7.0.0.0 Tx in Skilled Nurs­ing Fa­cili. & Nurs­ing Homes

Man­age­ment of di­a­betes in the long-‍term care (LTC) set­ting (i.e., nurs­ing homes and skilled nurs­ing fa­cil­i­ties) is unique. In­di­vid­u­al­iza­tion of health care is im­por­tant in all pa­tients; how­ev­er, prac­ti­cal guid­ance is need­ed for med­i­cal pro­viders as well as the LTC staff and care­givers (46). Train­ing should in­clude di­a­betes de­tec­tion and in­sti­tu­tion­al qual­i­ty as­sess­ment. LTC fa­cil­i­ties should de­vel­op their own poli­cies and pro­ce­dures for pre­vention and man­age­ment of hy­po­glycemia.

Re­sources

Staff of LTC fa­cil­i­ties should re­ceive ap­pro­pri­ate di­a­betes ed­u­ca­tion to im­prove the man­age­ment of older adults with di­a­betes. Treat­ments for each pa­tient should be in­di­vid­u­al­ized. Spe­cial man­age­ment con­sid­erations in­clude the need to avoid both hy­po­glycemia and the com­pli­ca­tions of hy­per­glycemia (2,47). For more in­for­ma­tion, see the ADA po­si­tion state­ment “Man­age­ment of Di­a­betes in Long-‍term Care and Skilled Nurs­ing Fa­cilities” (46).

Nu­tri­tion­al Con­sid­erations

An older adult re­si­ding in an LTC fa­cil­i­ty may have irreg­u­lar and un­pre­dictable meal con­sump­tion, undernu­tri­tion, anorex­ia, and im­paired swal­low­ing. Fur­ther­more, ther­a­peu­tic diets may in­ad­ver­tent­ly lead to de­creased food in­take and con­tribute to un­in­ten­tion­al weight loss and undernu­tri­tion. Diets tai­lored to a pa­tient’s cul­ture, pref­er­ences, and per­son­al goals may in­crease qual­i­ty of life, sat­is­fac­tion with meals, and nu­tri­tion sta­tus (48).

Hy­po­glycemia

Older adults with di­a­betes in LTC are es­pe­cial­ly vul­ner­a­ble to hy­po­glycemia. They have a dispro­por­tionately high num­ber of clin­i­cal com­pli­ca­tions and co­mor­bidi­ties that can in­crease hy­po­glycemia risk: im­paired cog­ni­tive and renal func­tion, slowed hor­mon­al reg­u­la­tion and counterreg­u­la­tion, subop­ti­mal hy­dra­tion, vari­able ap­petite and nu­tri­tional in­take, polyphar­ma­cy, and slowed in­testi­nal ab­sorp­tion (49). Oral agents may achieve sim­i­lar glycemic out­comes in LTC pop­u­la­tions as basal in­sulin (34,50).

An­oth­er con­sid­eration for the LTC set­ting is that, un­like the hos­pi­tal set­ting, med­i­cal pro­viders are not re­quired to eval­u­ate the pa­tients daily. Ac­cord­ing to fed­er­al guide­lines, as­sess­ments should be done at least every 30 days for the first 90 days after ad­mis­sion and then at least once every 60 days. Al­though in prac­tice the pa­tients may ac­tu­al­ly be seen more fre­quent­ly, the con­cern is that pa­tients may have uncon­trolled glu­cose lev­els or wide ex­cur­sions with­out the prac­ti­tion­er being notified. Providers may make ad­just­ments to treat­ment reg­i­mens by tele­phone, fax, or in per­son di­rect­ly at the LTC fa­cil­i­ties pro­vided they are given time­ly notification of blood glu­cose man­age­ment is­sues from a stan­dardized alert sys­tem.

The fol­lowing alert strat­e­gy could be con­sid­ered:

1. Call pro­vider im­me­di­a­tely: in case of low blood glu­cose lev­els (≤70 mg/dL [3.9 mmol/‍L]).
2. Call as soon as pos­si­ble: a) glu­cose val­ues be­tween 70 and 100 mg/dL (3.9 and 5.6 mmol/‍L) (reg­i­men may need to be ad­just­ed), b) glu­cose val­ues greater than 250 mg/dL (13.9 mmol/‍L) with­in a 24-h pe­ri­od, c) glu­cose val­ues greater than 300 mg/dL (16.7 mmol/‍L) over 2 con­sec­u­tive days, d) when any read­ing is too high for the glu­come­ter, or e) the pa­tient is sick, with vom­it­ing, symp­tomatic hy­per­glycemia, or poor oral in­take.