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Management of Diabetes in Long- term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Abstract. 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. The UPDATE statement in SQL is used to modify data in a database table. One or more columns can be updated at a time.Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life. Introduction. The epidemic growth of type 2 diabetes in the U. S. In 2. 01. 2, the prevalence of diabetes among people aged . In the long- term care (LTC) population, the prevalence of diabetes ranges from 2. 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 diabetes in 2. Average medical expenditures for people with diagnosed diabetes were 2. LTC costs for people with diabetes were estimated at $1. The high prevalence of diabetes in older adults is due to age- related physiological changes, such as increased abdominal fat, sarcopenia, and chronic low- grade inflammation, that lead to increased insulin resistance in peripheral tissues and relatively impaired pancreatic islet function (6). Diabetes increases the risk of cardiovascular and microvascular complications but also increases the risk of common geriatric syndromes, including cognitive impairment, depression, falls, polypharmacy, persistent pain, and urinary incontinence (7,8). The older diabetes population is highly heterogeneous in terms of comorbid illnesses and functional impairments. These characteristics have frequently been used to exclude older individuals from randomized 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 diabetes, most recommendations in this position statement are directed toward that population. However, we have suggested specific recommendations for patients with type 1 diabetes when appropriate. General Approach to Care. Recommendations. Management of diabetes among older adults residing in LTC facilities is challenging due to heterogeneity in this population. Careful evaluation of comorbidities and overall health is needed before developing goals and treatment strategies for diabetes management. EDiabetes management in LTC patients (residents) requires different approaches because of unique challenges faced by this population and the workings of LTC facilities. 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Several organizations have developed diabetes guidelines for patients living in LTC settings. Almost all of these guidelines emphasize the need to individualize care goals and treatments related to diabetes, the need to avoid sliding scale insulin (SSI) as a primary means of regulating blood glucose, and the importance of providing adequate training and protocols to LTC staff who may be operating without the presence of a practitioner for prolonged periods. The American Medical Directors Association Guidelines. The most extensive guideline available was developed by the American Medical Directors Association (AMDA) (1. These guidelines include a 1. LTC staff that comprises all phases of diabetes care from diabetes detection to institutional quality assessment. ![]() The glucose- lowering steps advocated by the AMDA are consistent with those published in the ADA position statement on patient- centered individualized approaches to glucose lowering in adults with diabetes (1. In terms of A1. C goals, the AMDA guidelines are also consistent with those recommended in the 2. ADA consensus report (9). To achieve goals, it is acknowledged that the notion of a “diabetic diet” is outdated and that a more liberal diet may be appropriate among LTC patients. The guidelines are fairly nonspecific with regard to choice of glucose- lowering agents but advise practitioners to avoid the use of SSI and to transition to scheduled basal insulin (and prandial as required) shortly after admission. Beyond these long- term goals of care, the AMDA guidelines provide recommendations to LTC staff regarding when to call a practitioner (1. The guidelines recommend that LTC facilities develop their own facility- specific policies and procedures for hypoglycemia treatment. These guidelines emphasize that frail patients with cognitive impairment may present with atypical symptoms, mainly neuroglycopenic or behavioral in nature. The unique needs of patients with diabetes who are terminally ill or have limited life expectancy are also discussed. Other Guidelines. Along with the AMDA guidelines, guidelines from the ADA, the International Association of Gerontology and Geriatrics (IAGG), and the European Diabetes Working Party for Older People (EDWPOP) have provided selective guidance for LTC populations. The ADA consensus panel identified the challenges of caring for patients in LTC facilities, such as irregular and unpredictable meal consumption, inadequate staffing, and frequent transitions in care (9). Additionally, the IAGG and EDWPOP have called to reduce the prevalence and burden of pressure ulcers (1. Building on a core set of principles from these guidelines, this position statement elaborates on unique features of diabetes management in patients in LTC facilities and provides practical strategies to the clinical staff caring for them. Goals and Strategies. Recommendations. Hypoglycemia risk is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. BSimplified treatment regimens are preferred and better tolerated. ESole use of SSI should be avoided. CLiberal diet plans have been associated with improvement in food and beverage intake in this population. To avoid dehydration and unintentional weight loss, restrictive therapeutic diets should be minimized. BPhysical activity and exercise are important in all patients and should depend on the current level of the patient’s functional abilities. CEstablishing the goals of care and management strategies for an individual in the LTC setting requires an acknowledgment of heterogeneity in terms of stage of disease, complications, comorbidities, self- care ability, life expectancy, and risk of adverse drug events (2–4). The most important aspects of developing goals and strategies for a patient residing in LTC are described below. Hypoglycemia. Care goals should be established at the time of admission to the LTC facility for all chronic conditions. Glycemic goals in particular are dependent on the patient’s risk of hypoglycemia. Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and insulin- treated type 2 diabetes (1. Multiple factors increase the risk of hypoglycemia in older adults, including impaired renal function, slowed hormonal regulation and counterregulation, variable appetite and nutritional intake, polypharmacy, and slowed intestinal absorption (1. The strongest predictors of severe hypoglycemia have been found to be advanced age, recent hospitalization, and polypharmacy (1. LTC population. Advanced age is associated with higher rates of cognitive dysfunction, causing difficulty in carrying out complex care activities such as glucose monitoring and adjustment of insulin doses. ![]() ANEGDOTEBI (1) . NOVITEC FERRARI F (1) ? Hot Pursuit: Limited Edition (2. RUS/ENG/MULTI/Repack) (1) . 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