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Sliding Scale Insulin In Long Term Care

New Guidance On Diabetes Care In Elderly Residential Facilities

New Guidance On Diabetes Care In Elderly Residential Facilities

New Guidance on Diabetes Care in Elderly Residential Facilities New American Diabetes Association (ADA) guidelines addressing diabetes management in long-term care and skilled nursing facilities emphasize treatment simplification, avoidance of hypoglycemia, and the need to reassess therapeutic goals for patients who are nearing the end of life. The guidelines were published in the February issue of Diabetes Care by Medha N Munshi, MD, director of the Joslin Geriatric Diabetes Program, Boston, Massachusetts, and colleagues. Previous statements from the ADA have addressed care for the elderly in community settings and diabetes care among hospitalized patients, but this is the first to specifically address the unique needs of patients in long-term care settings, where the approach to diabetes management often needs to be dramatically altered from those in younger and healthier patients, Dr Munshi told Medscape Medical News. "We've developed great protocols for looking at the numbers in managing diabetes. My fight in geriatric diabetes is we need to look at what the patient needs," she said. The guidelines are aimed at a variety of audiences. For endocrinologists and primary-care clinicians with expertise in diabetes, they provide additional information about the special considerations in institutionalized elderly patients. This includes guidance on the assessment of functional capacity and common comorbidities that may interfere with diabetes care and strategies for simplifying treatment regimens the opposite of the usual practice of adding more medications. "As a geriatrician, I see a lot of inappropriate care and things done to patients at the end of life, not because people aren't trying to help or aren't paying attention, but simply because they don't know what to do. Continue reading >>

Amda – The Society For Post-acute And Long-term Care Medicine

Amda – The Society For Post-acute And Long-term Care Medicine

Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home. SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s physiologic insulin needs nor is it efficient in the long-term care (LTC) setting in medically stable individuals. Use of SSI is associated with more frequent glucose checks and insulin injections, leads to greater patient discomfort and increased nursing time and resources. With SSI regiments, patients may be at risk from wide glucose fluctuations or hypoglycemia when insulin is given when food intake is erratic. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. Continue reading >>

Sliding Scale Insulin And Hypoglycemia In Long-term Care

Sliding Scale Insulin And Hypoglycemia In Long-term Care

Sliding Scale Insulin and Hypoglycemia in Long-Term Care Santiago Lopez, MD Renee Pekmezaris, PhD Liron Sinvani, MD Jinny Caldentey, MD Andrzej Kozikowski, PhD Volume 23 - Issue 2 - February 2015 - ALTC The prevalence of diabetes mellitus (DM) continues to increase steadily as obesity reaches epidemic proportions worldwide in all segments of the population, including older adults residing in long-term care facilities.1-3 Today, approximately 25% of adults aged 65 and older in the United States have diabetes.4 The incidence of diabetes will increase exponentially, as noted by Narayan and colleagues5: These increases are largest for the two oldest age groups: 220% among those aged 65 to 74 years and 449% among those aged 75 years and older between 2005 and 2050. In the long-term care setting, the management of type 2 DM is critically important; however, it remains particularly challenging due to the complex and fragile nature of older adults in long-term care settings.6,7 With a plethora of available medications to treat diabetes, prescribing often hinges on provider preferences, goals of treatment, and individual patient preferences and characteristics. This is exemplified by a recent study highlighting the widespread variability and inconsistency among prescribing patterns in older adults with diabetes in US nursing homes.8 In 2012, the American Geriatrics Society (AGS) Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults challenged the widely accepted traditional practice of DM management with sliding scale insulin (SSI), which typically consists of providing patients with short-acting insulin from 4 to 6 times per day, based on finger-stick glucose level immediately prior to insulin injections. In this recommendation, the AGS suggested Continue reading >>

American Diabetes Association Releases First-ever Guidelines For Managing Diabetes In Ltc

American Diabetes Association Releases First-ever Guidelines For Managing Diabetes In Ltc

