RCNi Portfolio and interactive CPD quizzes, RCNi Learning with 200+ evidence-based modules, 10 articles a month from any other RCNi journal. … is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB4HP19211 “Geriatric Education Centers.”. Enter multiple addresses on separate lines or separate them with commas. 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 understanding requires knowledge of the patient population as well as the functioning of the facilities. As patients move into this phase, the importance of glycemic control is less apparent and preventing hypoglycemia is of greater significance. 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). Original Article . At the patient level, improvement is recommended for advocacy and social support, disease state knowledge, empowerment and self-efficacy, health literacy/fluency, and cognitive status. Additionally, the IAGG and EDWPOP have called to reduce the prevalence and burden of pressure ulcers (13). Nursing leadership training programs for nurses working in LTC facilities that include skills in diabetes management can also help to improve quality of care offered to patients in these facilities (55,56). These guidelines emphasize that frail patients with cognitive impairment may present with atypical symptoms, mainly neuroglycopenic or behavioral in nature. Thus, a five‐step process was used, namely formulation of the review question, literature search, critical appraisal of guidelines identified, data extraction and data analysis. (1991). European Heart Journal, November 20, 2020 Lessons Learned on Increasing Nursing Student Diversity OJIN: The Online Journal of Issues in Nursing , November 19, 2020 Buy now. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. To avoid dehydration and unintentional weight loss, restrictive therapeutic diets should be minimized. Notes. Patient and caregiver education regarding the telltale signs of dehydration and hypoglycemia and an appropriate plan of action is of vital importance. Killion, Molly M. MS, RN, CNS; Article Content It is estimated that 6% to 9% of pregnancies are complicated by diabetes; approximately 90% of which are gestational diabetes mellitus (GDM) (American College of Obstetricians and Gynecologists [ACOG], 2017). Diabetes is a common, morbid, and costly disease in older adults. Plastic surgical nursing: official journal of the American Society of Plastic and Reconstructive Surgical Nurses, 11(1), 20-25. To achieve goals, it is acknowledged that the notion of a “diabetic diet” is outdated and that a more liberal diet may be appropriate among LTC patients. Specific recommendations for management of hyperglycemia, hypoglycemia, corticosteroid use, and education for patients and families are well described in a recent guideline (50). We do not capture any email address. 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. However, there is no clearly defined practical guide to switch patients who are admitted to LTC from SSI to basal–bolus insulin. 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). Everyday nursing work, including diabetes management, is mediated through talk [ 17 ], and there is increasing recognition in the research literature that nurse-patient encounters have both a content component and a relational component, both of which are important [ 18 – 20 ]. The high prevalence of diabetes among older adults has contributed to the unsustainable growth of health care costs in the U.S. The aim of this study was to investigate the effectiveness of a nurse-led diabetes self-management education on glycosylated hemoglobin. Interventions for self-management of type 2 diabetes: An integrative review. 1. 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. One theory is that this may be linked to the switch to a diet more typical of developed countries – that is, one rich in high glycaemic index foods (World Health Organization, 2016; Carrera-Bastos et al, 2011). Inadequate communication between inpatient and outpatient providers and a lack of an effective communication infrastructure contribute to poor patient outcomes (35,36). While carbohydrate intake should be taken into consideration, “no concentrated sweets” or “no sugar” diet orders are ineffective for glycemic management and should not be recommended. In the long-term care (LTC) population, the prevalence of diabetes ranges from 25% to 34% across multiple studies (2–4). doi: 10.7748/ns.2018.e11250, Palk LE (2018) Assessing and managing the acute complications of diabetes mellitus. Certain conditions such as cognitive dysfunction, depression, physical disabilities, eating problems, and repeated infections are commonly found in the LTC population. is a consultant for Sanofi and Novo Nordisk. 2. 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. These documents include a table that covers the essential information that should accompany every transitioning patient, an AMDA Universal Transfer Form, the Recommended Elements of a Discharge or Course-of-Treatment Summary, Practitioner Request for Notification of Medication Changes, and an Example of a Skilled Nursing Facility-to-Emergency Department transition. The LTC facility should have processes in place for planned and, even more importantly, unplanned transitions. 