In some patients, agents that might cause nausea, gastrointestinal disturbance, or excess weight loss (e.g., metformin or glucagon-like peptide 1 receptor agonist) may need to be discontinued, while in other patients it may be appropriate to withdraw therapy, including insulin, during the terminal stage. The presenting symptoms of hypoglycemia in older adults can be primarily neuroglycopenic (confusion, delirium, dizziness) rather than adrenergic (palpitation, sweating, tremors) (20). N.P. A pharmacist-provided medication regimen review may not be readily available in all assisted living facilities, which increases the risk of medication errors, unnecessary medications, and potential drug–drug interactions (e.g., sulfonylureas and antibiotics) (39). E, Liberal diet plans have been associated with improvement in food and beverage intake in this population. Meal plans that avoid weight loss, nonpharmacological options to prevent or manage behavioral problems, and timely identification and management of depression should be used to improve the quality of remaining life. Standing orders for glucose monitoring and practitioner notification that are approved by the facility and the practitioner at the time of admission may be useful. It requires a dedicated interprofessional team composed of registered nurses, certified nursing assistants, diabetes educators, dietitians, food service managers, consultant pharmacists, physical therapists, social workers, and practitioners to manage older patients with diabetes in LTC facilities. 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. Most practitioners in this case would simply withdraw all oral hypoglycemic agents and stop insulin in most patients with type 2 diabetes. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association, Prevalence, quality of care, and complications in long term care residents with diabetes: a multicenter observational study, Prevalence of diabetes and the burden of comorbid conditions among elderly nursing home residents, Economic costs of diabetes in the U.S. in 2012, Diabetes and altered glucose metabolism with aging, Diabetes and the risk of multi-system aging phenotypes: a systematic review and meta-analysis, American Association of Clinical Endocrinologists, American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control, Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes, Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes, Rates of complications and mortality in older patients with diabetes mellitus: the diabetes and aging study, Frequency and predictors of hypoglycaemia in type 1 and insulin-treated type 2 diabetes: a population-based study, Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration, Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas, National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011, Lack of knowledge of symptoms of hypoglycaemia by elderly diabetic patients, The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes: a decision analysis, Polypharmacy in the elderly: a literature review, Study of Osteoporotic Fractures Research Group, Diabetes and incidence of functional disability in older women, Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility, American Geriatrics Society 2012 Beers Criteria Update Expert Panel, American Geriatrics Society updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, The prevalence and persistence of sliding scale insulin use among newly admitted elderly nursing home residents with diabetes mellitus, Position of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities, Glycemic control in patients with type 2 diabetes mellitus with a disease-specific enteral formula: stage II of a randomized, controlled multicenter trial, Enteral nutritional support and use of diabetes-specific formulas for patients with diabetes: a systematic review and meta-analysis, Improving care transitions: current practice and future opportunities for pharmacists, Preventing medication errors in transitions of care: a patient case approach, Transitions of care consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine, Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care, Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study, Posthospital medication discrepancies: prevalence and contributing factors, Tying up loose ends: discharging patients with unresolved medical issues, Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas, Lost in transition: challenges and opportunities for improving the quality of transitional care, Nursing home staff turnover and retention: an analysis of national level data, Improving diabetes care and patient outcomes in skilled-care communities: successes and lessons from a quality improvement initiative, Global guideline for type 2 diabetes: recommendations for standard, comprehensive, and minimal care, Diabetes Management in Long-Term Settings: A Clinician's Guide to Optimal Care for the Elderly, Diabetes management in patients receiving palliative care, Developing clinical guidelines for end-of-life care: blending evidence and consensus, Diabetes and end of life: ethical and methodological issues in gathering evidence to guide care, Evidence-informed guidelines for treating frail older adults with type 2 diabetes: from the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) program, American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons, Pharmacological