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Jered Yalung, PharmD

Diabetes is a nationwide epidemic. It consistently has been the top 10 leading cause of death for Americans and is continuing to affect both youth and older adults alike.

In 2019, an estimated 37.3 million people had diabetes, costing $327 billion per year. Of this group, 15.9 million Americans aged 65 or more years had diabetes, according to the Centers for Disease Control and Prevention and Twenty percent of assisted living residents had diabetes in 2018, according to a 2021 report from the CDC.

Those older adults are relying on their healthcare professionals to assist in managing their disease.

Type 1 diabetes requires insulin, whereas type 2 diabetes treatments can change depending on the current progression of the disease. Some people can manage type 2 diabetes with lifestyle modifications such as healthful eating and exercise, combined with oral medications. Many cases of type 2 diabetes, however, remain uncontrolled and result in insulin use. Insulin therapy is used to keep blood sugar levels at a healthy level to prevent symptoms of hyper (and hypo) glycemia and increased diabetic complications.

Once on insulin, the prescriber typically will prescribe a conventional insulin therapy, which includes both short-acting and/or long-acting insulin to take throughout the day. The long-acting insulin serves as coverage throughout the day, whereas the short-acting insulin helps prevent spikes in blood sugar associated with meals.

It also is common to prescribe a slide scale insulin dose for which the prescriber creates a chart of insulin dosages based on multiple factors, including the individual’s response to insulin, pre-meal blood sugar levels, and the mealtime. Although there may be benefits to sliding scale insulin, such as not requiring carbohydrate calculations at meal time and an easy standard to follow of “if then” — If blood sugar equals this amount, then give this amount of insulin — the practice has been considered a “historical artifact,” according to the journal Diabetes Care.

The practice of sliding scale insulin was started as far back as the 1930s. Its use can lead to “poor and erratic control with unpredictable hypoglycemia,” according to the journal Endocrinology and Metabolism Clinics of North America. It is neither effective nor efficient as it is a practice of reactivity to hyperglycemia rather than proactively looking at the root cause of “why.” Why does the resident have consistently high blood sugar? It also puts the pressure to manage the resident’s diabetes on facility floor staff rather than on a prescriber.

So what can be done? Emphasis needs to be put on diabetes management in both facilities and in homes. Insulin is not an excuse to eat a poor diet. It is used in conjunction with diet and exercise.

Providers should focus on a more intensive insulin therapy that bases insulin dose on a basal insulin and nutritional insulin depending on the meal. Yes, this means more work for the prescriber. It also can mean working in conjunction with a registered dietitian and diabetes educator pharmacist to significantly lower the risk of having hyper- and hypoglycemic events.

In an ideal world, residents in senior living and care communities always will have healthy blood sugar levels, but this is never the case. Having a standing order of sliding scale insulin still still be needed in case of hyperglycemic crisis, so facility staff does not have to scramble for a new order of insulin during a time of need after all other resources, such as fluid therapy, have been exhausted. Aside from having a hypo- or hyperglycemic crisis, diabetes often can be a silent killer. Senior living and care must dedicate more resources on education and prevention, and industry professionals must work in collaboration to combat this ever-growing epidemic.

Jered Yalung, PharmD, is director of marketing and operations at Options for Senior America.

The opinions expressed in each McKnight’s Senior Living marketplace column are those of the author and are not necessarily those of McKnight’s Senior Living.

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