Managing Diabetes in Older Adults: Current Approaches in Long-Term Care Facilities

Abstract

Purpose of Review

This narrative review aims to explore the literature on advancements in diabetes management within long-term care facilities (LTCFs). Managing chronic diseases like diabetes in LTCFs is particularly challenging due to the dynamic nature of these environments and the significant changes they have undergone over the past decade. Various factors, including rising care costs and government regulations, influence the quality-of-care residents receive in these settings.

Recent Findings

Many diabetes medications have not been extensively studied in LTCFs, and high-risk medications such as sulfonylureas and sliding scale insulin are still in use, potentially increasing the risk of morbidity and mortality among residents. Additionally, the adoption of diabetes technologies, such as continuous glucose monitors (CGMs) and insulin pumps, remains limited in LTCFs.

Summary

Despite the high prevalence of diabetes, significant research gaps persist. Diabetes technologies have the potential to greatly improve diabetes management and outcomes for residents. However, more research is needed to evaluate their efficacy and safety in long-term care settings. Furthermore, there is a pressing need to address the gap in staff training on the use of these technologies. Closing these research gaps is essential for developing evidence-based guidelines and improving the quality of diabetes care in LTCFs.

Introduction

Care for older adults has evolved significantly over the past century. In 1935, the Social Security Act introduced the Old Age Assistance (OAA) program to help states provide financial aid to low-income senior citizens, regardless of their work history. This act laid the foundation for developing long-term care institutions, which are now heavily regulated by the Centers for Medicare & Medicaid Services (CMS) [1, 2]. Today, long-term care facilities offer various levels of services, including nursing homes (NH), skilled nursing facilities (SNF), and assisted living facilities (ALF). The length of stay in these settings can vary widely, with averages ranging from few weeks to a number of years [3].

As of 2020, there are over 15,000 nursing homes in the U.S., accommodating 1.6 million residents [4]. Most of these residents are older adults, with those aged 65 and above making 80% of the population [5]. By 2060, the number of people aged 65 and over is projected to reach 94.7 million, accounting for 23.4% of the U.S. population, compared to 56.1 million (16.9%) in 2020. The population of adults aged 85 and older is also expected to grow rapidly, from nearly 7 million to 19 million by 2060. Additionally, only 10% of current U.S. homes are aging-ready, which will place significant pressure on expanding nursing homes in the future [5].

Projections from CMS estimate that spending on long-term care facilities will increase from $209.3 billion to $337.4 billion over the next decade [6]. Nursing home expenses are typically covered by state Medicaid programs, while Medicare funds post-acute care following hospitalization [5]. To manage rising costs and improve care quality, CMS has introduced bundled payment initiatives for post-acute care services, which cover a range of services, including laboratory tests and durable medical equipment [7].

CMS also utilizes a rating system to assess facilities it covers, evaluating multiple metrics such as clinical outcomes and staffing levels, which gained increased interest during the COVID-19 pandemic. Prior to 2020, it was reported that three out of four nursing homes failed to meet the minimum nursing personnel requirements set by CMS and experienced significant turnover [8]. In 2021, one-third of nursing homes in the United States reported staff shortages within a four-week period, predominantly affecting nursing staff [9].

In summary, long-term care facilities are dynamic environments where multiple factors affect the quality of care provided to their residents. Government regulations, reimbursements, staffing, and other system-level factors will directly affect the care delivered for chronic conditions, such as diabetes.

Diabetes Prevalence and Trajectories

Global diabetes prevalence is expected to increase by nearly 60%, reaching 1.3 billion individuals between 2021 and 2050 [10]. In the US, diabetes affects 1 in 10 individuals, approximately 38.4 million people as of 2021 (ADA, CDC) [11, 12]. Among older adults, 1 in 3 is affected by diabetes, totaling 16.5 million; this figure is expected to rise to 26.7 million by 2050, with the majority diagnosed with type 2 diabetes (T2D) [13–15]. According to the CDC, the incidence rate per 1,000 is more than doubled in older adults compared to those aged 18–44 (6.8 vs. 3.0). Furthermore, the prevalence of prediabetes is highest among older adults, reaching 48.8% [16].