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. Clear and direct communication of treatment plans and follow-up expectations with patients and/or caregivers by health care providers is critical to decrease patient/family barriers. This population is heterogeneous and presents unique challenges pertaining to diabetes management. Abstract: Diabetes mellitus is a chronic disease impacting glucose metabolism. Diabetes Management Journal intends to publish peer-reviewed, original articles that address the global health concerns related to diabetes. The Journal Impact 2019-2020 of Journal of Diabetes Nursing is 0.230, which is just updated in 2020.Compared with historical Journal Impact data, the Metric 2019 of Journal of Diabetes Nursing grew by 4.55 %.The Journal Impact Quartile of Journal of Diabetes Nursing is Q3.The Journal Impact of an academic journal is a scientometric Metric that reflects the yearly average … 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 raise awareness of the condition, Diabetes UK has launched the 4Ts campaign, which highlights the four most common symptoms of diabetes. Whereas some patients may have extremely painful symptoms, others with a more marked neuropathic deficit may be asymptomatic. LTC costs for people with diabetes were estimated at $19.6 billion in 2012 (5). The 2012 ADA consensus report states that goals that minimize severe hyperglycemia are indicated for all patients (9). It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities. Persistent SSI use leads to wide blood glucose excursions. The authors acknowledge Dr. Jane L. Chiang's invaluable editorial contribution throughout the development of this position statement. Transitional care is defined as “actions that ensure coordination and continuity of care and are based on a comprehensive care plan” (32). This article aims to enhance nurses’ knowledge of the acute metabolic complications of diabetes, such as diabetic ketoacidosis and hyperosmolar hyperglycaemic state, to assist in their recognition and management in clinical practice. Several organizations have developed diabetes guidelines for patients living in LTC settings. Prev Article Next Article . Nurses have a key role to play in the prevention, treatment and management of diabetes. The clinical complexity and functional and psychosocial heterogeneity of the older population in LTC facilities require innovative thinking and individualized strategies to care for them (7,21–24). 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. About this journal. 3. hyperglycaemia - Ford-Dunn et al. Focused, interprofessional quality improvement initiatives have been shown to decrease hypoglycemia rates and improve processes of diabetes care in skilled nursing facilities (42). B, Simplified treatment regimens are preferred and better tolerated. Type 1 diabetes … A two-arm parallel-group randomized controlled trial with … Randomized controlled trials have found DSFs favorable to SFs for blood glucose management. All relevant guidelines were subsequently … Diabetes Educator (TDE) is a peer-reviewed bi-monthly journal that serves as the official research publication of the Association of Diabetes Care and Education Specialists.TDE publishes papers on aspects of patient education; professional education; population, cardiometabolic and public health; and technology-based needs while serving as a … Barriers at the patient or family level may include limited disease state knowledge and erroneous or unrealistic expectations. Diabetes mellitus most often results in defects in insulin secretion, insulin action, or even both. Diabetes-specific enteral nutrition formulas (DSFs) (e.g., Glucerna, Glytrol, Diabetisource AC) are available to help to manage glycemic excursions during tube feedings. 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). 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. Studies have reported that nurses, compared to other healthcare professionals, are more likely to promote preventive healthcare seeking behaviors. Liberal diets have been associated with improvement in food and beverage intake in the LTC population to better meet caloric and nutrient requirements (27). Once the challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life. The type of activity recommended should depend on the patient’s current level of activity and ability. 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. R.R.K. These characteristics have frequently been used to exclude older individuals from randomized clinical trials. 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. Moreover, patients in LTC are now more likely to undergo invasive interventions and treatments such as gastrostomies for enteral feeding, hemodialysis, prolonged courses of intravenous antibiotics, advanced wound care treatments, and even chronic ventilator management. Management of these conditions requires an in-depth knowledge of blood glucose monitoring. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. The epidemic growth of type 2 diabetes in the U.S. has disproportionately affected the elderly. Journals & Books; Help Download PDF Download. 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. Adjustments to treatment regimens can be made by telephone, fax, or order entry into electronic health records. (52) questioned the benefit of tight glycemic control and raised the concern about potential harm in patients with diabetes approaching the end of life. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. Almost all of these guidelines emphasize the need to individualize care goals and treatments related to diabetes, the need to avoid sliding scale insulin (SSI) as a primary means of regulating blood glucose, and the importance of providing adequate training and protocols to LTC staff who may be operating without the presence of a practitioner for prolonged periods. You can also register with journals to receive email alerts about their latest publications and content. B, Physical activity and exercise are important in all patients and should depend on the current level of the patient’s functional abilities. But if you have diabetes, you need to know how foods affect your blood sugar levels. Diabetes self-management education and support (DSMES) addresses the comprehensive blend of clinical, educational, psychosocial, and behavioral aspects of care needed for daily self-management and provides the foundation to help all people with diabetes navigate their daily self-care with confidence and improved outcomes (1, 2). In addition, Wagle (44) provides a sample form using an electronic medical record. Thus, the need to obtain further testing or outpatient follow-up may not be adequately communicated or coordinated by the LTC providers (38). diabetes - Therefore, the need to restart oral therapies (e.g., metformin), typically discontinued in the inpatient setting, can be overlooked. LTC facilities that are noncompliant may be subject to financial penalties. Acknowledgments. Diabetes Mellitus Nursing Care Plan & Management. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. 331 Views 0 CrossRef citations to date Altmetric Original Articles Long-term treatment management of diabetes mellitus. Despite the reported increase in the rate of palliative care enrollment over the past 2 decades, about one-third of patients have been enrolled within last 2 weeks of their lives, preventing them from receiving the full benefits of palliative care services. 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). 1. F-tags can be given at an annual state licensing survey or in response to a complaint survey at any time of the year. Consensus exists on reducing or avoiding the intake of processed red meats, refined grains and sugars (especially sugar sweetened drinks) both for prevention and management of type 2 diabetes, again with some cautions. High staff turnover is another issue that may affect the continuity of care of LTC patients (41). The management strategies for community-dwelling and hospitalized patients with diabetes have been previously described by the American Diabetes Association (ADA) (9,10). Use the following to access and submit articles about diabetes care to leading journals. E. Concerns about diabetes management at end of life have been reported by providers (45), but until fairly recently, no guidelines were available. The presence of cognitive impairment coupled with hypoglycemia unawareness puts some older adults with diabetes in LTC facilities at increased risk because they may not recognize and/or fail to communicate hypoglycemia to their caregivers. E.S.H. International Journal of Nursing Sciences. Careful evaluation of comorbidities and overall health is needed before developing goals and treatment strategies for diabetes management. The guidelines are fairly nonspecific with regard to choice of glucose-lowering agents but advise practitioners to avoid the use of SSI and to transition to scheduled basal insulin (and prandial as required) shortly after admission. Nurses commonly encounter patients with type 1 or type 2 diabetes mellitus in their practice. Along with the AMDA guidelines, guidelines from the ADA, the International Association of Gerontology and Geriatrics (IAGG), and the European Diabetes Working Party for Older People (EDWPOP) have provided selective guidance for LTC populations. In terms of A1C goals, the AMDA guidelines are also consistent with those recommended in the 2012 ADA consensus report (9). Therefore, it is important to have timely discussions about nutritional support, advance directives, and ethical issues, involving the patient, family, and caregivers in the decision process. 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). Many other glucose-lowering agents are now available; Table 4 outlines the advantages, disadvantages, and caveats in using common glucose-lowering agents in the LTC population. The ADA consensus panel identified the challenges of caring for patients in LTC facilities, such as irregular and unpredictable meal consumption, inadequate staffing, and frequent transitions in care (9). Early identification of patients who require end-of-life care is critical. Type 1 diabetes or (also known as insulin-dependent diabetes mellitus (IDDM) and juvenile diabetes melliuts) is a chronic illness characterized by the body… Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. Most practitioners in this case would simply withdraw all oral hypoglycemic agents and stop insulin in most patients with type 2 diabetes. MCN, The American Journal of Maternal/Child Nursing. Thus, glycemic goals for patients in LTC are guided by preventing hypoglycemia while avoiding extreme hyperglycemia. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. Practitioners must use this stage to begin a dialogue with patients and caregivers about reducing the intensity of glycemic control. Furthermore, the lack of a readily available complete interprofessional care team may present challenges for nursing staff providing daily care, especially when clarifying medication orders due to formulary conversions or trying to answer questions from patients or family members (30). Additionally, pending results, such as those regarding renal function after contrast dye studies are performed, may not be shared with the LTC facility, leading to test duplication. Glycemic goals in particular are dependent on the patient’s risk of hypoglycemia. Characteristics of older adults and their diabetes management based on living situation. Table 2 provides a framework for considering treatment goals for patients living in different settings, facing distinct clinical circumstances. It is an open access, online, international journal with a primary objective to reach the readers and researchers … It's not only the type of food you eat but also how much you eat and the combinations of food types you eat.What to do: 1. However, risk of hypoglycemia remains high with insulin in this population, especially due to irregular eating patterns, evolving health status, and the inappropriate use of SSI. It is also a burden for patients and requires significant nursing time and resources (26). E, At the time of admission to a facility, transitional care documentation should include the current meal plan, activity levels, prior treatment regimen, prior self-care education, laboratory tests (including A1C, lipids, and renal function), hydration status, and previous episodes of hypoglycemia (including symptoms and patient’s ability to recognize and self-treat). 