Diabetes is very common in people living in post-acute and long-term environments, affecting 25% to 34% of these individuals.
Now there’s a wonderful new resource for those caring for them in the revised Clinical Practice Guideline for Diabetes Management in the Post-Acute and Long-Term Care Setting, which was recently published by the Post-Acute and Long-Term Care Medical Association.
This new clinical practice guideline provides a comprehensive process for assessing patients and residents for diabetes, developing an individualized and person-centered approach to care, and providing ways to prevent and manage diabetes-related consequences.
New, evidence-based philosophies of care for diabetes are provided and include evidence to support avoiding restricting diets among older adults with diabetes, avoiding strict adherence to hemoglobin A1C levels, and developing personalized goals using the Four M’s of an Age-Friendly Health System: Mentation, Medication, Mobility and what Matters.
There is also a strong rationale provided to avoid use of sliding-scale insulin and to consider the use of oral agents and the newer classes of drugs (DPP-4 inhibitors; SGLT2 inhibitors; and oral or injectable GLP1-Ras).
Use of these drugs can improve diabetes management without increasing risk for hypoglycemia (hypoglycemia is not strictly avoided but is much less common vs. other drug classes like sulfonylureas) or other negative outcomes (there are definitely side effects with the new agents including GI symptoms and pancreatitis with the GLP-1s and UTI and fungal infections with the SGLT-2 agents).
Further, they can be given by staff either orally or with weekly injections, without the need for regular monitoring of blood glucose with finger sticks, which can be burdensome for both patients and staff.
Highlights of this newly revised guideline include updated tables that provide information about new oral and injectable agents for diabetes, along with when these should be used and for whom. These agents can help avoid the need for insulin and allow individuals to remain in settings of care where caregivers are unavailable to provide frequent insulin injections and glucose monitoring. The clinical practice guideline further provides information on how to transition patients and residents from sliding-scale insulin toward better options for medication management.
In addition to the assessment and management of diabetes, the clinical practice guideline addresses the assessment and management of hypoglycemia, which is a major complication of diabetes and diabetes management. The “Rule of 15” is introduced, which is the administration of 15 grams of carbohydrates and rechecking the patient’s blood glucose level in 15 minutes.
This can help guide staff in the management of hypoglycemia and may help to prevent the transfer of a patient to a more intensive care setting. Examples of different hypoglycemia scenarios are provided to guide clinicians in the management of the hypoglycemic episode.
Another table provides 11 additional clinical indicators that should be evaluated to help prevent hypoglycemia and other complications of diabetes. These include factors such as blood glucose levels, blood pressure, foot care, pain control and cognition. There is also information about continuous glucose monitoring and the advantages, disadvantages and challenges (e.g., insurance coverage) of using these devices.
Lastly, within the clinical practice guidelines there is a special section to address the use of the guideline in assisted living communities and the special considerations needed for these sites of care. The guideline is free for all and available in the November online Journal of the American Medical Directors Association. We strongly encourage healthcare providers to review it and share it with colleagues within their facilities.
Barbara Resnick, PhD, CRNP is a Professor at the University of Maryland School of Nursing, the Associate Dean of Research and the Sonya Ziporkin Gershowitz Chair in Gerontology. She is currently the co-editor of the Journal of the American Medical Directors Association.
Paul Katz, MD, CMD is a Professor of Medicine at McMaster and Florida State University.
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