucose levels c Focus needs to be interpreting A1C of hypoglycemia
on better quality due to presence
of life of many
that interfere
with A1C levels
Patients at end c Avoid invasive c No benefit of c No role of A1C c Avoid c Monitoring
of life diagnostic or glycemic control symptomatic periodically only to
therapeutic except avoiding hyperglycemia avoid symptomatic
procedures that symptomatic hyperglycemia
have little benefit hyperglycemia

Strategies to Improve Diabetes agents are now available; Table 4 out- undernutrition, which is the opposite
Management lines the advantages, disadvantages, and of the desired outcome. In response,
The clinical complexity and functional caveats in using common glucose-lowering LTC facilities have shifted away from
and psychosocial heterogeneity of the agents in the LTC population. therapeutic diets, offering a wider vari-
older population in LTC facilities require ety of food choices, addressing personal
innovative thinking and individualized SSI food preferences, and providing dining
strategies to care for them (7,21–24). Across existing guidelines, one consis- options in regard to time and type of
Certain conditions such as cognitive dys- tent recommendation is to avoid the meals. Liberal diets have been associ-
function, depression, physical disabil- sole use of SSI, which was recently ated with improvement in food and bev-
ities, eating problems, and repeated added to the Beers Criteria for Poten- erage intake in the LTC population to
infections are commonly found in the tially Inappropriate Medication Use in better meet caloric and nutrient re-
LTC population. Moreover, patients in Older Adults (25). Unfortunately, it is quirements (27). While carbohydrate in-
LTC are now more likely to undergo customary in most facilities to check take should be taken into consideration,
invasive interventions and treatments premeal and bedtime blood glucose lev- “no concentrated sweets” or “no sugar”
such as gastrostomies for enteral feed- els and to rely on the sole use of SSI or diet orders are ineffective for glycemic
ing, hemodialysis, prolonged courses either oral agents or basal insulin ac- management and should not be recom-
of intravenous antibiotics, advanced companied by SSI as the primary means mended. Instead, a consistent carbohy-
wound care treatments, and even to control blood glucose. Persistent SSI drate meal plan that allows for a wide
chronic ventilator management. Possi- use leads to wide blood glucose excur- variety of food choices (e.g., general
ble strategies to manage diabetes in sions. It is also a burden for patients and diet) may be more beneficial for both
some of these clinical presentations requires significant nursing time and nutritional needs and glycemic control
are described in Table 3. resources (26). However, there is no in patients with type 1 diabetes or
clearly defined practical guide to switch type 2 diabetes on mealtime insulin.
Medication Management patients who are admitted to LTC from
Glucose-lowering medications also re- SSI to basal–bolus insulin. Table 5 pro- Enteral Nutrition Support
quire attention to comorbid conditions vides strategies to convert insulin treat- Diabetes-specific enteral nutrition for-
and other medications to avoid side ef- ment from an SSI-based regimen to mulas (DSFs) (e.g., Glucerna, Glytrol,
fects and drug interactions. Unlike in scheduled insulin therapy. Diabetisource AC) are available to
older adults living in the community, in- help to manage glycemic excursions
sulin injections for individuals in LTC are Improving Nutrition Health during tube feedings. These formulas
usually given by the facility staff. How- Historically, therapeutic “diabetic” diets generally have lower carbohydrate
ever, risk of hypoglycemia remains high have been prescribed to older adults in and higher monounsaturated fat con-
with insulin in this population, especially the LTC setting. There is growing evi- tent compared with standard formulas
due to irregular eating patterns, evolving dence that such therapeutic diets may (SFs). Randomized controlled trials
health status, and the inappropriate use inadvertently lead to decreased food in- have found DSFs favorable to SFs for
of SSI. Many other glucose-lowering take, unintentional weight loss, and blood glucose management. However,
312 Position Statement Diabetes Care Volume 39, February 2016