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. E, Liberal diet plans have been associated with improvement in food and beverage intake in this population. Self-Management Toolkit for High-Risk Patients With Type 2 Diabetes and the Effect on Nurses' Confidence Across existing guidelines, one consistent recommendation is to avoid the sole use of SSI, which was recently added to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (25). Using these forms can facilitate the development of a process for the transition of patients and improve safety and quality of diabetes care. The therapeutic decisions for diabetes management at end of life should be made after consideration of 1) risk of hypoglycemia and hyperglycemia, 2) presence of geriatric syndromes and comorbidities, and 3) life expectancy. 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. Table 5 provides strategies to convert insulin treatment from an SSI-based regimen to scheduled insulin therapy. Journal Veterinary Nursing Journal Volume 22, 2007 - Issue 12. glycaemic control - At this point, care is focused on patient comfort and preparatory bereavement counseling for caretakers and patients, where appropriate. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548. some type 2 diabetes patients may measure their glucose levels and would normally test daily; type 2 diabetes is a progressive condition and even with metformin and diet only, patients may need to test their blood glucose periodically to observe trends in rising blood glucose. Oral glucose-lowering agents are preferred, as are simplified insulin regimens with a low hypoglycemic risk and avoidance of complex regimens with higher treatment burden, to reduce the risk of adverse effects and medication errors (48). Description . Hypoglycemia risk is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Beyond these long-term goals of care, the AMDA guidelines provide recommendations to LTC staff regarding when to call a practitioner (11). Age-related decrease in β-adrenergic receptor function and defective glucose counterregulatory hormone responses increase the vulnerability of older adults to severe hypoglycemia (6). Learn about carbohydrate counting and portion sizes. Available from, Sign In to Email Alerts with your Email Address. Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. Healthy eating is a cornerstone of healthy living — with or without diabetes. Journal of diabetes science and technology, 4(3), 750-753. However, this recommendation about DSFs remains controversial in the LTC population (28,29). Unlike in older adults living in the community, insulin injections for individuals in LTC are usually given by the facility staff. Commonly found comorbidities in LTC and strategies to improve diabetes care. Patients admitted to LTC facilities are not seen daily by a practitioner. The most extensive guideline available was developed by the American Medical Directors Association (AMDA) (11). However, in most patients residing in LTC facilities with type 2 diabetes, a high frequency of capillary monitoring of blood glucose should only be considered under special circumstances (e.g., starting corticosteroids) and where the danger of hypoglycemia is particularly high (e.g., with significant nutritional problems). These could include sharing data with managerial staff, providing staff education, and planning a performance improvement project. A review of the literature, Evaluation of a leadership development academy for RNs in long-term care, Evaluation and Management of Youth-Onset Type 2 Diabetes: A Position Statement by the American Diabetes Association, Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association, Diabetes and Hypertension: A Position Statement by the American Diabetes Association, Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, http://www.idf.org/sites/default/files/IDF-Guideline-for-older-people-T2D.pdf, http://www.guideline.gov/content.aspx?id=45527, Diabetes Management During Transitions of Care, Diabetes Management in Patients at End of Life (Including Issues for Palliative Care and Hospice Patients), Integration of Diabetes Management Into LTC Facilities. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Building on a core set of principles from these guidelines, this position statement elaborates on unique features of diabetes management in patients in LTC facilities and provides practical strategies to the clinical staff caring for them. The last 90 years have seen considerable advances in the management of type 1 and type 2 diabetes. E. The challenge of caring for older adults with diabetes arises not only from their clinical heterogeneity but also from their considerable variability in living arrangements and social support, which significantly impacts diabetes management. The effects of diabetes mellitus on wound healing. Nursing science could benefit from the feasible translation of the theory in diverse clinical settings to generate health-promoting behavioral interventions for individuals with diabetes and other … 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. 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. No other potential conflicts of interest relevant to this article were reported. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. Government. R.R.K. Diabetes management in the long term care setting [Internet], 2010. E. Patients admitted to LTC facilities are typically seen by a medical provider at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Most pediatric patients with diabetes have type 1 diabetes mellitus (T1DM) and a lifetime dependence on exogenous insulin. nursing management of gestational diabetes mellitus as no such analysis has been found. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. The guidelines recommend that LTC facilities develop their own facility-specific policies and procedures for hypoglycemia treatment. N.P. Diabetes mellitus (DM)is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin, an anabolic hormone. Table 6 delineates the practical recommendations for the LTC staff in management of specific situations in patients with diabetes. In recent years, great emphasis has been placed on the role of nonpharmacological self-management in the care of patients with diabetes. 