Diabetes Management

Angie Szumlinski
June 24, 2013

Dr. Naushira Pandya, CMD and Dr. Meenakshi Patel were recently quoted in an article published by the American Medical Director’s Association:

“In 2013 and beyond, diabetes management in the nursing home involves individualizing care and eliminating sliding scale insulin dosing”. 

What does this mean to us, the caregivers of frail, elderly residents with diabetes diagnoses?  It means a lot in how we manage the care of these individuals while maintaining blood glucose and HgbA1c levels.  The article published in the June, 2013 issue of “Caring for the Ages” discusses why the use of sliding scale insulin in the management of diabetes in the elderly is no longer the standard. 

The goal of diabetes management is to prevent episodes of hypoglycemia.  Studies have shown that the persistent use of sliding scale insulin regimens which can lead to both hypoglycemia and hyperglycemia has recently been singled out by several professional medical groups as a practice that should be replaced with more physiological approaches.  Additionally, sliding scale insulin was added to the Beers Criteria in February 2012!

Several new guidelines address diabetes management in the elderly.  Though they differ somewhat on specifics, all generally call for personalization of treatment goals, less restrictive diets and looser numeric targets for blood glucose and blood pressure than those used to guide therapy in younger diabetes patients. 

In addition to the new guidelines, the AMDA also identified several potential F Tag citations related to diabetes outcomes including:

  • F 309 – Quality of Care – residents with poorly controlled diabetes can experience symptoms of hypoglycemia that may result in neurological sequelae, hyperglycemia that can lead to malaise, worsening neuropathic pain, poor wound healing, incontinence secondary to polyuria, and occasional dehydration.
  • F 314 – Wound Care – Hyperglycemia can delay wound healing, and diabetes is associated with increased risk for pressure ulcers because it takes less pressure on a diabetic heel to produce the same injury in someone without diabetes.
  • F 315 – Urinary Incontinence – Patients with diabetes may be at greater risk for or worsening of incontinence because of the combination of polyuria resulting from hyperglycemia and glycosuria, neuropathy and leg weakness or gait instability.
  • F 323 – Environment – Patients with diabetes who are rushing to the bathroom because of urgency, worsening neuropathy or cognitive impairment may be at increased risk for falls, particularly in the setting of hypoglycemia or blurred vision due to significant hyperglycemia.
  • F 329 – Inappropriate Medication Management – Prolonged, nonemergency use of sliding scale insulin is inappropriate
  • F 501 – Medical Director’s Role – Includes developing policies for eliminating sliding scale insulin use and moving toward more appropriate medication regimens.

Okay now that I have your attention, (talking about citations always does that), are your systems in line with the most recent recommendations?  Are your residents being provided with appropriate care and services to prevent negative outcomes related to their diabetes diagnosis?  If you aren’t sure, take some time to review what your current practices are regarding diabetic management.  If you need assistance please refer to the following resources and as always, feel free contact your HealthCap Risk Manager. 




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