Table 3—Commonly found comorbidities in LTC and strategies to improve diabetes care
Clinical presentation that may interfere
with diabetes management Possible strategies to manage diabetes
Confusion, cognitive dysfunction, c Irregular dietary intake or skipped meals c Offer a regular diet and preferred food items
delirium c Refusal of blood glucose monitoring c Offer food substitutions if meal intake is ,75%
c Refusal of medications or injections c Administer prandial insulin immediately after
meals to match carbohydrate intake to avoid
c Block testing (monitoring at different times of the
day to identify patterns, e.g., checking fasting
glucose on some days, prelunch or predinner on
other days) to provide pattern without multiple
daily checks
c Increase glucose monitoring during acute mental
status or behavior changes
c Switch to a long-acting form of oral medications
that can be given once daily or to crushed or liquid
c Switch to mixed insulin to decrease daily injections,
although hypoglycemia risk will remain high
Depression c Not interested in activities c Assess and treat depression
c Weight loss, refusal to eat c Encourage physical activity as possible
c Excessive intake of sugary foods c Encourage socialization, especially during meals

Physical disability c Unable to exercise c Encourage activity that patient can perform, e.g.,
c High risk of deconditioning and pressure ulcers exercise pedals for non–weight-bearing patients
c Require assistance with food and fluid intake c Assessment for pressure ulcers
c High risk of functional disability c Encourage ADL independence

Excessive skin problems, e.g., infections, c Causes hyperglycemia c Nutrition consult

ulcers, delayed wound healing c Anorexia, poor dietary intake c More frequent glucose monitoring and temporary
c May decrease physical activity regimen intensification
c Exercises appropriate for non–weight-bearing
c Regular skin checks and foot assessments by
nursing staff
Hearing and vision problems c Decreased hearing can lead to isolation and c Continue hearing and vision screening and
depression preventive strategies if feasible
c Low vision has large impact on quality of life

Oral health problems, teeth decay, c High risk of infection c Regular oral health evaluations and cleaning
dry mouth c Weight loss due to loss of chewing ability c Ensure appropriate daily oral care
c Loss of taste sensation

ADL, activities of daily living (such as bathing, toileting, eating, dressing, transferring).

this recommendation about DSFs re- balance, and overall strength are impor-
plan, activity levels, prior treatment
mains controversial in the LTC popu- tant for all patients in LTC facilities.
regimen, prior self-care education,
lation (28,29). Nutrition goals should
DIABETES MANAGEMENT DURING laboratory tests (including A1C, lip-
be guided by, among other things,
TRANSITIONS OF CARE ids, and renal function), hydration
the patient’s prognosis and expressed
status, and previous episodes of hy-
preferences and include a discussion Recommendations
poglycemia (including symptoms
with the patient and family whenever c Care transitions are important
and patient’s ability to recognize
possible. times to revisit diabetes manage-
and self-treat). E
ment targets, perform medication
Physical Activity
reconciliation, provide patient and
Frailty, fear of falls, inadequate staff su- Transitions from the hospital or home to
caregiver education, reevaluate the
pervision, and lack of incentives act as LTC, transitions across care settings in LTC
patient’s ability to perform diabetes
barriers to regular physical activity for facilities, changes in providers, and dis-
self-care behaviors, and have close
patients in the LTC facility. However, charges to the community setting are
communication between transfer-
physical activity should be encouraged high-risk times for patients with diabetes.
ring and receiving care teams to
in all individuals to improve indepen- For older adults with diabetes, especially
ensure patient safety and reduce
dence, functionality, and quality of life. those with complex comorbidities, lim-
readmission rates. E
The type of activity recommended ited health literacy, cognitive impairment,
c At the time of admission to a facility,
should depend on the patient’s current five or more prescribed medications, or
transitional care documentation
level of activity and ability. Programs end-of-life care, the risk for adverse out-
should include the current meal
to enhance mobility, endurance, gait, comes during these care transitions is Munshi and Associates 313

Table 4—Advantages, disadvantages, and caveats in using glucose-lowering agents in LTC population
Advantages Disadvantages Caveats in LTC population
Biguanides c Low hypoglycemia risk c Many contraindications in population c Can be used until estimated glomerular
with high comorbidity burden filtration rate is ,30 mL/min/1.73 m2
Metformin c Low cost c May cause weight loss or c Extended release formulation has lower
c Known side effects gastrointestinal upset in frail patients complexity and fewer gastrointestinal
c Established safety record side effects
c Assess for vitamin B12 deficiency

