Diabetes in Long-Term-Care and Skilled Nursing Facilities: The ADA Position Statement

US Pharm. 2016;41(10)(Diabetes suppl):7-11.

ABSTRACT: As the number of elderly people in the United States continues to rise, an increasing proportion of older adults will develop diabetes and will need long-term or skilled care. In early 2016, the American Diabetes Association issued a position statement on the management of diabetes in long-term-care and skilled nursing facilities. This statement provides recommendations for the general approach to care; goals and strategies for glycemic control; diabetes management during transitions of care and end of life; and suggestions for integration of diabetes management into long-term-care facilities. Pharmacists can play an active role in each of these areas in order to help optimize glycemic control in their patients.

The prevalence of diabetes in the long-term-care (LTC) setting is estimated to range from 25% to 34%,¹ which is equal to or higher than trends seen in the general population. The latest National Diabetes Statistics Report (2014) estimates that, in the United States, 25.9% of persons aged ≥65 years have diabetes, compared with 16.2% of those aged 45 to 64 years and 4.1% of those aged 20 to 44 years.² Among persons aged 65 to 74 years and those aged ≥75 years, there was an increase of 113% and 140%, respectively, in the rate of diagnosed cases of diabetes from 1993 to 2014.³ Diabetes is the seventh leading cause of death in the U.S.² As baby boomers continue to age, the proportion of older adults with diabetes who will need nursing homes (NHs) or skilled care is expected to rise. Pharmacists who serve residents in the LTC environment must be prepared to meet this challenge.

Type 2 diabetes (T2D) accounts for 90% to 95% of diabetes in the U.S. Age-related changes in older adults that predispose them to the T2D development include increased insulin resistance secondary to adiposity, sarcopenia, and physical inactivity; impaired insulin secretion; coexisting illnesses; and greater use of medications that alter insulin sensitivity, insulin secretion, or both.^4-6 Recently, researchers identified two genes, found only in humans, that are associated with age-dependent changes in islet-cell proliferation and function and may contribute to the development of diabetes.⁷

In February 2016, the American Diabetes Association (ADA) released a position statement that consists of 13 recommendations in five key areas and is designed to help improve the management of diabetes in LTC (i.e., NHs) and skilled nursing facilities (SNFs) (TABLE 1).¹ This position statement identifies the need for different approaches to managing diabetes in LTC; discusses the current literature on diabetes management in this setting; provides recommendations on preventing hypoglycemia and hyperglycemia; describes methods to improve diabetes management in the presence of multiple comorbidities; focuses on the advantages, disadvantages, and caveats associated with various pharmacologic treatment options; and recommends avoiding the use of sliding-scale insulin (SSI). It also calls for improved nutritional health and provides assistance with enteral-nutrition support; stresses the role of physical activity (albeit limited in many cases) in managing diabetes; highlights tools to successfully manage transitions of care (TOCs) for patients with diabetes; addresses diabetes management in patients at the end of life (EOL); and makes recommendations for and identifies barriers to integrating diabetes management in the LTC setting. This position statement acknowledges that challenges exist concerning the development of standardized intervention strategies for all older adults with diabetes because of this population’s heterogeneity and the lack of clinical-trial data for this age group.¹ This article will focus on issues identified in the ADA’s position statement that will impact pharmacists servicing LTC residents with diabetes.