American Diabetes Association releases first-ever guidelines for managing diabetes in LTC American Diabetes Association releases first-ever guidelines for managing diabetes in LTC Hypoglycemia and care transitions are among the topics in the first-ever guidelines relating to diabetes management in long-term care facilities. Management of Diabetes in Long-term Care and Skilled Nursing Facilities , released Tuesday by the American Diabetes Association, highlights the differences in diabetes management for younger and older people. The guidelines primarily focus on type 2 diabetes, since the majority of diabetic long-term care residents have that type, according to the ADA. For older diabetes patients, especially those needing long-term care, hypoglycemia risk, commonly known as low blood sugar, is the most important factor in determining glycemic goals, the guidelines warn. Long-term care residents need plans that strike a balance in maintaining glycemic levels, the guidelines suggest. Long-term care facilities should also avoid sole use of sliding scale insulin, as it leads to wide variations in blood glucose levels, is a burden for patients and uses up more nursing time and resources, the ADA notes. Liberal diet plans are also preferable for diabetic residents, compared to therapeutic diets, as more food choices benefits nutritional needs and glycemic control. The ADA statement also stresses the importance of communication between healthcare providers and the need for patient documentation to be transferred between facilities. For end-of-life care, ADA recommends providers relax glycemic targets, simplify regimens and respect patients' right to refuse diabetes treatment. The full guidelines can be found in the February issue of Diabetes Care . Continue reading >>

Don’t Use Sliding Scale Insulin (ssi) For Long-term Diabetes Management For Individuals Residing In The Nursing Home.

Don’t Use Sliding Scale Insulin (ssi) For Long-term Diabetes Management For Individuals Residing In The Nursing Home.

Rationale and Comments: SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s insulin needs nor is it efficient in the long-term care setting. Use of SSI leads to greater patient discomfort and increased nursing time because patients’ blood glucose levels are usually monitored more frequently than may be necessary and more insulin injections may be given. With SSI regimens, patients may be at risk from prolonged periods of hyperglycemia. In addition, the risk of hypoglycemia is a significant concern because insulin may be administered without regard to meal intake. Basal insulin, or basal plus rapid-acting insulin with one or more meals (often called basal/bolus insulin therapy) most closely mimics normal physiologic insulin production and controls blood glucose more effectively. Sponsoring Organizations: American Medical Directors Association Sources: Expert consensus Disciplines: Endocrinologic Geriatric Medicine References: • Sue Kirkman M, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS. Consensus Development Conference on Diabetes and Older Adults. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012 Dec;60(12):2342-56. • American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. • Haq J. Insulin sliding scare, does it exist in the nursing home. JAMDA. 2010 Mar;11(3):B14. • Hirsch IB. Sliding scale insulin—time to stop sliding. JAMA. 2009;301(2):213-214. • American Medical Directors Asso Continue reading >>

Endocrine Society Reading Room | Managing Glycemia In Long-term Care | Medpage Today

Endocrine Society Reading Room | Managing Glycemia In Long-term Care | Medpage Today

From acute rehab to palliative care, patients' needs change This Reading Room is a collaboration between MedPage Today and: Kelsi Deaver, MD Endocrinology Fellow, PGY5 University of Colorado Aurora, CO Diabetes affects up to a third of patients living in skilled nursing or elderly residential homes, but there have not been clear guidelines for care in these facilities. The ADA created a position statement in Diabetes Care in 2016 to address this need. Specific recommendations include avoidance of sliding scale insulin alone and removing the "diabetic diet" restraint on sometimes frail, sarcopenic elderly patients. The author points out that it is critical to individualize treatment and minimize risks for each person, depending on the kind of setting they live in. Challenges may include daily alterations in appetite, mobility, dexterity for injections, delirium/dementia, and the degree of nursing care available. Minimizing hypoglycemia should be the first priority given its sometimes dire and acute consequences. Then providers should focus on reducing severe hyperglycemia, polyuria, and risk of dehydration, infection, and cognitive impairment. Treatment of those with diabetes who reside in long-term care facilities should be guided by maintaining quality of life while minimizing the risks associated with hypoglycemia and severe hyperglycemia. Diabetes is significant among patients in long-term care: as reflected across several studies, it affects 25% - 34% of people who live in skilled nursing or elderly residential facilities. Long-term care patients often fall into one of three categories: Individuals at skilled nursing facilities after a stroke, surgery, serious infection, or other event who may go home after their rehabilitation is over Persons in long-term care set Continue reading >>

Diabetes In Long-term-care And Skilled Nursing Facilities: The Ada Position Statement

Diabetes In Long-term-care And Skilled Nursing Facilities: The Ada Position Statement