Sulfonylureas c Low cost c High risk of hypoglycemia c Avoid if inconsistent eating pattern
c Glyburide has the highest risk of c Careful glucose monitoring during acute
hypoglycemia and should be avoided illness or weight loss
c Consider discontinuing if already on
substantial insulin dose (e.g., .40
Meglitinides c Short duration of action c Can be held if patient refuses to eat c Some risk of hypoglycemia
c Increased regimen complexity due to
multiple daily mealtime doses
TZDs c Low hypoglycemia risk c Many contraindications in population c Less concern for bladder cancer if
c Low cost with high comorbidity burden shorter life expectancy
c Can be used in renal impairment

DPP-4 c Low hypoglycemia risk c High cost c Can be combined with basal insulin for a
inhibitors c Once-daily oral medication c Lower efficacy low complexity regimen
SGLT2 c Low hypoglycemia risk c High cost c Watch for increased urinary frequency,
inhibitors c Limited evidence in LTC population incontinence, lower blood pressure,
genital infections, and dehydration
GLP-1 c Low hypoglycemia risk c High cost c Monitor for anorexia and weight loss
agonists c Once-daily and once-weekly formulation c Injection
Insulin c No ceiling effect c High risk of hypoglycemia c Basal insulin combined with oral agents
c Many different types can be used to c Matching carbohydrate content with may lower postprandial glucose while
target hyperglycemia at different prandial insulin if variable appetite reducing hypoglycemia risk and regimen
times of the day complexity
c Continue basal–bolus regimen in patients
with type 1 or insulin-deficient type 2
DPP-4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide 1; SGLT2, sodium–glucose cotransporter 2; TZDs, thiazolidinediones.

even greater (30,31). Transitional care is between inpatient and outpatient pro- of SSI after admission or transfer back to
defined as “actions that ensure coordina- viders and a lack of an effective commu- the LTC facility is a long-standing problem
tion and continuity of care and are based nication infrastructure contribute to poor for patients with diabetes (26).
on a comprehensive care plan” (32). patient outcomes (35,36). Often neither the provider responsi-
Poorly executed transitional care can re- ble for the patient’s care nor the consul-
sult in significant financial burdens for pa- Challenges in Transition Care ting pharmacists are present on-site at
tients, payers, facilities, and the U.S. To date, there is no standard transition LTC facilities on a daily basis. Thus, the
health care system as a whole. Prevent- of care document with all the needed need to obtain further testing or outpa-
able costs occur because of unnecessary information for diabetes management tient follow-up may not be adequately
rehospitalizations, inconsistent patient that accompanies a patient from one communicated or coordinated by the
monitoring, duplicative tests, medication setting to another (30). Discharge sum- LTC providers (38). Furthermore, the
errors, delays in diagnosis, and lack of maries often lack crucial information lack of a readily available complete in-
follow-through on referrals (33,34). such as diagnostic test results, treat- terprofessional care team may present
Transitions in care indicate that a pa- ment or hospital course, discharge challenges for nursing staff providing
tient is undergoing changes in health sta- medications, test results pending at daily care, especially when clarifying
tus, which may include physical and/or discharge, patient or family education, medication orders due to formulary
cognitive function, changes in dietary pat- and follow-up plans (37). Therefore, the conversions or trying to answer ques-
terns, and ability to perform diabetes self- need to restart oral therapies (e.g., met- tions from patients or family members
care behaviors. For example, an older formin), typically discontinued in the in- (30). A pharmacist-provided medication
adult on insulin may experience delirium patient setting, can be overlooked. regimen review may not be readily avail-
as a common complication during and Additionally, pending results, such as able in all assisted living facilities, which
after hospitalization or may require a those regarding renal function after con- increases the risk of medication errors,
change in insulin dose when recuperating trast dye studies are performed, may not unnecessary medications, and potential
from acute illness and as nutritional intake be shared with the LTC facility, leading to drug–drug interactions (e.g., sulfonyl-
improves. Inadequate communication test duplication. In addition, continuance ureas and antibiotics) (39). Another
314 Position Statement Diabetes Care Volume 39, February 2016