General Approach to Care

When a diabetes treatment regimen is being designed, it is important to address comorbidities and health status. LTC and SNF residents may face challenges involving caregiver support, concomitant medical and psychiatric conditions, and functional limitations in activities of daily living (ADLs) and instrumental ADLs, as well as diabetes self-care deficits that can adversely impact blood glucose (BG) management. These issues may be particularly pertinent to SNF residents, whose goal of care is typically to optimize BG control to promote rehabilitation and recuperation with the target of being discharged home. In order to adequately manage diabetes, patients must be able to perform appropriate self-care upon discharge; however, <65% of those aged ≥65 years perform daily BG self-monitoring.⁸ New or complex medication regimens may be too difficult for an older adult to manage at home. Pharmacists can play a major role in preventing readmission of the diabetic patient. NH residents, who are generally more chronically ill than SNF patients, face additional challenges, including erratic food and fluid intake, excessive use of SSI, and administrative barriers (e.g., staff inadequately trained in the management of the older diabetic patient, high staff turnover, time constraints, lack of diabetes-specific protocols, variability in practitioner procedures).¹

The ADA position statement identifies current literature on guidelines for the management of diabetes in LTC patients. These guidelines were previously reviewed by this author.⁹

Goals and Strategies

Additional patient-specific factors to consider in the development of an individualized treatment plan include the disease stage, disease-related complications, life expectancy, and the risk of adverse drug effects. Major concerns with BG management in older adults are hypoglycemia—which is the most important factor in determining glycemic goals—and hyperglycemia.¹

Hypoglycemia and Hyperglycemia: Too often, tight BG control is inappropriately applied to a frail, vulnerable LTC population, resulting in profound hypoglycemia and ADL impairment, falls, arrhythmias, and death.^10-13 Risk factors for developing hypoglycemia include neurologic disease (i.e., stroke, transient ischemic attack, dementia, cognitive impairment), heart failure, depression, sulfonylurea use, insulin, advanced age, impaired renal function, slowed hormonal regulation and counterregulation, decreased hepatic-enzyme activity, reduced beta-adrenergic receptor function, decreased or inconsistent nutritional intake, polypharmacy, recent hospitalizations, and slowed intestinal absorption.^1,14-16 In older adults, hypoglycemia may manifest as confusion, delirium, or dizziness, as opposed to palpitations, sweating and tremor, which occur more commonly in younger patients. Cognitive impairment, dementia, and the use of beta-blockers may further contribute to the underrecognition of hypoglycemia in older adults.¹

Severe hyperglycemia, which may manifest as dehydration, electrolyte abnormalities, urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome, should be minimized in older adults with diabetes.¹ When a hyperglycemic crisis occurs, the death rate among those aged ≥75 years is 14.8 per 100,000 diabetic population.¹⁷

Management Strategies: The ADA position statement provides a framework for considering diabetes-management goals, including glycosylated hemoglobin (HbA_1c) and fasting and premeal glucose targets, based on the patient’s institutional residency, life expectancy, rehabilitative potential, benefit or harm from tight glycemic control, and quality of life. Strategies are also provided on how to manage comorbidities, such as confusion, cognitive dysfunction, delirium, depression, physical disability, skin infections and ulcers, hearing and vision problems, and oral health problems, which may impact diabetes management.¹

Medication Management: The ADA position statement identifies advantages, disadvantages, and caveats for the use of hypoglycemic agents—including biguanides, metformin, sulfonylureas, meglitinides, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, sodium-glucose contransporter-2 inhibitors, glucagon-like peptide-1 agonists, and newer forms of insulin—that must be weighed in this vulnerable population.¹ The sulfonylureas chlorpropamide and glyburide are on the Beers list of potentially inappropriate medications in older adults because, compared with other oral antidiabetic agents (OADAs), they are associated with a higher risk of severe, prolonged hypoglycemia in this population. Furthermore, chlorpropamide use is associated with the development of the syndrome of inappropriate antidiuretic hormone.¹⁸ Alternative OADAs to Beers Criteria medications include short-acting sulfonylureas (such as glipizide and gliclazide) and metformin.¹⁹ Centers for Medicare and Medicaid Services (CMS) regulations for LTC address monitoring and adverse consequences of insulin and oral hypoglycemics. The CMS advises that the use of antidiabetic medication include monitoring (e.g., periodic BG) for effectiveness based on desired goals for that individual and identifying complications of treatment, such as hypoglycemia and impaired renal function. It also recommends that chlorpropamide and glyburide not be used.²⁰