US Pharm. 2016;41(10)(Diabetes suppl):7-11. ABSTRACT: As the number of elderly people in the United States continues to rise, an increasing proportion of older adults will develop diabetes and will need long-term or skilled care. In early 2016, the American Diabetes Association issued a position statement on the management of diabetes in long-term-care and skilled nursing facilities. This statement provides recommendations for the general approach to care; goals and strategies for glycemic control; diabetes management during transitions of care and end of life; and suggestions for integration of diabetes management into long-term-care facilities. Pharmacists can play an active role in each of these areas in order to help optimize glycemic control in their patients. The prevalence of diabetes in the long-term-care (LTC) setting is estimated to range from 25% to 34%,1 which is equal to or higher than trends seen in the general population. The latest National Diabetes Statistics Report (2014) estimates that, in the United States, 25.9% of persons aged ≥65 years have diabetes, compared with 16.2% of those aged 45 to 64 years and 4.1% of those aged 20 to 44 years.2 Among persons aged 65 to 74 years and those aged ≥75 years, there was an increase of 113% and 140%, respectively, in the rate of diagnosed cases of diabetes from 1993 to 2014.3 Diabetes is the seventh leading cause of death in the U.S.2 As baby boomers continue to age, the proportion of older adults with diabetes who will need nursing homes (NHs) or skilled care is expected to rise. Pharmacists who serve residents in the LTC environment must be prepared to meet this challenge. Type 2 diabetes (T2D) accounts for 90% to 95% of diabetes in the U.S. Age-related changes in older adults that predispose them to the T Continue reading >>

Ada Addresses Diabetes Management In Long-term Care Facilities

Ada Addresses Diabetes Management In Long-term Care Facilities

ADA Addresses Diabetes Management in Long-Term Care Facilities ADA Addresses Diabetes Management in Long-Term Care Facilities Position statement outlines strategies for managing diabetes in long-term care facilities. A recent position statement from the American Diabetes Association (ADA) addresses the management of diabetes in older adults in long-term care (LTC) and skilled nursing facilities (SNF), focusing on the unique needs of this diverse population.1 The statement, published in the February issue of Diabetes Care, provides clear and practical guidance, often in tabular form, that LTC and facilities can incorporate into their diabetes protocols. It emphasizes the prevention of hypoglycemia, the consideration of patient comorbidities in tailoring goals and strategies, and the adjustment of treatment for individuals at the end of life.1 The position statement addresses more specifically some of the issues discussed broadly in a 2012 ADA/American Geriatrics Society statement on diabetes in older adults, explained Hermes Florez, MD, PhD, professor of public health and medicine at the University of Miami and director of the Geriatric Research, Education, and Clinical Center at the Miami VA Healthcare System, who co-authored the 2016 statement. There is a growing concern about how to care for older patients with diabetes who have experienced significant functional decline and consequently need admission to assisted living, skilled nursing, and nursing facilities, he stated. The recent position statement addresses this concern. Of primary importance is the avoidance of hypoglycemia, which can have catastrophic consequences leading to emergency room (ER) visits and acute hospitalizations in this population, Dr Florez explained. The ADA recommends that clinicians admitti Continue reading >>

Sliding-scale Insulin: An Ineffective Practice

Sliding-scale Insulin: An Ineffective Practice

By Mark D. Coggins, PharmD, CGP, FASCP Aging Well Vol. 5 No. 6 P. 8 In the United States, approximately 26 million people have diabetes mellitus, including 10.9 million adults aged 65 or older.1 The number of those newly diagnosed with diabetes continues to rise, and the Agency for Healthcare Research and Quality reports that over the past decade there has been a 26% increase in the number of patients discharged from hospitals with a primary diagnosis of diabetes. The overall costs related to diabetes treatment place a tremendous burden on the healthcare system, with one in five US healthcare dollars being spent on the condition. Patients with diabetes typically have medical expenses that are 2.3 times higher than those of nondiabetics,1 and families with a child who has diabetes reportedly spend as much as 10% of their income on the disease.2 Beyond the financial cost, diabetes can have a tremendous negative impact on patients and their families due to associated intangibles that are more difficult to measure, such as pain, depression, anxiety, inconvenience, and a lower quality of life. Diabetes Complications The primary goal of diabetes management is to achieve a level of glycemic control that closely mimics that of nondiabetic patients in an effort to prevent the long- and short-term complications associated with the disease. Inadequate blood glucose control over an extended period of time can result in significant long-term complications affecting multiple organ systems with reduced quality of life and increased mortality and morbidity (see Table 1 below). Short-term complications related to the failure to control glycemic levels can result in symptoms associated with periods of hyperglycemia. Issues related to hypoglycemia, when severe and left untreated, can lead Continue reading >>

Original Study Sliding Scale Insulin Vs Basal-bolus Insulin Therapy In Long-term Care: A 21-day Randomized Controlled Trial Comparing Efficacy, Safety And Feasibility

Original Study Sliding Scale Insulin Vs Basal-bolus Insulin Therapy In Long-term Care: A 21-day Randomized Controlled Trial Comparing Efficacy, Safety And Feasibility