Between 1990 and 2019, the prevalence of type 1 diabetes (T1D) in older adults worldwide increased from 400 to 514 per 100,000 individuals. In North America, the age-standardized prevalence of T1D among older adults also rose from 1,051 to 1,248 per 100,000 during the same period [17]. With significant gains in life expectancy, a reduction in diabetes-related mortality, and the United States leading the world in newly diagnosed cases of T1D, there will be increasing pressure to enhance accommodations, provide advanced diabetes technology, and specialized training for healthcare providers in both geriatric care and diabetes management [17, 18]. In LTCF, the prevalence of diabetes is estimated to be between 24 and 34% which is expected to rise in these settings for both T1D and T2D in the future [19–21].

Furthermore, diabetes disparities have been documented extensively, with some racial and ethnic minority and underserved populations having a higher prevalence of diabetes [22]. Hispanic and non-Hispanic Black patients have the highest prevalence of diabetes (> 20%), compared to non-Hispanic white adults (12.1%) [23]. Inequities also exist in the trend of prescribing newer DM medications such as Glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose co-transporter 2 (SGLT-2) inhibitors [24]. This extends to older adults with T2D where a low proportion of ethnic or racial minorities survive to into their 80s or older [25]. According to the CDC, in older adults, the prevalence of diabetes is significantly higher among Blacks and Hispanics than among non-Hispanic Whites, with rates of 37%, 38%, and 25%, respectively, in 2017 [26]. It was also reported that older adults from minority groups receive low-quality care and are more often co-diagnosed with diabetes complications [26]. Furthermore, following discharge from the hospital, older adults who are from racial or ethnic minorities were less likely to receive home health services within 14 days when compared to non-Hispanic Whites [27]. It was also noted that the majority of Blacks and Hispanics were admitted to a small portion of SNFs that are currently available in the US. These facilities also had a poorer quality of care and often missed quality metrics such as re-hospitalization, and Medicare five-star quality ratings [28]. Significant inequalities also extended to those residents in long-term care facilities, according to multiple reports [29, 30].

The Cost of Diabetes

In 2022, the total cost of providing care to individuals with diabetes nationwide exceeded $400 billion [12]. The proportion of healthcare expenditures attributed to diabetes for the older adult population increased from 61% in 2017 to 67% in 2022. Per capita healthcare expenditures attributable to diabetes were highest for those over 65, with $533 spent per person compared to $251 for younger adults. Consequently, yearly attributable healthcare expenditures per person for older adults with diabetes exceeded those of younger adults by nearly $10,000 ($17,180 vs. $7,482) [12].

Compared to younger adults, older adults accounted for 71% of all nursing home days. This difference was reflected in health expenditures, with older adults incurring $6.363 billion in costs, compared to $3.217 billion for younger adults in 2022 to pay for LTCF days utilization. Older adults also accounted for 61% of home health visits and 76% of medication prescriptions [12]. In a different report, total costs related to diabetes care in older adults > 65 in LTCF were estimated to equal 13,536 billion dollars in 2013 [31]. As the number of older adults with diabetes requiring care in long-term care facilities (LTCFs) increases, the financial burden on the healthcare system is expected to rise. This trend underscores the urgent need for more efficient care strategies and resources to manage diabetes in this population effectively.

Frailty and Diabetes in Long-Term Care Facilities

The prevalence of frailty among older adults is estimated to range from 10 to 25%. In many cases, frailty remains undiagnosed, particularly without the expertise of geriatricians [32]. Older adults with frailty experience ongoing deterioration of multiple organ systems, making them more susceptible to various stressors. Frailty is a significant predictor of mortality, hospitalization, and cardiovascular events in the geriatric population, particularly in the context of diabetes [33]. Frail older adults are more likely to require admission to long-term care facilities (LTCFs). However, estimating frailty prevalence in these settings is challenging [34]. This difficulty arises from the diverse definitions of frailty and the limited implementation of comprehensive assessments within many LTCFs [35]. Pooled analyses from multiple studies suggest that frailty prevalence in LTCFs may reach as high as 50% [35, 36].

Diabetes influences and is influenced by the presence of frailty in older adults, with both conditions sharing common pathological changes [37]. Aging affects muscle and fat ratio in the human body leading to weakness and sarcopenia in older adults. This decrease in muscle mass and increase in adipose tissue is closely related to insulin resistance [38].