SSI: Avoiding the use of SSI is a consistent recommendation across clinical guidelines. SSI—the sole use of short- or rapid-acting insulins to manage or avoid hyperglycemia in the absence of basal or long-acting insulin—is on the Beers list of potentially inappropriate medications for older adults. According to the Beers Criteria, SSI confers a higher risk of hypoglycemia without improvement in hyperglycemia management. This recommendation, however, does not apply to the use of short- or rapid-acting insulins to titrate basal insulin or to their use in conjunction with a routinely scheduled insulin dosage.¹⁸ The Society for Post-Acute and Long-Term Care Medicine (AMDA) has identified SSI avoidance as one of its “Choosing Wisely” recommendations, which are designed to heighten awareness of potentially inappropriate treatments and procedures. According to the AMDA, SSI is not effective in managing hyperglycemia associated with diabetes because it is reactive, responding only to excursions of BG without addressing basal needs. SSI also is associated with greater patient discomfort, increased nursing time, and heightened risk of hypoglycemia because insulin may be administered without regard to meal intake.²¹ Further, the CMS advises that the continued or long-term need for SSI for nonemergency coverage may indicate inadequate BG control.²⁰ The ADA position statement offers strategies to replace SSI in LTC.

Diet and Physical Activity: A consistent carbohydrate diet is advised over the use of a therapeutic diet or the avoidance of added sugar. Although the use of tube feedings in diabetes may be controversial, there are diabetes-specific enteral-nutrition formulas that can help minimize glucose excursions. These products have a lower carbohydrate content and a higher monounsaturated fat content compared with standard preparations. Physical activity should be encouraged whenever possible, with the goal of enhancing mobility, endurance, gait, balance, and overall strength.¹

Pharmacists can play a major role in minimizing the risk of hypoglycemia and the use of SSI and in the selection of appropriate hypoglycemic therapy based on an individualized, thorough, patient-focused assessment.²²

Diabetes Management During TOCs

During a TOC, it is important to provide coordination and continuity of care that is based on a comprehensive care plan. Unfortunately, there is no standard, all-inclusive guidance to help ensure a smooth and safe transition.¹

Factors that increase the risk of harm occurring during a TOC include the presence of complex comorbidities, limited health literacy, cognitive impairment, polypharmacy, EOL care, lack of availability of an interdisciplinary care team, high staff turnover, absence of a patient-care navigator, and inadequate staff communication during patient transfer. Resultant harm can contribute to unnecessary rehospitalizations, inconsistent patient monitoring, duplication of diagnostic procedures, medication errors, delays in diagnosis, or lack of referral follow-up.¹

The ADA position statement identifies the AMDA clinical practice guidelines as offering assistance in navigating TOCs.²³ These guidelines identify barriers and provide strategies to overcome these obstacles, which exist at system, provider, and patient levels. Sample admission and transfer forms, including Practitioner Request for Notification of Medication Changes, may be found in the AMDA’s Transitions of Care in the Long-Term Care Continuum Clinical Practice Guideline.²⁴

Pharmacist-conducted medication reconciliation and medication therapy management can help fill this vacuum in care. Pharmacists can foster in patients and their families realistic expectations about the management of the patient’s diabetes, enhance disease-state knowledge, and encourage empowerment and self-efficacy.

