|Recommendation||Quality of Evidence||Strength of Recommendation|
|1. The management of patients with diabetes in the PA-LTC setting should be individualized and guided by functional and cognitive status, patient preference, and life expectancy||Low||Strong|
|2. The medication regimen for diabetes should be verified and communicated to receiving practitioners if the patient is transferred to another site of care||Low||Strong|
|3. Patients in the PA-LTC setting should be screened for diabetes or pre-diabetes unless they are terminally ill||Moderate||Strong|
|4. Factors causing or exacerbating hyperglycemia should be sought||Low||Strong|
|5. Patients with diabetes should be evaluated for the presence of macrovascular and microvascular complications||High||Strong|
|6. Patients with diabetes should be assessed for the presence of cognitive impairment||Low||Weak|
|7. Patients with diabetes should be assessed for the presence of depression||Strong||Strong|
|8. Patients with diabetes should be assessed for the presence of foot complications||Moderate||Strong|
|9. In general, patients with diabetes should be offered a regular diet||Low||Strong|
|10. In general, metformin is preferred as an initial oral medication for the treatment of diabetes in the absence of absolute or relative contraindications||Low||Strong|
|11. If treatment with insulin is required, basal insulin is the preferred initial choice if its use can achieve glycemic targets||Low||Strong|
|12. The use of sliding-scale insulin alone to control blood glucose levels should be avoided||Moderate||Strong|
|13. It is reasonable to aim for A1C targets between 7.5% and 8.5% for most patients, although higher targets may be appropriate for certain individuals||Moderate||strong|
|14. A blood-pressure goal of less than 150/90 is recommended for most older patients with diabetes||High||Strong|
|15. Statin therapy is recommended for all older patients with diabetes who are able to tolerate it and who lack contraindications||High||Strong|
|16. Blood glucose patterns should be reviewed regularly to allow logical adjustment of the pharmacological regimen||Low||Strong|
|17. Patients being treated for diabetes should be monitored for the occurrence of hypoglycemia and the treatment regimen adjusted as necessary||Moderate||Strong|
|18. The facility should monitor its management of patients with diabetes by measuring and tracking selected relevant process and outcome indicators||Moderate||Strong|
- Multimorbidity, functional impairments, and psychosocial issues increases the complexity of diabetes management in the PA/LTC.
- Cardiovascular mortality, functional impairment and cognitive decline increase with hyperglycemia.
- Hypoglycemia (frequent or prolonged) can cause cognitive impairment, falls and functional impairment. Prolonged or frequent hypoglycemia can affect cognition and increase the chance of falls, seizures and stroke.
- Cardiovascular mortality, cognitive decline, falls and functional impairment are increased in older adults with DM.
Knowledge and Skills Needed by Interprofessional Team Members
- Patient-specific issues that can affect diabetes management, such as dementia, depression, frailty, undernutrition, drug interactions, hypoglycemia risk, existing complications, and goals of care.
- Need for balancing clinical benefit with potential harm and patient preferences.
STEP 1: Is Diabetes Present?
Problems and Complications Associated With Diabetes in Older Adults
- Accelerated atherosclerosis
- Weight gain or loss
- Cognitive impairment
- Decline in ability to perform activities of daily living
- Problems with infections, vision, skin, foot, bladder and oral health
- Hyperosmolar coma
Criteria for a Diagnosis of Diabetesa
- A1C ≥6.5%, or
- FPG ≥126 mg/dL (7.0 mmol/L) (fasting is defined as no caloric intake for ≥8 h), or
- 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT, or
- In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L)
a In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing.
Laboratory Values Indicating Prediabetesa
- 2-h plasma glucose in the 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) (IGT)
- A1C 5.7–6.4%
a For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range.
STEP 2: Screen for Possible Diabetes in Patients Without a Diagnosis
- Elevated blood glucose with acute change of condition and symptoms of diabetes.
- Elevated blood glucose on incidental lab test or in accompanying records.
- Current use of antipsychotic medication.
STEP 3: Identify Factors Contributing to the Patient’s Diabetes
- Acute illness
- Metabolic syndrome
- Pancreatic disease
- Glucocorticoid use
STEP 4: Evaluate the Nature and Severity of Diabetic Complications
- Screening for complications of diabetes should be individualized, with a focus on those that could lead to impaired function.
Suggested Approach to Screening for Diabetes-Associated Complications
Assess the patient for the following conditions if appropriate:
- Coronary artery disease (symptomatic)
- Heart failure, hypertension
- Neurogenic bladder
- Peripheral neropathy
- Depression, dementia
- Vision or hearing impairment
- Suboptimal foot care, foot ulcers
- Gait imbalance
- Periodontal disease, tooth loss
STEP 5: Identify the Impact of Diabetes on the Patient and Summarize the Patient’s Condition
- Interprofessional assessment within 14 days to assess physical, functional and psychosocial effects of diabetes.