management of persistent pain in older persons, Managing diabetes mellitus in patients with advanced cancer: a case note audit and guidelines, Improving diabetes care for hospice patients, An approach to diabetes mellitus in hospice and palliative medicine, Management of diabetes during the last days of life: attitudes of consultant diabetologists and consultant palliative care physicians in the UK, Enhancing nursing leadership in long-term care. To address these issues, it is important to educate patients, families, and other providers about the fact that Healthcare Effectiveness Data and Information Set (HEDIS) measures do not apply to hospice patients and that it is acceptable to keep blood glucose levels between 200 and 300 mg/dL in hospice patients taking glucose-lowering medication. Management of these conditions requires an in-depth knowledge of blood glucose monitoring. They proposed three strata for management of patients with diabetes and advanced disease. In general, the facility medical leadership and nursing administration have the opportunity to develop and implement patient care policies that can facilitate optimal management of the older patient with diabetes and to coordinate efforts with the multidisciplinary team. These guidelines emphasize that frail patients with cognitive impairment may present with atypical symptoms, mainly neuroglycopenic or behavioral in nature. A key to many diabetes management plans is learning how to count carbohydrates. Nurses commonly encounter patients with type 1 or type 2 diabetes mellitus in their practice. Diabetes-specific enteral nutrition formulas (DSFs) (e.g., Glucerna, Glytrol, Diabetisource AC) are available to help to manage glycemic excursions during tube feedings. Journals are a great way to learn about how others are improving diabetes care in the UK and across the world. Several meta-analyses have demonstrated that SME is associated with clinically important benefits in people with diabetes, such as reductions in glycated hemoglobin (A1C) and improvements in cardiovascular (CV) risk factors and reductions in foot ulcerations, infections and amputations .A large population-based cohort study of 27,278 people with type 2 diabetes … Learn about carbohydrate counting and portion sizes. To date, there is no standard transition of care document with all the needed information for diabetes management that accompanies a patient from one setting to another (30). Barriers at the patient or family level may include limited disease state knowledge and erroneous or unrealistic expectations. In addition, it is important to respect the patient’s right to refuse treatment as well as to consider religion and cultural traditions, including the care of the body after death. • To improve your knowledge of the causes, pathophysiology and treatment of the acute complications of diabetes mellitus, in particular diabetic ketoacidosis and hyperosmolar hyperglycaemic state, • To understand what is involved in the assessment and management of diabetic ketoacidosis and hyperosmolar hyperglycaemic state, which will enable you to provide effective patient care, • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers), • To contribute towards your professional development and local registration renewal requirements (non-UK readers). Pages 12-14 … 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. Liberal diets have been associated with improvement in food and beverage intake in the LTC population to better meet caloric and nutrient requirements (27). was an advisory group member for AstraZeneca as part of a 1-day meeting. RCNi Portfolio and interactive CPD quizzes, RCNi Learning with 200+ evidence-based modules, 10 articles a month from any other RCNi journal. Age-related decrease in β-adrenergic receptor function and defective glucose counterregulatory hormone responses increase the vulnerability of older adults to severe hypoglycemia (6). Nurses commonly encounter patients with type 1 or type 2 diabetes mellitus in their practice. In the long-term care (LTC) population, the prevalence of diabetes ranges from 25% to 34% across multiple studies (2–4). However, there is no clearly defined practical guide to switch patients who are admitted to LTC from SSI to basal–bolus insulin. In fact, more than 10 per cent of people living with diabetes … Most pediatric patients with diabetes have type 1 diabetes mellitus (T1DM) and a lifetime dependence on exogenous insulin. E, It is important to respect a patient’s right to refuse treatment and withdraw oral hypoglycemic agents and/or stop insulin if desired during the end-of-life care. Thus, glycemic goals for patients in LTC are guided by preventing hypoglycemia while avoiding extreme hyperglycemia. Before developing glycemic goals and a treatment strategy, each patient’s overall health, coexisiting medical conditions, personal preferences, coping capacity, and factors affecting quality of life should be considered. Programs to enhance mobility, endurance, gait, balance, and overall strength are important for all patients in LTC facilities. doi: 10.7748/ns.2018.e11250, Palk LE (2018) Assessing and managing the acute complications of diabetes mellitus. Carbohydrates are the foods that often have the biggest im… Diabetes mellitus is a group of metabolic diseases that occurs with increased levels of glucose in the blood. Table 2 provides a framework for