Table 5—Strategies to replace SSI in LTC

Current regimen Suggested steps
SSI is the sole mode of insulin treatment c Review average daily insulin requirement over prior
5–7 days
c Give 50–75% of the average daily insulin requirement as basal
c Stop SSI
c Use noninsulin agents or fixed-dose mealtime insulin for
postprandial hyperglycemia
c Consider giving basal insulin in the morning to impact
postprandial hyperglycemia and reduce risk of early-morning
SSI is being used in addition to scheduled basal insulin c Add 50–75% of the average insulin requirement used as SSI to the
existing dose of basal insulin
c Use noninsulin agents or fixed-dose mealtime insulin for
postprandial hyperglycemia
SSI is being used in addition to basal and scheduled meal time insulin c If correction dose is required frequently, add the average
(i.e., correction dose insulin) correction dose before a meal to the scheduled mealtime insulin
dose at the preceding meal. For example, if glucose values are
consistently elevated before lunch or dinner requiring 2–3 unit
corrections, the scheduled breakfast or lunchtime dose of insulin
could be increased by the average correction dose (2 units),
respectively. Similarly, if glucose values are consistently elevated
before breakfast requiring correction doses, the scheduled basal
insulin dose could be increased by the average correction dose used
SSI is used in short term due to irregular dietary intake or due to acute c Short-term use may be needed for acute illness and irregular
illness dietary intake
c As health and glucose levels stabilize, stop SSI and return to
previous regimen as tolerated
Wide fluctuations in glucose levels in patients with cognitive decline and/or c Use scheduled basal and mealtime insulin based on individual
irregular dietary intake on a chronic basis needs with the goal of avoiding hypoglycemia
c May use a simple scale, such as “give 4 units of mealtime insulin if
glucose .300 mg/dL”
c Keep patients hydrated, especially when glucose levels are high
(e.g., .300 mg/dL)

factor contributing to the challenges dur- chronic and progressive nature of type 2 of information, identification of medical
ing care transitions is the lack of a single diabetes or of the possible need to con- home or coordinating clinician, coordina-
clinician taking responsibility for coordina- vert from oral therapies to insulin therapy tion of care across the continuum, national
tion across the continuum of the patient’s despite appropriate dietary intake in pa- standards, and standardized metrics for
overall health care, regardless of setting tients with long-standing illness. Clear quality improvement. The LTC facility
(40). High staff turnover is another issue and direct communication of treatment should have processes in place for planned
that may affect the continuity of care of plans and follow-up expectations with pa- and, even more importantly, unplanned
LTC patients (41). Well-designed systems tients and/or caregivers by health care transitions. Several sample admission
of care, thorough documentation, and ap- providers is critical to decrease patient/ and transfer forms are available for down-
propriate communication can help to alle- family barriers. load from the AMDA Web site (http://
viate some of the problems associated
with high staff turnover and meet the Strategies for Successful Transitions These documents include a table that
often complex care needs of patients A successful transition is a process covers the essential information that
with diabetes. Focused, interprofessional whereby senders and receivers validate should accompany every transitioning pa-
quality improvement initiatives have been the transfer, accept the information, tient, an AMDA Universal Transfer Form,
shown to decrease hypoglycemia rates clarify any discrepancies, and act on the Recommended Elements of a Dis-
and improve processes of diabetes care the information to ensure a smooth charge or Course-of-Treatment Summary,
in skilled nursing facilities (42). and safe transition of care (32). The Practitioner Request for Notification of
AMDA clinical practice guidelines have Medication Changes, and an Example
Patient-Level Factors identified a series of steps, potential of a Skilled Nursing Facility-to-Emergency
Barriers at the patient or family level may barriers, and strategies for management Department transition. In addition, Wagle
include limited disease state knowledge at system and provider levels as well as (44) provides a sample form using an elec-
and erroneous or unrealistic expectations. the patient level (32,43). At the system and tronic medical record. Using these forms
For example, some patients or family provider level, there is a focus on account- can facilitate the development of a pro-
members may not be aware of the ability, communication, timely interchange cess for the transition of patients and Munshi and Associates 315