Abstract Introduction Sliding scale insulin (SSI) therapy remains a common means of insulin therapy in long-term care (LTC) for the management of type 2 diabetes mellitus, despite current recommendations not supportive of the form of therapy today. Lack of randomized trial data on the efficacy and safety of basal-bolus insulin (B-BI) therapy in nursing home residents may have precluded this form of insulin administration in the LTC setting. Our study is a comparison of the efficacy of SSI (control) and B-BI (intervention) therapies during a 21-day intervention trial in older nursing home residents. Fourteen LTC facilities in the US participated; 110 residents with type 2 diabetes volunteered to participate; 35 failed inclusion criteria, 75 signed informed written consent, and 11 were discharged to home/hospital or withdrew consent; data from 64 participants are reported. Recent fasting blood glucose (FBG), hemoglobin A1c, and chemistries were obtained. Four glucose readings (prior to breakfast, lunch, dinner, and bedtime), oral antiglycemic drug, and insulin doses and changes, and all adverse events/serious adverse events, both those related to glucose control [hypoglycemic (<70 mg/dL) and hyperglycemic (>200 mg/dL) episodes] and those unrelated, were recorded daily. Patients were randomized to either remain on SSI or be shifted to the B-BI group. Nursing home residents 80 ± 8 (standard deviation) years, 66% female participated; Control and Intervention participants had similar age, gender, race distributions, comorbidity, and 3-day average pretrial FBG levels (all P > .05). At study end, B-BI volunteers had significantly lower 3-day average FBG levels vs pretrial (P = .0231) while SSI participants had no change in 3-day average FBG (P > .05). During the trial, partici Continue reading >>

Choosing Wisely | Amda

Choosing Wisely | Amda

Ten Things Physicians and Patients Should Question in Post-Acute and Long-Term Care: 1. Don't insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings. Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient's comfort or reduce suffering; it may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems. According to William Smucker, MD, CMD, one of the AMDA members who participated in the Choosing Wisely workgroup, "People make some logical but incorrect assumptions about the potential benefits of tube feeding. As dementia progresses to the advanced stages, people have trouble eating enough to stay healthy, leading to weight loss. Since weight loss and poor nutrition can lead to problems such as functional decline and pressure ulcers, people think that tube feeding will result in reversal of these conditions. However, this isn't supported by the clinical evidence. In fact, the evidence shows that up to half of Medicare patients with advanced dementia who have feeding tubes inserted die within six months and that this inter Continue reading >>

Burden Of Sliding Scale Insulin Use In Elderly Long-term Care Residents With Type 2 Diabetes

Burden Of Sliding Scale Insulin Use In Elderly Long-term Care Residents With Type 2 Diabetes

Burden of Sliding Scale Insulin Use in Elderly Long-Term Care Residents with Type 2 Diabetes Sliding scale insulin (SSI) th Sliding scale insulin (SSI) therapy provides a suboptimal approach to glycemic control. Despite its limitations, SSI is commonly used for patients with type 2 diabetes mellitus (T2DM) in the long-term care (LTC) setting. This retrospective study assessed the burden associated with SSI use in elderly patients with T2DM in selected LTC facilities in the United States using medical chart data merged with the Minimum Data Set (MDS) assessment.[br]Patients were included if they were admitted to a LTC facility, stayed for [ge]3 months, had [ge]1 full MDS assessment, had insulin dispensed on [ge]2 occasions with no insulin pump use, and were not comatose or in hospice care during their LTC stay. Data were descriptively analyzed to provide a summary of preliminary findings from an initial sample of patients meeting the study inclusion criteria.[br]In the first wave of the study, 29 patients from 3 facilities were identified. Patients had an average of 3-months follow-up (62% female, 59% white, mean [[plusmn]SD] age of 77 [plusmn] 11.5 years, 83% having [ge]1 HbA1c value recorded, mean [[plusmn]SD] HbA1c 6.6 [plusmn] 1.0%, 67% with HbA1c [le]7%, and mean [[plusmn]SD] fasting blood glucose 137 [plusmn] 39 mg/dL). Almost all patients (n=28) were on a SSI regimen for the entire duration of follow-up, and 35% (n=10) were on a SSI regimen exclusively. On average, patients received 22 [plusmn] 6.9 SSI-related finger sticks per week, and of these an average of 16 [plusmn] 7.4 finger sticks (73% of all finger sticks administered) did not result in insulin administration because the blood glucose was below sliding scale threshold levels.[br]Despite patients in this Continue reading >>

Sliding-scale Insulin Use In Long-term Care: An Updated Perspective.

Sliding-scale Insulin Use In Long-term Care: An Updated Perspective.

