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Management of Diabetes Mellitus in Nursing

Diabetes mellitus (DM), primarily type 2, is a prevalent, resource-intensive


condition in nursing homes (NHs), which may have significant impact on
residents’ function and quality of life. Upon admission to a NH, 26.4% of
residents have a diagnosis of DM, including short-stay (< 6 mo) and long-stay
residents (> 6 mo), whose placement may be permanent.1 Almost half of
residents with DM will become long-stay residents.1 Compared to those admitted
without DM, residents with DM have a higher burden of comorbid disease,
disability, and cognitive impairment, pain, depression, polypharmacy, and require
more nursing care.1 Older adults with DM are at higher risk of developing several
geriatric syndromes, including injurious falls,2,3 incident disability,4 cognitive
impairment,5 urinary incontinence (UI),6 depression,7 and persistent pain,8 if not
already present. While the goals of care for short-stay and long-stay residents
may differ, avoiding iatrogenic harm is a major focus for both. This is particularly
true for frail NH residents with DM who are at high risk for hypoglycemia or other
complications of medical therapy, such as postural hypotension.
As a result, management of DM in the long-term care (LTC) setting requires
supreme clinical judgment, taking into account the resident’s care preferences,
comorbid conditions, and estimated life expectancy. All of this information must
be used to make a realistic assessment of the likely benefits and risks of
treatment for DM, and associated conditions consistent with the resident’s short-
and long-term goals.
In 2003, an expert panel convened by the California Healthcare
Foundation/American Geriatrics Society published Guidelines for Improving the
Care of the Older Person with Diabetes Mellitus. The major aim of the guideline
was to provide clinicians with a framework for prioritizing recommendations for
the management of glycemia, and preventing micro- and macrovascular disease
in the population of older adults with DM and heterogeneous health status.9 The
guideline noted that while intensive risk management is appropriate for robust
older adults with good function, it might be inappropriate in frail older adults with
limited life expectancy, where the focus of care often shifts to prevention of
symptomatic hyperglycemia and reduction of the burden of medical therapy.
Furthermore, the guideline noted that geriatric syndromes might complicate the
management of DM or constitute a primary focus of care. As a result, it
recommended that healthcare providers screen for and manage geriatric
syndromes. The guideline provides the basics of a framework to help clinicians
prioritize competing comorbidities. Subsequent guidelines by the American
Diabetes Association have included explicit reference to these guidelines and
have endorsed its message.