Diabetes Management in Patients at EOL

Recently, clinical practice guidelines for diabetes at EOL have been developed.^25-27 Factors to consider in creating a diabetes treatment plan for patients at EOL include the risk of hypoglycemia and hyperglycemia; the presence of geriatric syndromes and comorbidities (e.g., malnourishment, swallowing difficulties, anorexia-cachexia syndrome); life expectancy; compromised self-care secondary to fatigue or drowsiness; and religious or cultural traditions. The ADA position paper identifies strategies for diabetes management at EOL that include relaxing glycemic goals; simplifying drug regimens; using low-risk hypoglycemic agents; educating patients on signs and symptoms of hypoglycemia; and enhancing communication strategies. Unless a patient has T1D or is at high risk for experiencing a hypoglycemic or hyperglycemic event (e.g., nutritional problems or starting corticosteroids), the number of capillary glucose readings should be minimized as much as clinically possible. OADA and simplified insulin regimens with a low hypoglycemic risk are preferred. Antidiabetic agents that are associated with nausea, gastrointestinal disturbances, or excessive weight loss may need to be avoided. Consideration may be given to withdrawing insulin during the terminal phase of life.¹

Pain, which may be secondary to diabetes-related complications, should be addressed and relief provided. If present, depression should also be recognized and appropriately managed. Weight loss and problem behaviors should be identified and managed. The patient with diabetes and advanced cancer is at increased risk for hyperglycemia (secondary to corticosteroid use) or hypoglycemia (from chemotherapy-induced nausea).¹

To minimize the risk of hypoglycemia, tight glycemic control should be avoided. Healthcare Effectiveness Data and Information Set (HEDIS) measures do not apply in the hospice setting. BG levels of 200 to 300 mg/dL may be acceptable in hospice patients taking hypoglycemic agents. In the stable hospice patient, there is little need to routinely measure HbA_1c, and glycemic control may be deintensified. For the hospice patient with organ failure, the focus shifts to preventing hypoglycemia. Dosages of insulin and other hypoglycemic agents may need to be decreased owing to renal or hepatic dysfunction. In the dying hospice patient, emphasis is placed on comfort care, and clinicians may consider withdrawing OADAs and/or insulin in most patients with T2D.¹ Pharmacists who serve on hospice and palliative-care teams can assist in the establishment and management of glycemic goals in this population.¹

Integration of Diabetes Management Into LTC Facilities

Patient, institutional, and staff/practitioner-level challenges exist in the postacute and LTC environment that may adversely impact patients’ glycemic control. Because of the lack of continuous medical or interprofessional supervision in this setting, the ADA position statement offers recommendations for LTC staff regarding when interventions are needed, as in the case of an unresponsive hypoglycemic patient, the occurrence of multiple hypoglycemic or hyperglycemic episodes in a resident, any glucose reading that is too high or too low to be read by a glucometer, and  cases when the resident is not eating, is vomiting, or is unable to take oral hypoglycemics.¹ Pharmacists are encouraged to collect data, monitor trends, provide staff education, and develop strategies to help improve glycemic control in the LTC setting.¹

Conclusion

As medication experts, pharmacists play a unique role in the management of a disease state that relies heavily on the use of pharmacotherapy. Given the ever-increasing options in the diabetes armamentarium, pharmacists in the LTC setting can function as an active part of the interprofessional team to optimize residents’ glycemic control and quality of life.