improve safety and quality of diabetes of geriatric syndromes and comorbid- consideration when the patient has
care. At the patient level, improvement ities, and 3) life expectancy. These pa- limited life expectancy. The Interna-
is recommended for advocacy and social tients tend to have compromised self-care tional Diabetes Federation (IDF) guideline
support, disease state knowledge, em- due to end-stage disease itself in addi- describes management of blood pres-
powerment and self-efficacy, health tion to fatigue and drowsiness from sure, lipids, and foot care at end of
literacy/fluency, and cognitive status. medicines. In addition, it is important life in patients with diabetes (http://
to respect the patient’s right to refuse
DIABETES MANAGEMENT IN treatment as well as to consider religion Guideline-for-older-people-T2D.pdf).
PATIENTS AT END OF LIFE and cultural traditions, including the Pain is an important component of
(INCLUDING ISSUES FOR care of the body after death. end-of-life management. Pain could be
PALLIATIVE CARE AND HOSPICE Strategies for diabetes management related to diabetes complications and
PATIENTS) may include relaxing glycemic targets, comorbidities, such as peripheral neu-
Recommendations simplifying regimens, using low-risk ropathy, depression, falls, trauma, skin
c Goals for diabetes management at glucose-lowering agents, providing edu- tears, and periodontal disease, and
end of life need to focus on pro- cation on recognition of hypoglycemia, should be well managed (49). For those
moting comfort; controlling dis- and enhancing communication strate- with evidence of cognitive dysfunction,
tressing symptoms (including pain, gies. Several conditions may result in hy- end-of-life planning and a communication
hypoglycemia, and hyperglycemia); poglycemia (anorexia–cachexia syndrome strategy should be undertaken while the
avoiding dehydration; avoiding from chemotherapy and opiate analge- individual can still make rational deci-
emergency room visits, hospital ad- sics, malnourishment, swallowing disor- sions. Meal plans that avoid weight loss,
missions, and institutionalization; ders). Therefore, it is important to have nonpharmacological options to prevent
and preserving dignity and quality timely discussions about nutritional sup- or manage behavioral problems, and
of life. E port, advance directives, and ethical is- timely identification and management
c Decreasing complexity of treat- sues, involving the patient, family, and of depression should be used to improve
ment and a higher threshold for caregivers in the decision process. the quality of remaining life.
additional diagnostic testing in- Diabetes management in patients
Glucose Monitoring
cluding capillary monitoring of glu- with advanced cancer presents unique
It is not always possible to decrease the
cose should be considered. E challenges. Specific recommendations
frequency of capillary glucose monitoring
c It is important to respect a patient’s for management of hyperglycemia, hy-
in patients with type 1 diabetes. How-
right to refuse treatment and with- poglycemia, corticosteroid use, and ed-
ever, in most patients residing in LTC
draw oral hypoglycemic agents ucation for patients and families are
facilities with type 2 diabetes, a high
and/or stop insulin if desired during well described in a recent guideline (50).
frequency of capillary monitoring of
the end-of-life care. E blood glucose should only be considered
Treatment Strategies
under special circumstances (e.g., starting
Simplified treatment regimens are gener-
corticosteroids) and where the danger of
Overall Strategy to Manage Diabetes ally recommended. Common reasons for
hypoglycemia is particularly high (e.g.,
Concerns about diabetes management at overly tight glycemic control in hospice
with significant nutritional problems).
end of life have been reported by pro- patients were found to be 1) discomfort
Capillary monitoring of blood glucose
viders (45), but until fairly recently, no with discussions about reducing or stop-
could vary from twice daily to once every
guidelines were available. Dunning et al. ping chronic medications, 2) concern
3 days depending on the patient’s condi-
(46) proposed the development of one of about mild hyperglycemia especially by
tion. Oral glucose-lowering agents are
the first clinical practice guidelines for patients and caregivers, and 3) worry
preferred, as are simplified insulin regi-
diabetes and end-of-life care (47). Early iden- about not achieving quality indicators
mens with a low hypoglycemic risk and
tification of patients who require end-of- for glycemic control (51). To address
avoidance of complex regimens with
life care is critical. Despite the reported these issues, it is important to educate
higher treatment burden, to reduce the
increase in the rate of palliative care en- patients, families, and other providers
risk of adverse effects and medication er-
rollment over the past 2 decades, about about the fact that Healthcare Effective-
rors (48). Tables 4 and 5 provide addi-
one-third of patients have been enrolled ness Data and Information Set (HEDIS)
tional information on insulin therapy. In
within last 2 weeks of their lives, prevent- measures do not apply to hospice pa-
some patients, agents that might cause
ing them from receiving the full benefits of tients and that it is acceptable to keep
nausea, gastrointestinal disturbance, or
palliative care services. One way to im- blood glucose levels between 200 and
excess weight loss (e.g., metformin or glu-
prove the timely identification of patients 300 mg/dL in hospice patients taking
cagon-like peptide 1 receptor agonist)
that might benefit from earlier enrollment glucose-lowering medication.
may need to be discontinued, while in
in palliative care would be to use diabetes Similarly, Angelo et al. (52) questioned
other patients it may be appropriate to
registries in collaboration with the pallia- the benefit of tight glycemic control and
withdraw therapy, including insulin, dur-
tive care team and primary care services. raised the concern about potential harm
ing the terminal stage.
The therapeutic decisions for diabetes in patients with diabetes approaching the
management at end of life should be Management of Comorbidities end of life. They proposed three strata for
made after consideration of 1) risk of hy- Comorbidities in patients with diabe- management of patients with diabetes
poglycemia and hyperglycemia, 2)presence tes present challenges and special and advanced disease.
316 Position Statement Diabetes Care Volume 39, February 2016