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. Agency for Healthcare Research and Quality. Dunning et al. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life. Management of diabetes among older adults residing in LTC facilities is challenging due to heterogeneity in this population. Diagnosis requires careful examination of the lower limbs. 2. type 1 diabetes - Several conditions may result in hypoglycemia (anorexia–cachexia syndrome from chemotherapy and opiate analgesics, malnourishment, swallowing disorders). To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. Average medical expenditures for people with diagnosed diabetes were 2.3 times higher than among people without diabetes. Duality of Interest. The high prevalence of diabetes in older adults is due to age-related physiological changes, such as increased abdominal fat, sarcopenia, and chronic low-grade inflammation, that lead to increased insulin resistance in peripheral tissues and relatively impaired pancreatic islet function (6). Explore this zone to keep up with what’s happening in diabetes nursing. About one-fourth of patients of this system receive … In practice, patients are seen within the first week of admission and also when medically necessary (although this may be several days after an event or change of condition). Advanced. Similarly, Angelo et al. Pain is an important component of end-of-life management. Possible strategies to manage diabetes in some of these clinical presentations are described in Table 3. These patients tend to have compromised self-care due to end-stage disease itself in addition to fatigue and drowsiness from medicines. Management of these conditions requires an in-depth knowledge of blood glucose monitoring. 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 … 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). Poorly executed transitional care can result in significant financial burdens for patients, payers, facilities, and the U.S. health care system as a whole. Advantages, disadvantages, and caveats in using glucose-lowering agents in LTC population. Diabetes management in older adults requires careful assessement of clincial, functional, and psychosocial factors. Because of this reality, successful diabetes care needs to include a dedicated interprofessional team. It provides clinicians with the latest findings and opinions on the optimum therapies to check the ever expanding diabetes. We use cookies on this site to enhance your user experience. Comorbidities in patients with diabetes present challenges and special consideration when the patient has limited life expectancy. insulin therapy - A key to many diabetes management plans is learning how to count carbohydrates. 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. Management of the disease is especially important because diabetes can lead to numerous complications, including kidney, eye and nerve issues. (46) proposed the development of one of the first clinical practice guidelines for diabetes and end-of-life care (47). 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 … Approximately 90% to 95% of newly diagnosed cases of diabetes are T2DM. insulin resistance - However, physical activity should be encouraged in all individuals to improve independence, functionality, and quality of life. 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. 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. insulin - Background: Early screening, ... Journal of Advanced Nursing, 52, 546). 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. Programs to enhance mobility, endurance, gait, balance, and overall strength are important for all patients in LTC facilities. However, we have suggested specific recommendations for patients with type 1 diabetes when appropriate. It discusses the causes, pathophysiology and treatment of these complications, which are regarded as potentially life-threatening medical emergencies. These guidelines include a 12-step program for LTC staff that comprises all phases of diabetes care from diabetes detection to institutional quality assessment. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. You will find relevant clinical articles, including must-read recommendations, Self-assessment and Journal Club articles for CPD, and related news and opinion. This system means that patients may have uncontrolled blood glucose levels or wide excursions without the practitioner being notified. As the challenges and self-care responsibilities change in these different environments, different recommendations are needed for each setting on how to manage diabetes in individual patients (Table 1). 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. 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. is supported in part by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (K23-DK093583). 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. Journals & Books; Register Sign in. Diabetes mellitus is a group of metabolic diseases that occurs with increased levels of glucose in the blood. Multiple factors increase the risk of hypoglycemia in older adults, including impaired renal function, slowed hormonal regulation and counterregulation, variable appetite and nutritional intake, polypharmacy, and slowed intestinal absorption (17). These patients are inclined to simply continue with their previous regimen. • 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). Type 2 diabetes mellitus (T2DM) stems from the inability of the body to utilize endogenous insulin properly. Advanced age is associated with higher rates of cognitive dysfunction, causing difficulty in carrying out complex care activities such as glucose monitoring and adjustment of insulin doses. These formulas generally have lower carbohydrate and higher monounsaturated fat content compared with standard formulas (SFs). type 2 diabetes, Alternatively, you can purchase access to this article for the next seven days. Prof MacLean of Guy's Hospital wrote in the Postgraduate Medical Journal in 1926 about the numerous challenges that faced patients