Conflicting data exist regarding the association between frailty and dysglycemia, specifically whether it correlates with increased hyperglycemia [39], hypoglycemia [40], or both. Nevertheless, identifying and managing frailty in older adults with diabetes is crucial, since the coexistence of these conditions significantly elevates the risk of morbidity and mortality [41]. Poorly controlled diabetes, particularly when complicated by diabetic neuropathy, can exacerbate frailty through sensory and motor dysfunctions. This leads to decreased muscle strength, impaired postural control, and balance, thereby increasing the risk of falls [42]. Older adults with diabetes are often prescribed multiple medications, including high-risk agents such as insulin and sulfonylureas, which may further elevate the risk of falls [43]. Additionally, the reliance on hemoglobin A1c (HbA1c) should be avoided in older adults with frailty since normal or controlled levels might mask events of severe hypo- or hyperglycemia.

Updates on Medical Approaches for the Management of DM in Long-Term Care Facilities

The management of diabetes in long-term care facilities (LTCFs) requires individual therapeutic strategies, recognizing the diverse health profiles of older adults in these settings who often require personalized care interventions [19, 44, 45]. Major guidelines recommend concentrating efforts on the avoidance of hypoglycemia in LTCF because hypoglycemia has been linked to cardiac arrhythmia, ED visits and falls that lead to fractures [46–48]. Medication de-intensification is frequently advocated, with glycemic targets being adjusted in line with national guidelines to reflect the reduced life expectancy of this population [49, 50]. More recently, the post-acute and long-term care medical association has published a practical guideline on the management of diabetes in LTCF emphasizing the 4Ms of age friendly care delivery [51]. This framework emphasizes what matters when it comes to quality of life, medications, mentation, and mobility [51].

The evidence base for many diabetes medications in LTCF populations is limited, as recommendations are often extrapolated from studies conducted in ambulatory settings. However, a recent serial cross-sectional study conducted between 2016 and 2020, involving 71,200 to 120,861 older adults residing in LTCFs, indicated that older-generation diabetes medications remain prevalent in these facilities [52]. This finding highlights the critical need for further research tailored to the unique needs of LTCF residents to inform evidence-based prescribing practices.

Older-Generation Medications

Metformin remains one of the most commonly prescribed medications in LTCFs, followed by sulfonylureas (SUs), with 68% and 30% usage rates, respectively, in 2020 [52]. While metformin is generally safe for older adults, it is contraindicated in those with advanced kidney disease and in individuals with decreased oral intake due to the potential for adverse effects such as nausea and diarrhea [53]. Metformin and SUs are cost-effective in managing hyperglycemia in individuals with type 2 diabetes. However, unlike metformin, the use of SUs is associated with a significantly higher risk of hypoglycemia, poor outcomes, and increased mortality in the geriatric population [20, 54–57]. (Table 1)

Table 1.

Summary of approaches to enforce and/or to avoid for diabetes management at LTCF

Good Practices	Practices to Avoid
General Considerations
Screen for frailty in all newly admitted residents
Emphasize healthy diet that is high in protein	Ingestion of sweetened beverages and extensive use of high glycemic index food
Incorporate resistance exercises routine as tolerated
Medical Management
Injectable:
Insulin:
Consider basal insulin coverage at 0.15 U/kg/day for high BG if not controlled on oral medications.	Avoid the sole use of sliding scale insulin.
Must be continued for pwT1DM.
GLP1:
Consider for obese patients and in patient with CVD or renal disease.	Avoid in frail older adults with normal weight, or at risk of dehydration. Avoid in history of pancreatitis or medullary thyroid carcinoma.
OAD:
Metformin:
Start low dose and watch for GI AE.	Avoid in advanced CKD.
SU:
Consider short acting preparations.	Generally, avoid due to risk of hypoglycemia.
DPP-4 inhibitors:
Can be used as monotherapy or to replace low dose prandial insulin. Well-tolerated.	Avoid in history of pancreatitis and adjust to renal functions.
SGLT-2i:
Recommended for pw HF and in CKD.	Avoid in high-risk individuals for UTI, dehydration, DKA or in T1DM. Monitor urinary incontinence symptoms.
Thiazolidinedione:
Rarely considered a good choice.	Avoid in patients with HF, osteoporosis or liver disease.
Areas to be Studied
• Safety and efficacy of diabetes medications in LTCF environment • Diabetes technology (CGM and insulin pump) efficacy in glucose control and health care utilization

CKD, chronic kidney disease; DKA, diabetic ketoacidosis; DPP-4i, dipeptidyl peptidase-4; GI AE, gastrointestinal adverse events; GLP-1, glucagon-like peptide-1; HF, heart failure; CVD, cardiovascular disease; SGLT-2i, sodium-glucose cotransport 2 inhibitor; SU, sulfonylurea; pwT1DM, patients with type 1 diabetes mellitus

The use of sulfonylureas (SUs) has decreased from 37 to 30%, while insulin usage has remained relatively stable between 2016 and 2020, including prandial insulin only (22% vs. 18% in 2016 and 2020, respectively). A study in VA nursing homes indicated that the proportion of sliding scale insulin use is nearly double that of scheduled or fixed insulin [58], a practice discouraged by both geriatric and diabetes associations nationwide [51, 59]. The exclusive use of sliding-scale insulin is not recommended due to the heightened risk of hypoglycemia. Switching from a sliding scale to small-dose basal insulin may reduce hypoglycemia risk in the geriatric population [60].