REFERENCES

1. Munshi MN, Florez H, Huang ES, et al. Management of diabetes in long-term care and skilled nursing facilities: a position statement of the American Diabetes Association. Diabetes Care. 2016;39:308-318.
2. CDC. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014.
3. CDC. Rates of diagnosed diabetes per 100 civilian, non-institutionalized population, by age, United States, 1980-2014. www.cdc.gov/diabetes/statistics/prev/national/figbyage.htm. Accessed June 1, 2016.
4. American Diabetes Association. Fast facts: data and statistics about diabetes. http://professional2.diabetes.org/admin/UserFiles/0%20-%20Sean/Documents/Fast_Facts_12-2015a.pdf. Accessed June 1, 2016.
5. Gambert SR, Pinkstaff S. Emerging epidemic: diabetes in older adults: demography, economic impact, and pathophysiology. Diabetes Spectr. 2006;19:221-228.
6. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35:2650-2664.
7. Arda HE, Li L, Tsai J, et al. Age-dependent pancreatic gene regulation reveals mechanisms governing human beta cell function. Cell Metab. 2016;23:909-920.
8. CDC. Age-adjusted percentage of adults aged 18 years or older with diagnosed diabetes performing daily self-monitoring of blood glucose, United States, 1994-2010. www.cdc.gov/diabetes/statistics/preventive/fx_glucose.htm. Accessed June 1, 2016.
9. Lisi DM. Diabetes in the older adult: recommendations for glycemic control. US Pharm. 2014;39(10)(Diabetes suppl):6-10.
10. Basso A, Peruzzi P, Carollo MC, et al. Assessment of glycemic control among diabetic residents in nursing homes. Diabetes Res Clin Pract. 2012;96:e80-e83.
11. Abbatecola AM, Bo M, Armellini F, et al. Tighter glycemic control is associated with ADL physical dependency losses in older patients using sulfonylureas or mitiglinides: results from the DIMORA study. Metabolism. 2015;64:1500-1506.
12. Kachroo S, Kawabata H, Colilla S, et al. Association between hypoglycemia and fall-related events in type 2 diabetes mellitus: analysis of a U.S. commercial database. J Manag Care Spec Pharm. 2015;21:243-253.
13. Abdelhafiz AH, Sinclair AJ. Hypoglycaemia in residential care homes. Br J Gen Pract. 2009;59:49-50.
14. Bramlage P, Gitt AK, Binz C, et al. Oral antidiabetic treatment in type-2 diabetes in the elderly: balancing the need for glucose control and the risk of hypoglycemia. Cardiovasc Diabetol. 2012;11:122.
15. Feil DG, Rajan M, Soroka O, et al. Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr Soc. 2011;59:2263-2272.
16. Abbatecola AM, Bo M, Barbagallo M, et al. Severe hypoglycemia is associated with antidiabetic oral treatment compared with insulin analogs in nursing home patients with type 2 diabetes and dementia: results from the DIMORA study. J Am Med Dir Assoc. 2015;16:349.e7-e12.
17. CDC. Crude and age-adjusted death rates for hyperglycemic crises as underlying cause per 100,000 diabetic population, United States, 1980-2009. www.cdc.gov/diabetes/statistics/mortalitydka/fratedkadiabtotals.htm. Accessed June 1, 2016.
18. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-2246.
19. Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications included in the use of high-risk medications in the elderly and potentially harmful drug–disease interactions in the elderly quality measures. J Am Geriatr Soc. 2015;63:e8-e18.
20. CMS. State operations provider certification. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r22soma.pdf. Accessed June 15, 2016.
21. Choosing Wisely. Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home. www.choosingwisely.org/clinician-lists/amda-sliding-scale-insulin-for-long-term-diabetes-management. Accessed June 1, 2016.
22. Garza H. Minimizing the risk of hypoglycemia in older adults: a focus on long-term care. Consult Pharm. 2009;24(suppl B):18-24.
23. American Medical Directors Association (AMDA). Diabetes Management in the Long Term Care Setting. Columbia, MD: AMDA; 2010.
24. AMDA. Transitions of Care in the Long-Term Care Continuum Clinical Practice Guideline. Columbia, MD: AMDA; 2010.
25. Dunning T, Duggan N, Savage S, Martin P. Diabetes and end of life: ethical and methodological issues in gathering evidence to guide care. Scand J Caring Sci. 2013;27:203-211.
26. McCoubrie R, Jeffrey D, Paton C, Dawes L. Managing diabetes mellitus in patients with advanced cancer: a case note audit and guidelines. Eur J Cancer Care (Engl). 2005;14:244-248.
27. International Diabetes Federation. Managing older people with type 2 diabetes: global guideline. www.idf.org/sites/default/files/IDF-Guideline-for-older-people-T2D.pdf. Accessed June 1, 2016.

To comment on this article, contact rdavidson@uspharmacist.com.