and their healthcare professionals in delivering safe and effective diabetes care at that time. This article focuses on the initial treatment of T2DM based on the 2017 American Association of Clinical … Author links open overlay panel Roger Carpenter a Toni DiChiacchio b Kendra … At the system and provider level, there is a focus on accountability, communication, timely interchange of information, identification of medical home or coordinating clinician, coordination of care across the continuum, national standards, and standardized metrics for quality improvement. This leads to an increased concentration of glucose in the blood (hyperglycaemia). E, Decreasing complexity of treatment and a higher threshold for additional diagnostic testing including capillary monitoring of glucose should be considered. There is very little role for measuring A1C in these patients. Glucose-lowering medications also require attention to comorbid conditions and other medications to avoid side effects and drug interactions. E, Diabetes management in LTC patients (residents) requires different approaches because of unique challenges faced by this population and the workings of LTC facilities. 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). The older diabetes population is highly heterogeneous in terms of comorbid illnesses and functional impairments. Framework for considering diabetes management goals. In addition, continuance of SSI after admission or transfer back to the LTC facility is a long-standing problem for patients with diabetes (26). Nursing Standard. The middle range theory has the potential to masterfully influence individuals’ response to diabetes-related stress, thus resulting in better diabetes self-management behaviors. The presenting symptoms of hypoglycemia in older adults can be primarily neuroglycopenic (confusion, delirium, dizziness) rather than adrenergic (palpitation, sweating, tremors) (20). diabetic ketoacidosis - They proposed three strata for management of patients with diabetes and advanced disease. This report was written to highlight the main aspects of nursing management for patients with Type 2 diabetes. Self-Management Education. 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. In fact, more than 10 per cent of people living with 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). One of the more troubling complications of this disease is the risk of developing a foot ulcer. is supported in part through the following grants: Midcareer Investigator Award in Patient-Oriented Research (K24 DK105340), the Chicago Center for Diabetes Translation Research (P30 DK092949), and a project grant (R01 HS018542). 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. One way to improve the timely identification of patients that might benefit from earlier enrollment in palliative care would be to use diabetes registries in collaboration with the palliative care team and primary care services. Tables 4 and 5 provide additional information on insulin therapy. It is the most common endocrine disease; since 1980, prevalence has risen from 4.7% to 8.… 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. Diabetes Care is a journal for the health care practitioner that is intended to increase knowledge, stimulate research, and promote better management of people with diabetes. doi: 10.7748/ns.2018.e11250, This article has been subject to external double-blind peer review and checked for plagiarism using automated software, blood glucose - 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). 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. The Journal of Continuing Education in Nursing. 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. In response, LTC facilities have shifted away from therapeutic diets, offering a wider variety of food choices, addressing personal food preferences, and providing dining options in regard to time and type of meals. The strongest predictors of severe hypoglycemia have been found to be advanced age, recent hospitalization, and polypharmacy (18,19), all of which are common in the LTC population. 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. © 2020 by the American Diabetes Association. hypoglycaemia - Challenges specific to staff and practitioners include multiple changing treatment approaches, lack of team communication, excessive reliance on SSI, inappropriate dosing or timing of insulin, knowledge deficits, lack of comfort with new insulin and injectable agents, failure of timely stepwise advance in therapy, failure to individualize care, and therapeutic nihilism. 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. 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. Terranova, A. These practitioners are responsible for the primary management of diabetes and can refer their patients with diabetes to specialty care (e.g., endocrinology, ophthalmology, renal care, and podiatry) and educational resources (e.g., a diabetes nurse educator, the nutrition clinic, and diabetes group management). was an advisory group member for AstraZeneca as part of a 1-day meeting. M.N.M. Nursing Standard. Some older adults live independently, some in assisted care facilities that provide partial support with medical management, and some in fully supervised LTC facilities. It is not always possible to decrease the frequency of capillary glucose monitoring in patients with type 1 diabetes. 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. Funding. 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. Thank you for your interest in spreading the word about Diabetes Care. 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. (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. 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). Well-designed systems of care, thorough documentation, and appropriate communication can help to alleviate some of the problems associated with high staff turnover and meet the often complex care needs of patients with diabetes. 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