Stable Patients (53) suggested that treatment and mon- necessary (although this may be several
These patients are inclined to simply itoring be stopped in patients with days after an event or change of condi-
continue with their previous regimen. type 2 diabetes once they are in the ter- tion). This system means that patients
Practitioners must use this stage to minal phase, but there was less con- may have uncontrolled blood glucose
begin a dialogue with patients and care- sensus for the management of type 1 levels or wide excursions without the
givers about reducing the intensity of diabetes under similar scenarios. At practitioner being notified. Adjustments
glycemic control. There is very little this point, care is focused on patient to treatment regimens can be made by
role for measuring A1C in these pa- comfort and preparatory bereavement telephone, fax, or order entry into elec-
tients. Patients should be warned and counseling for caretakers and patients, tronic health records. Standing orders
educated about the signs of hypoglyce- where appropriate. for glucose monitoring and practitioner
mia and hypoglycemia unawareness. notification that are approved by the fa-
The acute risks of hyperglycemia as ex- INTEGRATION OF DIABETES cility and the practitioner at the time of
perienced in this stage center mainly on MANAGEMENT INTO LTC admission may be useful.
the risk of a hyperosmolar hyperglyce- FACILITIES
Table 6 delineates the practical rec-
mic state and associated complications, Recommendation ommendations for the LTC staff in man-
such as osmotic diuresis, recurrent in- c Patients admitted to LTC facilities agement of specific situations in patients
fection, and poor wound healing. are not seen daily by a practitioner. with diabetes.
Because of this reality, successful di-
Patients With Organ Failure
abetes care needs to include a ded- Challenges for Facilities and Staffing
As patients move into this phase, the
icated interprofessional team. This Pandya and Patel (54) have described the
importance of glycemic control is less
team may be composed of practi- challenges in managing diabetes in post-
apparent and preventing hypoglycemia
tioners (physicians, nurse practi- acute and LTC settings. The challenges
is of greater significance. Patient and
tioners, and physician assistants), specific to patients include altered phar-
caregiver education regarding the tell-
registered nurses, licensed practi- macokinetics and pharmacodynamics of
tale signs of dehydration and hypoglyce-
cal/vocational nurses, certified nurs- medications, increased risk of hypogly-
mia and an appropriate plan of action is
ing assistants, diabetes educators, cemia, unpredictable meal consump-
of vital importance. The risk of renal or
dietitians, food service managers, tion, comorbidities such as cognitive
hepatic failure becomes more evident at
consultant pharmacists, physical dysfunction and depression, psycholog-
this stage, and insulin or other glucose-
therapists, and/or social workers. E ical resistance to insulin, impaired vision
lowering medication dosages may need to
and dexterity, and greater potential for
be reduced in both patients with type 1
Patients admitted to LTC facilities are adverse effects and drug interactions.
diabetes and patients with type 2 diabetes.
typically seen by a medical provider at Institutional-level challenges include
Dying Patient least once every 30 days for the first staff turnover and lack of familiarity
Most practitioners in this case would 90 days after admission and at least once with patients, restrictive diet orders,
simply withdraw all oral hypoglycemic every 60 days thereafter. In practice, pa- inadequate review of glucose logs and
agents and stop insulin in most patients tients are seen within the first week of trends, lack of facility-specific diabetes
with type 2 diabetes. Ford-Dunn et al. admission and also when medically treatment algorithms for blood glucose

