June 2016 Issue

Dynamics of Diabetes: Diabetes Management in LTC Patients
By Janice H. Dada, MPH, RD, CDE
Today's Dietitian
Vol. 18 No. 6 P. 12

The American Diabetes Association (ADA) recently introduced a new position statement outlining better ways to manage diabetes in elderly patients residing in long term care (LTC) and skilled nursing facilities. The new guidelines are significant in that this is the first time the ADA specifically addressed the distinct needs of older patients in these settings and discussed how health care practitioners can overcome the challenges of caring for this population. Former guidelines addressed only the elderly in community settings.1

The new guidelines stress the need for health care practitioners to pay closer attention to patients in LTC and skilled nursing facilities due to the increased prevalence of diabetes in this population and its associated comorbidities, such as cardiovascular and microvascular diseases, cognitive impairment, depression, falls, polypharmacy, chronic pain, and urinary incontinence. Moreover, due to this population's heterogeneity, the guidelines urge health care practitioners to administer individualized care for each patient when developing goals and treatment strategies to achieve optimal glycemic control, meet dietary and nutritional needs, and prevent or manage diabetes complications. The guidelines were published in the February issue of Diabetes Care.1

Increased Prevalence
Type 2 diabetes disproportionately affects older Americans in the United States. In fact, about 1 in 4 adults over the age of 60 has diabetes.2 In 2012, the prevalence of diabetes among adults aged 65 and older (25.9%) was almost three times that of the general population (9.3%).2,3 In LTC facilities, diabetes affects about one-quarter to one-third of residents.4-6

Greater prevalence of diabetes in older adults is attributable to several age-related factors, such as increased adiposity, sarcopenia, organ system dysfunction, and an overall higher level of systemic inflammation, that lead to increased insulin resistance and impaired pancreatic islet function. As a result, diabetes can create a significant health burden, especially in the elderly with multiple medical problems.1

Hypoglycemia and Hyperglycemia
Among the many complications, or comorbid conditions, associated with diabetes in older adults, "hypoglycemia risk is the most important factor in determining glycemic goals due to the catastrophic consequences in this [elderly] population," according to Medha Munshi, MD, and colleagues, the authors of the new ADA position statement. Hypoglycemia in older adults often manifests itself as confusion, delirium, and dizziness vs palpitations, sweating, and tremors.1 A study published in the November 2013 issue of the Journal of the American Medical Directors Association examined 1,409 residents in LTC and skilled nursing facilities (average age of ~80) and found that hypoglycemia was associated with longer stays in the facility, more transfers to the hospital, and a two-fold increase in mortality risk.4

To better manage hypoglycemia, Munshi and colleagues recommend simplified treatment regimens and avoiding the sole use of sliding scale insulin (SSI).1 The term "sliding scale" refers to the progressive increase in the premeal or nighttime insulin dose, based on predefined blood glucose ranges.7 SSI use has been called a "relic of the past" by many, but it's still used in several health care settings today.8 SSI is a reactive method of blood glucose control that involves chasing the blood sugar by treating the current glucometer reading, rather than determining insulin dosage based on meal composition, metabolism, weight, and insulin sensitivity. The American Geriatrics Society Beers Criteria or Beers list was developed to improve the care of patients older than age 65 by providing clinicians with a list of medications considered inappropriate for LTC residents due to their propensity to cause hypoglycemia, such as chlorpropamide, glyburide, and the use of SSI.9 The Beers Criteria state that using SSI poses a "higher risk of hypoglycemia without an improvement in the management of hyperglycemia, regardless of the setting."10 In the ADA's new position statement, Munshi and colleagues provide alternatives to using SSI, including changing insulin delivery timing, correcting for high blood glucose, and switching to noninsulin therapy.1 In addition, the researchers provide an outline of the advantages and disadvantages of oral diabetes medications.1 For example, metformin is affordable and has an established safety record, but it's associated with weight loss and gastrointestinal upset in frail patients and may lead to vitamin B12 deficiency. However, the extended-release version of metformin has fewer reported gastrointestinal side effects.1

Munshi and colleagues describe the many factors that increase the risk of hypoglycemia, such as impaired renal function, variable appetite, polypharmacy, and slowed intestinal motility.1 In fact, advanced age has been cited as one of the strongest predictors of severe hypoglycemia.1 Dietitians working with this population can help prevent hypoglycemia by offering patients appropriate nutrition education. They can inform patients about the 15/15 rule for treating hypoglycemia. If a blood glucose reading is below 70 mg/dL, the resident should consume 15 g of fast-acting carbohydrate, such as 4 oz of juice, 6 oz of regular soda, 12 oz of nonfat milk, three glucose tablets, or glucose gel. The second step is to wait 15 minutes and then recheck blood glucose. If it remains under 70 mg/dL, repeat intake of 15 g carbohydrate. The 15/15 rule will work best for patients who don't have hypoglycemia unawareness (the inability to recognize low blood sugar symptoms) and don't suffer from severe cognitive deficits. In addition to the 15/15 rule, dietitians can work with patients to determine patterns in their blood sugar levels. For example, RDs can determine whether there's a trend in low blood glucose values after physical activity, which can prompt them to instruct patients to eat a carbohydrate snack before exercise.