considering treatment goals for patients living in different settings, facing distinct clinical circumstances. Nursing Standard. Nursing Standard. As patients move into this phase, the importance of glycemic control is less apparent and preventing hypoglycemia is of greater significance. Institutional-level challenges include staff turnover and lack of familiarity with patients, restrictive diet orders, inadequate review of glucose logs and trends, lack of facility-specific diabetes treatment algorithms for blood glucose levels and provider notifications, and, often, lack of administrative buy-in to promote the roles of the medical director, the director of nursing, and the consultant pharmacist. In order to assess and improve facility-wide management of diabetes directed by multiple practitioners, the facility leadership (e.g., the director of nursing, nurse managers, medical director, and consultant pharmacist) should collect data and trends and plan strategies to improve selected process or outcome indicators relevant to diabetes management. Management involves establishing that the neuropathy is caused by diabetes instead of more … hypoglycaemia -
Management of the disease is especially important because diabetes can lead to numerous complications, including kidney, eye and nerve issues. Volume 6, Issue 1, 10 January 2019, Pages 70-91. Review. In addition, Wagle (44) provides a sample form using an electronic medical record. Common reasons for overly tight glycemic control in hospice patients were found to be 1) discomfort with discussions about reducing or stopping chronic medications, 2) concern about mild hyperglycemia especially by patients and caregivers, and 3) worry about not achieving quality indicators for glycemic control (51). The type of activity recommended should depend on the patient’s current level of activity and ability. Diagnosis requires careful examination of the lower limbs. Care transitions are important times to revisit diabetes management targets, perform medication reconciliation, provide patient and caregiver education, reevaluate the patient’s ability to perform diabetes self-care behaviors, and have close communication between transferring and receiving care teams to ensure patient safety and reduce readmission rates. 2. Hypoglycemia risk is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Diabetes Management Journal intends to publish peer-reviewed, original articles that address the global health concerns related to diabetes. The older diabetes population is highly heterogeneous in terms of comorbid illnesses and functional impairments. Glycemic goals in particular are dependent on the patient’s risk of hypoglycemia. Journals & Books; Register Sign in. is a consultant for Sanofi and Novo Nordisk. The last 90 years have seen considerable advances in the management of type 1 and type 2 diabetes. Impaired renal function and reduced hepatic enzyme activity may interfere with the metabolism of sulfonylureas and insulin, thereby potentiating their hypoglycemic effects. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548. It is an open access, online, international journal with a primary objective to reach the readers and researchers … On a global scale, there has been a startling rise of diabetes in developing countries in recent years, especially type 2. Another factor contributing to the challenges during care transitions is the lack of a single clinician taking responsibility for coordination across the continuum of the patient’s overall health care, regardless of setting (40). Sign in Register. C. Establishing 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). Care transitions are important times to revisit diabetes management targets, perform medication reconciliation, provide patient and caregiver education, reevaluate the patient’s ability to perform diabetes self-care behaviors, and have close communication between transferring and receiving care teams to ensure patient safety and reduce readmission rates. Because of this reality, successful diabetes care needs to include a dedicated interprofessional team. 1. 1. diabetes -
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 (12). Journals & Books; Help Download PDF Download. For example, an older adult on insulin may experience delirium as a common complication during and after hospitalization or may require a change in insulin dose when recuperating from acute illness and as nutritional intake improves. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. (53) suggested that treatment and monitoring be stopped in patients with type 2 diabetes once they are in the terminal phase, but there was less consensus for the management of type 1 diabetes under similar scenarios. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities. This article discusses the different clinical presentations, diagnosis and management of children with diabetes, and includes two case studies to illustrate some of the challenges faced by emergency department nurses. To encourage nurses to take a leadership role in diabetes care, AJN, the American Association of Diabetes Educators, the American Diabetes Association, and the Joslin Diabetes Center convened an invitational symposium in September 2006 to examine the state of the science of diabetes self-care management, with an emphasis on exploring what nurses can do to help patients manage the disease … Discharge summaries often lack crucial information such as diagnostic test results, treatment or hospital course, discharge medications, test results pending at discharge, patient or family education, and follow-up plans (37). Advanced. A successful transition is a process whereby senders and receivers validate the transfer, accept the information, clarify any discrepancies, and act on the information to ensure a smooth and safe transition of care (32). As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Healthy eating is a cornerstone of healthy living — with or without diabetes. The guidelines recommend that LTC facilities develop their own facility-specific policies and procedures for hypoglycemia treatment. Type 2 diabetes mellitus (T2DM) stems from the inability of the body to utilize endogenous insulin properly. The 2012 ADA consensus report states that goals that minimize severe hyperglycemia are indicated for all patients (9). glycaemic control -
It is primarily aimed at nurses working in primary care, although may also be useful for nurses working in other areas. Dunning et al. E. Transitions from the hospital or home to LTC, transitions across care settings in LTC facilities, changes in providers, and discharges to the community setting are high-risk times for patients with diabetes. Author links open overlay panel Roger Carpenter a Toni DiChiacchio b Kendra … The authors acknowledge Dr. Jane L. Chiang's invaluable editorial contribution throughout the development of this position statement. Strategies for diabetes management may include relaxing glycemic targets, simplifying regimens, using low-risk glucose-lowering agents, providing education on recognition of hypoglycemia, and enhancing communication strategies. Certain conditions such as cognitive dysfunction, depression, physical disabilities, eating problems, and repeated infections are commonly found in the LTC population. International Journal of Nursing Sciences. Acknowledgments. B, Physical activity and exercise are important in all patients and should depend on the current level of the patient’s functional abilities. Self-Management Education. Specific recommendations for management of hyperglycemia, hypoglycemia, corticosteroid use, and education for patients and families are well described in a recent guideline (50). LTC costs for people with diabetes were estimated at $19.6 billion in 2012 (5). Often neither the provider responsible for the patient’s care nor the consulting pharmacists are present on-site at LTC facilities on a daily basis. Randomized controlled trials have found DSFs favorable to SFs for blood glucose management. Explore this zone to keep up with what’s happening in diabetes nursing. Focused, interprofessional quality improvement initiatives have been shown to decrease hypoglycemia rates and improve processes of diabetes care in skilled nursing facilities (42). LTC facilities that are noncompliant may be subject to financial penalties. This team may be composed of practitioners (physicians, nurse practitioners, and physician assistants), registered nurses, licensed practical/vocational nurses, certified nursing assistants, diabetes educators, dietitians, food service managers, consultant pharmacists, physical therapists, and/or social workers. R.R.K. These could include sharing data with managerial staff, providing staff education, and planning a performance improvement project. Thank you for your interest in spreading the word about Diabetes Care. Patients should be warned and educated about the signs of hypoglycemia and hypoglycemia unawareness. Frailty, fear of falls, inadequate staff supervision, and lack of incentives act as barriers to regular physical activity for patients in the LTC facility. Persistent SSI use leads to wide blood glucose excursions. The risk of renal or hepatic failure becomes more evident at this stage, and insulin or other glucose-lowering medication dosages may need to be reduced in both patients with type 1 diabetes and patients with type 2 diabetes. 2. Self-Management Toolkit for High-Risk Patients With Type 2 Diabetes and the Effect on Nurses' Confidence Journal of diabetes science and technology, 4(3), 750-753. The management strategies for community-dwelling and hospitalized patients with diabetes have been previously described by the American Diabetes Association (ADA) (9,10). A two-arm parallel-group randomized controlled trial with … You will find relevant clinical articles, including must-read recommendations, Self-assessment and Journal Club articles for CPD, and related news and opinion. Transitions in care indicate that a patient is undergoing changes in health status, which may include physical and/or cognitive function, changes in dietary patterns, and ability to perform diabetes self-care behaviors. Each year, the American DiabetesAssociation(ADA) publishes standards of care for patients with diabetes.2These standards are updated annually by a panel of experts in nursing, education, behavior, psychology, nutrition, pharmacology, and medicine. To raise awareness of the condition, Diabetes UK has launched the 4Ts campaign, which highlights the four most common symptoms of diabetes. The International Diabetes Federation (IDF) guideline describes management of blood pressure, lipids, and foot care at end of life in patients with diabetes (http://www.idf.org/sites/default/files/IDF-Guideline-for-older-people-T2D.pdf). Unfortunately, it