Table 6—Specific situations needing attention in patients with diabetes in LTC setting
Recommendations for LTC staff for diabetes management*
Glucose meter reading ,70 mg/dL and unresponsive c Treat hypoglycemia per protocol without any delay
Consecutive glucose meter readings ,70 mg/dL c Call practitioner
c Confirm low glucose value by laboratory test
c Evaluate nutritional intake
c Consider an increase in frequency of glucose monitoring for 24 h
c Adjust diabetes regimen as needed

Glucose meter readings .250 mg/dL two or more times within 24-h c Call practitioner
period accompanied by a new or change in medical or functional status c Increase frequency of glucose monitoring
Glucose meter readings .300 mg/dL during all or part of 2 consecutive c Confirm high glucose value by laboratory test
days c Evaluate nutritional intake
Any glucose reading too high to measure by glucose meter c Adjust diabetes regimen as needed
c If glucose levels are persistently high after changes to the diabetes
regimen, consider medical evaluation for other causes (i.e.,
Patient not eating, vomiting, or unable to take oral glucose-lowering c Call practitioner as soon as possible
medications c Consider insulin therapy and adjust dose accordingly based on
nutritional status
*It is more important to address persistently abnormal trends in blood glucose values rather than attempting to adjust the treatment regimen in
response to a few isolated abnormal values. Munshi and Associates 317