Munshi and colleagues also noted that persistent hyperglycemia is extremely risky and can lead to dehydration, electrolyte imbalances, dizziness, falls, and hyperglycemic hyperosmolar syndrome, a common condition in elderly people with diabetes characterized by extremely high blood glucose levels over 600 mg/dL and dehydration, leading the body to produce excess urine to eliminate sugar. Therefore, according to ADA's new position statement, the prevention of hypoglycemia and extreme hyperglycemia should guide glycemic goals for patients in LTC facilities.1 Munshi and colleagues provide a framework for considering diabetes management goals in which they recommend patients achieve fasting and premeal blood glucose targets of 100 to 200 mg/dL for "community dwelling patients at skilled nursing facilities for short rehab" and "patients residing in LTC."1

Individualized Diets
The ADA position statement also recommends health care practitioners develop individualized meal plans for patients that include a wide variety of foods and beverages to avoid dehydration and unintentional weight loss vs issuing a "diabetic diet," or a one-size-fits-all meal plan. Nutrition professionals should tailor meal plans to patients' taste preferences and suggest food substitutions if they eat less than 75% of meals. A one-size-fits-all approach to meal planning goes hand-in-hand with the use of SSI, in which patients receive a predetermined amount of food to eat and insulin dose. However, with so many effective diabetes treatment methods available, patients who eat a wide variety of foods still can control blood glucose when given the right medications.

"Food is a pleasure that becomes increasingly more important as we age, and liberalizing the diet allows the patient to enjoy this pleasure for as long as possible," says Jennifer DeFrain, MS, RD, owner of Dietitians of OC in Newport Beach, California, who frequently consults for LTC facilities.

Sarah Geary, MPH, RD, inpatient section chief at the VA Greater Los Angeles Healthcare System, says residents at the VA Community Living Center receive diet education and are encouraged to "self-select meals in our Heroes Café kiosk. Self-selecting meals allows residents with diabetes to have a more liberal diet and enjoy a more homelike environment."

The VA has led the nation in recognizing the importance of taking an individualized approach to diabetes management in older adults. In fact, it has incorporated this concept into its own diabetes guidelines since 2000.11 For LTC residents with type 2 diabetes who have three or more chronic diseases, two or more activities of daily living deficits, moderate to severe cognitive impairment, or life expectancy of less than five years (most are aged 80 and older), Thomas Yoshikawa, MD, deputy chief of staff for geriatrics and LTC at VA Greater Los Angeles Health Care System, recommends practitioners do the following:
• Prevent hypoglycemia as a primary goal, since patients die or suffer severe morbidity from hypoglycemia but rarely die from hyperglycemia.
• Aim to keep hemoglobin A1c (which reflects blood glucose status for the past 90 days) between 8.0 and 8.9, fasting glucose or before-meal glucose at 100 to 180 mg/dL, and bedtime glucose around 110 to 200 mg/dL, unless these levels still cause symptomatic polyuria and polydipsia.
• Limit using insulin, since this poses the greatest risk of hypoglycemia and cognitive impairment in patients (which includes many, if not most, LTC residents), who often don't recognize hypoglycemia symptoms.

Best Care for LTC Residents
Overall, there's strong consensus among health care practitioners that avoiding strict glycemic control and meal planning in the LTC population is best. Along those lines, RDs should provide dietary guidance based on patients' individual needs and taste preferences in LTC settings. Dietitians need to understand the mechanisms and side effects of diabetes medications to make the best individualized dietary recommendations. For example, patients on metformin should have their vitamin B12 levels monitored, and those taking sulfonylureas should be watched carefully since these agents may lead to hypoglycemia, especially in patients who have poor appetites.

Furthermore, ensure that all are on the same page. RDs should communicate with physicians, pharmacists, and nurses who are writing diabetes orders to understand each patient's individualized glucose targets so they can meet their appropriate dietary requirements. A collaborative health care model enables valuable communication among interdisciplinary health care team members, which leads to the best care for elderly patients with diabetes in LTC and skilled nursing facilities.

— Janice H. Dada, MPH, RD, CDE, is an educator, freelance writer, and owner of SoCal Nutrition & Wellness (www.socalnw.com), a nutrition consulting business in Newport Beach, California. Follow her on Twitter and Instagram @SoCalRD.

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(2):308-318.

2. Statistics about diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/. Updated April 1, 2016. Accessed April 13, 2016.

3. Centers for Disease Control and Prevention. National diabetes statistics report, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

4. Newton CA, Adeel S, Sadeghi-Yarandi S, et al. Prevalence, quality of care, and complications in long term care residents with diabetes: a multicenter observational study. J Am Med Dir Assoc. 2013;14(11):842-846.

5. Dybicz SB, Thompson S, Molotsky S, Stuart B. Prevalence of diabetes and the burden of comorbid conditions among elderly nursing home residents. Am J Geriatr Pharmacother. 2011;9(4):212-223.

6. Resnick HE, Heineman J, Stone R, Shorr RI. Diabetes in U.S. nursing homes, 2004. Diabetes Care. 2008;31(2):287-288.

7. Sliding scale therapy. University of California, San Francisco website. http://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-insulin-rx/sliding-scale-therapy/. Accessed April 10, 2016.

8. Childs BP. Death to the sliding scale! Diabetes Spectrum. 2003;16(2):68-69.

9. 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(11):2227-2246.

10. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.

11. Good M, Calenda S, Good CB. Helping to achieve safe medication use: VA hypoglycemia safety initiative: everyone on board! Medication Safety in Seconds. 2016;6(3):1-3.
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