is customary in most facilities to check premeal and bedtime blood glucose levels and to rely on the sole use of SSI or either oral agents or basal insulin accompanied by SSI as the primary means to control blood glucose. In 2008, the Royal College of Nursing Diabetes Nursing Forum identified an issue relating to the care and management of prisoners with diabetes while in detention. The challenges specific to patients include altered pharmacokinetics and pharmacodynamics of medications, increased risk of hypoglycemia, unpredictable meal consumption, comorbidities such as cognitive dysfunction and depression, psychological resistance to insulin, impaired vision and dexterity, and greater potential for adverse effects and drug interactions. Therefore, the need to restart oral therapies (e.g., metformin), typically discontinued in the inpatient setting, can be overlooked. Enter multiple addresses on separate lines or separate them with commas. Interventions for self-management of type 2 diabetes: An integrative review. Pain is an important component of end-of-life management. Pain could be related to diabetes complications and comorbidities, such as peripheral neuropathy, depression, falls, trauma, skin tears, and periodontal disease, and should be well managed (49). This population is heterogeneous and presents unique challenges pertaining to diabetes management. Management of these conditions requires an in-depth knowledge of blood glucose monitoring. Nutrition goals should be guided by, among other things, the patient’s prognosis and expressed preferences and include a discussion with the patient and family whenever possible. Management of diabetes among older adults residing in LTC facilities is challenging due to heterogeneity in this population. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is essential that nurses are aware of normal blood glucose levels, so that they can respond to complications caused by elevated and reduced blood glucose levels. 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). B, Simplified treatment regimens are preferred and better tolerated. Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and insulin-treated type 2 diabetes (14–16). Ford-Dunn et al. Simplified treatment regimens are generally recommended. R.R.K. For those with evidence of cognitive dysfunction, end-of-life planning and a communication strategy should be undertaken while the individual can still make rational decisions. Unlike in older adults living in the community, insulin injections for individuals in LTC are usually given by the facility staff. Instead, a consistent carbohydrate meal plan that allows for a wide variety of food choices (e.g., general diet) may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes on mealtime insulin. The acute risks of hyperglycemia as experienced in this stage center mainly on the risk of a hyperosmolar hyperglycemic state and associated complications, such as osmotic diuresis, recurrent infection, and poor wound healing. Several conditions may result in hypoglycemia (anorexia–cachexia syndrome from chemotherapy and opiate analgesics, malnourishment, swallowing disorders). Publishing your improvement and learning through journals can also help … For example, some patients or family members may not be aware of the chronic and progressive nature of type 2 diabetes or of the possible need to convert from oral therapies to insulin therapy despite appropriate dietary intake in patients with long-standing illness. In recent years, great emphasis has been placed on the role of nonpharmacological self-management in the care of patients with diabetes. 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. Capillary monitoring of blood glucose could vary from twice daily to once every 3 days depending on the patient’s condition. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. For older adults with diabetes, especially those with complex comorbidities, limited health literacy, cognitive impairment, five or more prescribed medications, or end-of-life care, the risk for adverse outcomes during these care transitions is even greater (30,31). Although much attention is rightly focused on hypoglycemia, persistent hyperglycemia increases the risk of dehydration, electrolyte abnormalities, urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome. type 2 diabetes, Alternatively, you can purchase access to this article for the next seven days. Consequently, ensuring a high level of care for patients with diabetes in LTC facilities is also necessary for compliance with federal regulations. MCN, The American Journal of Maternal/Child Nursing. The major sources of the glucose that circulates in the blood are through the absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food substances. Several sample admission and transfer forms are available for download from the AMDA Web site (http://www.amda.com/tools/guidelines.cfm). Thus, the need to obtain further testing or outpatient follow-up may not be adequately communicated or coordinated by the LTC providers (38). Similarly, Angelo et al. Goals for diabetes management at end of life need to focus on promoting comfort; controlling distressing symptoms (including pain, hypoglycemia, and hyperglycemia); avoiding dehydration; avoiding emergency room visits, hospital admissions, and institutionalization; and preserving dignity and quality of life.