levels and provider notifications, and, penalties. Consequently, ensuring a high 4. Resnick HE, Heineman J, Stone R, Shorr RI.
often, lack of administrative buy-in to level of care for patients with diabetes in Diabetes in U.S. nursing homes, 2004. Diabetes
Care 2008;31:287–288
promote the roles of the medical direc- LTC facilities is also necessary for compli- 5. American Diabetes Association. Economic
tor, the director of nursing, and the con- ance with federal regulations. costs of diabetes in the U.S. in 2012. Diabetes
sultant pharmacist. Challenges specific Care 2013;36:1033–1046
to staff and practitioners include multi- CONCLUSIONS 6. Kalyani RR, Egan JM. Diabetes and altered
ple changing treatment approaches, Diabetes is a common, morbid, and costly glucose metabolism with aging. Endocrinol
disease in older adults. This population is Metab Clin North Am 2013;42:333–347
lack of team communication, excessive 7. Lu FP, Lin KP, Kuo HK. Diabetes and the risk
reliance on SSI, inappropriate dosing or heterogeneous and presents unique chal- of multi-system aging phenotypes: a systematic
timing of insulin, knowledge deficits, lenges pertaining to diabetes manage- review and meta-analysis. PLoS One 2009;4:
lack of comfort with new insulin and in- ment. It is important for clinicians to e4144
jectable agents, failure of timely step- understand the characteristics, challenges, 8. Munshi M Managing the “geriatric syn-
and barriers related to the older population drome” in patients with type 2 diabetes. Consult
wise advance in therapy, failure to Pharm 2008;23 Suppl. B:12–16
individualize care, and therapeutic nihil- living in LTC facilities. This understanding 9. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes
ism. It requires a dedicated interprofes- requires knowledge of the patient popula- in older adults. Diabetes Care 2012;35:2650–2664
sional team composed of registered tion as well as the functioning of the facil- 10. Moghissi ES, Korytkowski MT, DiNardo M,
nurses, certified nursing assistants, dia- ities. Once the challenges are identified, et al.; American Association of Clinical Endocri-
individualized approaches can be designed nologists; American Diabetes Association.
betes educators, dietitians, food service American Association of Clinical Endocrinolo-
managers, consultant pharmacists, to improve diabetes management while gists and American Diabetes Association con-
physical therapists, social workers, and lowering the risk of hypoglycemia and sensus statement on inpatient glycemic
practitioners to manage older patients ultimately improving quality of life. control. Diabetes Care 2009;32:1119–1131
with diabetes in LTC facilities. 11. Agency for Healthcare Research and Qual-
ity. Diabetes management in the long term care
setting [Internet], 2010. Available from http://
Monitoring the Facility’s Management Acknowledgments. The authors acknowledge
Dr. Jane L. Chiang’s invaluable editorial contri-
of Diabetes Accessed 30 June 2015
bution throughout the development of this
In order to assess and improve facility- 12. Inzucchi SE, Bergenstal RM, Buse JB, et al.
position statement.
wide management of diabetes directed Management of hyperglycemia in type 2 diabe-
Funding. E.S.H. is supported in part through the
tes, 2015: a patient-centered approach: update
by multiple practitioners, the facility following grants: Midcareer Investigator Award
to a position statement of the American Diabe-
leadership (e.g., the director of nursing, in Patient-Oriented Research (K24 DK105340),
tes Association and the European Association
the Chicago Center for Diabetes Translation
nurse managers, medical director, and for the Study of Diabetes. Diabetes Care 2015;
Research (P30 DK092949), and a project grant
consultant pharmacist) should collect 38:140–149
(R01 HS018542). R.R.K. is supported in part by a
data and trends and plan strategies to 13. Sinclair A, Morley JE, Rodriguez-Ma~ nas L,
grant from the National Institute of Diabetes and
et al. Diabetes mellitus in older people: position
improve selected process or outcome Digestive and Kidney Diseases (K23-DK093583).
statement on behalf of the International Asso-
indicators relevant to diabetes manage- N.P. is supported by the Health Resources and
ciation of Gerontology and Geriatrics (IAGG),
Services Administration (HRSA) of the U.S. De-
ment. These could include sharing data partment of Health and Human Services (HHS)
the European Diabetes Working Party for Older
with managerial staff, providing staff People (EDWPOP), and the International Task
under grant number UB4HP19211 “Geriatric
education, and planning a performance Education Centers.” Force of Experts in Diabetes. J Am Med Dir Assoc
This information or content and conclusions are 2012;13:497–502
improvement project. In general, the fa- 14. Huang ES, Laiteerapong N, Liu JY, John PM,
cility medical leadership and nursing ad- those of the authors and should not be construed
as the official position or policy of, nor should any Moffet HH, Karter AJ. Rates of complications
ministration have the opportunity to endorsements be inferred by, HRSA, HHS, or the and mortality in older patients with diabetes
develop and implement patient care U.S. Government. mellitus: the diabetes and aging study. JAMA
policies that can facilitate optimal man- Duality of Interest. M.N.M. is a consultant for Intern Med 2014;174:251–258
Sanofi and Novo Nordisk. R.R.K. was an advisory 15. Donnelly LA, Morris AD, Frier BM, et al.;
agement of the older patient with dia- DARTS/MEMO Collaboration. Frequency and
betes and to coordinate efforts with the group member for AstraZeneca as part of a 1-day
meeting. No other potential conflicts of interest predictors of hypoglycaemia in type 1 and
multidisciplinary team. Nursing leader- relevant to this article were reported. insulin-treated type 2 diabetes: a population-
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