Dipeptidyl peptidase-4 (DPP-4) inhibitors are becoming increasingly popular among older adults to reduce postprandial glucose excursions. These inhibitors are also preferred for patients with chronic kidney disease, which is common in older adults [61]. Studies in LTCF settings have demonstrated that DPP-4i provide similar efficacy in controlling blood glucose with fewer hypoglycemic events than insulin glargine [62]. Despite their tolerability, the use of DDP-4i has not increased significantly between 2016 and 2020 (23% vs. 26%).

Finally, thiazolidinediones (TZDs), an older class of glucose-lowering medications, continued to be used in LTCFs, reaching 4% in 2020 [52]. However, TZDs are generally unfavored in older adults due to the risk of heart failure exacerbation, which has a prevalence of 40% in this setting [63], as well as the increased risk of fractures in older adults with decreased bone mineral density (BMD) [64–67].

Newer-Generation Medications

Glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose co-transporter 2 (SGLT-2) inhibitors are novel diabetes medications that have been shown to reduce major adverse cardiovascular events (MACE) in older adults over 65 years of age [68–70]. Despite their benefits, the prescription of these medications in LTCFs remains low, likely due to limited experience in these settings and their high costs. According to the latest data, 4% of patients use SGLT-2 inhibitors, and 7% use GLP-1 receptor agonists in LTCF [52].

In addition to cardiovascular benefits, emerging evidence suggests that GLP-1 receptor agonists have positive effects on kidney function, cognition, and psychiatric or addiction conditions [71–76]. Clinical trials with potent injectable GLP-1 receptor agonists have shown significant decreases in lean body mass [77, 78], and have not conclusively determined their effects on bone mineral density [79, 80]. However, the use of GLP-1 receptor agonists in LTCFs has not been extensively studied. Caution is advised for this population, which often suffers from sarcopenia and has a higher risk of falls. For older adults in LTCFs treated with potent GLP-1 receptor agonists such as semaglutide and tirzepatide [81, 82], constant weight monitoring and oral intake should be ensured. Screening for malnutrition before initiating these medications and a high-protein diet and routine resistance exercises are recommended [83, 84].

SGLT-2 inhibitors have been proven to reduce hospital admissions for heart failure and are strongly recommended for patients with concomitant congestive heart failure (CHF), which is prevalent among patients in LTCFs [63, 85–87]. This class of medicine is also known for slowing the progression of chronic kidney disease and reduce the risk of kidney failure in patients with diabetes [88]. While this class of medication is generally safe for older adults [89, 90], attention must be paid to potential side effects in LTCFs, including the risk of urinary tract infections (UTIs), worsening urinary incontinence, dehydration, and euglycemic diabetic ketoacidosis [91–95]. (Table 1)

Technological Advances in Diabetes Care in LTCFs

Diabetes technologies are continuously evolving for patients with type 1 and type 2 diabetes. National guidelines encourage their use for all patients with diabetes, including older adults in ambulatory settings [96]. However, applying these tools in LTCFs is challenging due to the scarcity of clinical trials evaluating their efficacy and safety and the complex reimbursement process for these relatively expensive tools. More importantly, education for staff and providers on the use of these technologies remains a significant obstacle to their implementation in LTCFs.

Continuous Glucose Monitoring (CGM)

Trials on the use of continuous glucose monitoring (CGM) in older adults, including those admitted to hospice with either T1D or T2D, have demonstrated significant benefits in detecting both hyperglycemia and hypoglycemia, including nocturnal hypoglycemia [97–100]. In LTCF, insulin and SU are responsible for most cases of hypoglycemia. The prevalence of hypoglycemia (< 70/mg/dL) is estimated to be between ~ 30–48% in older adults with diabetes at LTCF [20, 52, 101, 102]. Other risk factors that increase the risk of hypoglycemia in this population include decreased cognition, which impacts hypoglycemia awareness [103, 104], polypharmacy [105, 106], renal and hepatic dysfunction [107], as well as unpredictable eating behavior [19, 105, 108–110].