Consult Pharm. 2017 Feb 1;32(2):105-108. doi: 10.4140/TCP.n.2017.105. Sliding-Scale Insulin Use in Long-Term Care: An Updated Perspective. University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA. Diabetes affects approximately 26% of individuals oldeR THAN 65 years of age in the United States and up to 33% of patients in long-term care facilities. The most commonly prescribed insulin therapy for patients in long-term care is sliding-scale insulin (SSI): the use of finger-stick blood glucose testing to assess the need for insulin administration based on current blood glucose levels. SSI has been on the Beers Criteria of Potentially Inappropriate Medications since 2012. However, its sole use for long-term treatment is specifically not recommended by the American Diabetes Association and other stakeholders in diabetes management. This review discusses recent updates to several published guidelines, including Centers for Medicare & Medicaid Services, the Beers criteria, the American Medical Directors Association, and the American Diabetes Association regarding the use of SSI-only insulin regimens for elderly patients in long-term care. Continue reading >>

Sliding Scale Insulin Vs Basal-bolus Insulin Therapy In Long-term Care: A 21-day Randomized Controlled Trial Comparing Efficacy, Safety And Feasibility

Sliding Scale Insulin Vs Basal-bolus Insulin Therapy In Long-term Care: A 21-day Randomized Controlled Trial Comparing Efficacy, Safety And Feasibility

Introduction: Sliding scale insulin (SSI) therapy remains a common means of insulin therapy in long-term care (LTC) for the management of type 2 diabetes mellitus, despite current recommendations not supportive of the form of therapy today. Lack of randomized trial data on the efficacy and safety of basal-bolus insulin (B-BI) therapy in nursing home residents may have precluded this form of insulin administration in the LTC setting. Our study is a comparison of the efficacy of SSI (control) and B-BI (intervention) therapies during a 21-day intervention trial in older nursing home residents. Methods: Fourteen LTC facilities in the US participated; 110 residents with type 2 diabetes volunteered to participate; 35 failed inclusion criteria, 75 signed informed written consent, and 11 were discharged to home/hospital or withdrew consent; data from 64 participants are reported. Recent fasting blood glucose (FBG), hemoglobin A1c, and chemistries were obtained. Four glucose readings (prior to breakfast, lunch, dinner, and bedtime), oral antiglycemic drug, and insulin doses and changes, and all adverse events/serious adverse events, both those related to glucose control [hypoglycemic (200 mg/dL) episodes] and those unrelated, were recorded daily. Patients were randomized to either remain on SSI or be shifted to the B-BI group. Results: Nursing home residents 80 ± 8 (standard deviation) years, 66% female participated; Control and Intervention participants had similar age, gender, race distributions, comorbidity, and 3-day average pretrial FBG levels (all P > .05). At study end, B-BI volunteers had significantly lower 3-day average FBG levels vs pretrial (P = .0231) while SSI participants had no change in 3-day average FBG (P > .05). During the trial, participants from both group Continue reading >>

Managing Diabetes In Long-term Care Facilities

Managing Diabetes In Long-term Care Facilities

Managing Diabetes in Long-Term Care Facilities Allan S. Brett, MD reviewing Munshi MN et al. Diabetes Care 2016 Feb . An American Diabetes Association position statement reviews the goals and strategies of treatment in such facilities. In 2012, the American Diabetes Association (ADA) first published a position statement advocating a patient-centered approach for treatment of type 2 diabetes ( NEJM JW Gen Med Aug 15 2012 and Diabetes Care 2012; 35:1364). Among other things, the statement recognized that stringent glycemic control was not appropriate for patients with limited life expectancies, extensive comorbidities, and high risk for hypoglycemia. These characteristics apply to many people in long-term care (LTC) and skilled nursing facilities, and now the ADA has issued a position statement on managing diabetes in such facilities. Intensive glycemic control is of limited benefit in this population. Avoiding hypoglycemia is paramount; patients in LTC facilities are at high risk for hypoglycemia, and their ability to recognize its symptoms often is limited. However, severe hyperglycemia also has adverse effects including dehydration, electrolyte abnormalities, and the hyperosmolar syndrome in LTC patients. Sliding scale insulin generally should be avoided; simplified treatment regimens are preferred. In LTC facilities, blood glucose and glycosylated hemoglobin measurements should be performed as necessary to lower risk for hypoglycemia and severe hyperglycemia but not to achieve tight glycemic control. Restrictive diabetic diets often are counterproductive in this setting; patients' personal food preferences should be respected. This ADA statement reminds us that many of the principles of diabetes treatment for community-dwelling adults don't necessarily apply to patie Continue reading >>

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