Diabetes is a significant issue among the long-term care population, and diabetes medications are among the most common dispensed by post-acute care pharmacy providers. In fact, the American Diabetes Association reports that 11.2 million Americans age 65 and older—or approximately 26 percent of that population—have been diagnosed with diabetes. Many more have prediabetes, meaning they’re at risk of developing Type 2 diabetes.
These numbers are important because those with diabetes are at an increased risk of developing cardiovascular disease, which is the leading cause of death among seniors. The most common type of heart disease is coronary heart disease, in which there is a buildup of plaque in the heart’s arteries that can lead to angina, heart attack, and stroke.
Those with diabetes are also more likely to have other risk factors for heart disease, including high blood pressure, abnormal cholesterol, obesity, and lack of physical activity.
Luckily, these risk factors for heart disease are modifiable, meaning that they can be controlled in order to decrease the risk of complications from heart disease, including heart attack and stroke. Medications and medication management are one facet of care for diabetes, but there are other ways to help residents decrease their risk of heart disease and stroke.
Your Skilled Nursing Facility’s multidisciplinary team should work with residents to manage their “ABCs”—A1C, Blood pressure, Cholesterol, and Smoking.
Long-term Care Pharmacy Update: Understanding Diabetes Management
HbA1c is a way to measure long-term glucose control. The HbA1c test measures the amount of glucose that is attached to the hemoglobin of red blood cells over the entire lifespan of the red blood cell (approximately three to four months) and is directly correlated to the average blood glucose over a three-month period.
The 2017 American Diabetes Association (ADA) Standards of Care update recommends an HbA1c goal of <7.5% for healthy older adults who have few chronic illnesses, good cognitive and functional status, and a long life expectancy. For older adults who have three or more chronic conditions and a lower life expectancy, an appropriate HbA1c goal is <8%. Very frail older adults who have complex and/or end-stage chronic illnesses should be controlled to an HbA1c of <8.5%.
Controlling HbA1c per the ADA Standards of Care recommendations has been shown to reduce macrovascular complications of diabetes like cardiovascular disease and stroke. The best ways to manage a resident’s HbA1c are by encouraging exercise and movement, providing meals with proper portion sizes that are low in carbohydrates, fats, and sugary drinks, keeping the resident on a strict schedule for eating and medication administration, and checking HbA1c levels every three months.
A resident’s blood pressure should also be properly controlled in order to reduce the risk of heart attack and stroke. The 2014 JNC8 guidelines recommend the goal of blood pressure of <140/90 mmHg for those who have hypertension and diabetes.
The ways to help your residents manage their hypertension are similar to the ways to manage A1c—encourage your residents to participate in exercise and movement activities, provide meals that are well-balanced and low in sodium, work with long-term care pharmacy providers to ensure that blood pressure medications are taken properly, and frequently monitor the residents’ blood pressure.
Abnormal lipid levels, including low HDL (good cholesterol), high LDL (bad cholesterol), and high triglycerides can increase the risk of cardiovascular complications. The 2013 American College of Cardiology/American Heart Association cholesterol guidelines no longer recommend treating to a target cholesterol level, but rather recommend that all residents between the ages of 40 and 75 with diabetes are treated with a statin medication.
You can help your residents keep their cholesterol under control by, again, encouraging participation in exercise and movement activities, providing low-fat meals with proper portion sizes, and working with LTC pharmacy services providers to ensure that their statin medication is given daily.
Smoking increases blood pressure, decreases exercise tolerance, decreases HDL cholesterol, and causes atherosclerosis, all of which may lead to heart disease and its complications.
About 20 percent of all deaths from heart disease in the United States are directly related to smoking. On top of the risk for heart disease, smoking also increases the risk for respiratory diseases, infections, and cancer. It is always important to encourage your residents to quit smoking to reduce their risk of heart disease and other complications.
Long-term Care Pharmacy Update: The Bottom Line on Heart Disease and Diabetes
Overall, residents with diabetes are two to four times more likely to die from complications of heart disease than those without diabetes. In general, you can help your residents reduce their risk of heart disease by providing healthy meals, helping them participate in movement activities, ensuring they receive their medications as scheduled, and encouraging them to stop smoking.
Keeping an eye on lab values and signs and symptoms of heart disease will also help identify possible complications in a timely manner.
Our Grane Rx team stays up-to-date on the latest information—and passes that information on to you. Get started using our knowledge to your benefit by calling (866) 824-MEDS (6337).
Jennifer Devinney is the Chief Clinical Officer for Grane Rx. In this role, she works with clinical pharmacists and nurses in conjunction with facility staff to develop and oversee clinical initiatives. Additionally, she is the clinical EHR integration specialist.
Categories: Clinical Care Advantage