Consequently, interest in studying CGM, which can detect hypoglycemia, in LTCFs has grown over the last decade. Across 8 LTCF, the use of CGM for only 10 days has shown that 26% of participants had hypoglycemia (< 70 mg/dL), and only half of the cohort spent more than 50% within the range (70–180 mg/dL) [111]. This correlates with previous reports of high hypoglycemia prevalence in nursing home residents in France using blood capillary glucose regardless of their HbA1c control [112, 113], indicating the need for further implementation of CGM in these settings.

The use of CGM to guide insulin therapy was studied in 2 LTCF in Atlanta, Georgia, in 97 insulin-treated participants with T2D (age: 74.7 ± 11 years) who were randomized to an intervention or a standard of care control group. Patients in the standard of care (POCT group) wore a blinded Dexcom^® (San Diego, California) G6 CGM with treatment adjusted based on POCT results, while in the CGM group, treatment adjustment was based on daily CGM profile. The results of this trial showed that CGM led to similar diabetes control compared to standard of care. In addition, CGM technology detected significantly greater proportions of participants with hypoglycemia < 70 mg/dL (40.2 vs. 14%) and < 54 mg/dL (21 vs. 1.0%), and hyperglycemia > 250 mg/dL (77% vs. 56%) compared to POCT, all p<0.001 (Fig. 1).

Fig. 1.

Comparison between CGM and POCT in detecting glycemic events in 97 older adults residing in LTCF: (this is an original figure)

A chart showing the ability of CGM in detecting hypoglycemia when compared to POCT in LTCF. Chart adopted from Idrees et al., [114].

More importantly, the acceptance of this technology by nursing staff, patients, and providers was high, and the retention was optimal [114]. More recently, a sequential and single-arm study in Spain was conducted on the applicability of a telehealth system using CGM and smart insulin caps in LTCF to guide insulin therapy. Compared to baseline, there was a decrease in hypoglycemia events, time below range (TBR < 70 mg/dL), and the number of insulin injections [115]. The study also reported substantial acceptance of the telehealth program by the LTCF staff [115].

In addition, the use of CGM in older patients residing in LTCFs has the benefit of decreasing exposure to communicable diseases, which was a major concern during the COVID-19 pandemic. Until 2022, COVID-19 infections led to the deaths of more than 149,000 residents and nearly 2,200 staff members in LTCFs [5].

Insulin Pumps

The use of insulin pumps, on the other hand, appears to be beneficial for older adults. Numerous studies have shown that sensor-augmented or automated insulin delivery systems significantly improve dysglycemia in older adults, and their use is relatively easy in this population [116–129]. However, using insulin pumps in LTCFs requires superior staff knowledge of setting adjustments and troubleshooting, which is currently lacking. Proper training and education for LTCF staff are essential to ensure the effective use of these devices. Without adequate knowledge, staff may struggle to manage insulin pump settings, leading to potential errors and suboptimal diabetes management.

Discontinuation of insulin pumps in LTCFs could lead to worsening dysglycemia in older adults with T1D upon their admission to these facilities. This is particularly concerning as maintaining stable glucose levels is crucial for preventing complications such as hypoglycemia and hyperglycemia, which can have severe consequences in older adults. The transition from an insulin pump to other forms of insulin delivery should be carefully managed to avoid abrupt changes in glucose control. Further studies are required in these settings to develop best practices for using insulin pumps in LTCFs. Research should focus on identifying the most effective training programs for staff, understanding the barriers to insulin pump use in these facilities, and evaluating the long-term outcomes of insulin pump therapy in older adult.

Conclusion

As the prevalence of older adults with diabetes continues to rise, the proportion of patients with diabetes in long-term care facilities (LTCFs) will also increase. Given the diverse functional statuses, comorbidities, and life expectancies of these residents, this trend will present significant challenges in managing blood glucose levels. Effective diabetes management in LTCFs will require tailored approaches that consider these variations. The use of newer and beneficial classes of diabetes medications, as well as advanced diabetes technologies, necessitates further study in LTCFs. Such research is essential to optimize treatment protocols and reduce the morbidity and mortality associated with diabetes in these settings. By addressing these challenges, the quality of care and outcomes for older adults with diabetes residing in LTCFs can be improved significantly.

Data Availability

No datasets were generated or analysed during the current study.