Wellness iNPractice Diabetes

Helping Patients with Diabetes in Long-term Care

In long-term care facilities, approximately one-fourth to one-third of the population has diabetes.1 The high prevalence of diabetes in this population is due to age-related physiological changes, including increased amounts of abdominal fat, sarcopenia, and chronic low-grade inflammation. These changes contribute to increased insulin resistance in peripheral tissues and impaired pancreatic islet cell function.1

The management of diabetes in patients who reside in long-term care facilities must take into account their specific needs related to living arrangements and social support.1 As the challenges of diabetes and capacities for self-care are different for patients in assisted living facilities or skilled nursing facilities, so too are the recommendations for diabetes management.1

For example, when prescribing glucose-lowering medications, certain considerations should be kept in mind (see table below).

Table 1 – ADA recommendations in glucose-lowering agents in long-term care population1

 

Medication class Caveats in the long-term care population
  • Biguanides
    • Can be used until estimated glomerular filtration rate is <30 ml/min/1.73m2
  • Metformin
    • Extended release formulation has lower complexity and fewer gastrointestinal side effects
    • Assess for vitamin B12 deficiency
  • Sulfonylureas
    • Avoid if inconsistent eating pattern
    • Careful glucose monitoring during acute illness or weight loss
    • Consider discontinuing if already on substantial insulin dose (e.g., >40 units/day)
  • Meglitinides
    • Some risk of hypoglycemia
    • Increased regimen complexity due to multiple daily mealtime doses
  • TZDs
    • Less concern for bladder cancer if shorter life expectancy
  • DPP-4 inhibitors
    • Can be combined with basal insulin for a low complexity regimen
  • SGLT2 inhibitors
    • Watch for increased urinary frequency, incontinence, lower blood pressure, genital infections, and dehydration
  • GLP-1 agonists
    • Monitor for anorexia and weight loss
  • Insulin
    • Basal insulin combined with oral agents may lower postprandial glucose while reducing hypoglycemia risk and regimen complexity
    • Continue basal-bolus regimen in patients with type 1 or insulin-deficient type 2 diabetes
    DPP-4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide 1; SGLT2, sodium-glucose cotransporter 2; TZDs, thiazolidinediones.

    Specific guidance in the care of patients with diabetes in the long-term care setting can be found in the 2016 American Diabetes Association position statement, Management of Diabetes in Long-term Care and Skilled Nursing Facilities.

    Additional resources can also be found in the Link Library.

    The downloadable brochures, “Looking After Residents with Diabetes,” can help you care for patients with diabetes who are residents of long-term care facilities. These brochures address the specific needs of two different populations – those in assisted living facilities and those in skilled nursing facilities.

    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.