Table 3

Commonly found comorbidities in LTC and strategies to improve diabetes care

Clinical presentation that may interfere with diabetes managementPossible strategies to manage diabetes
Confusion, cognitive dysfunction, delirium• Irregular dietary intake or skipped meals
• Refusal of blood glucose monitoring
• Refusal of medications or injections
• Offer a regular diet and preferred food items
• Offer food substitutions if meal intake is <75%
• Administer prandial insulin immediately after meals to match carbohydrate intake to avoid hypoglycemia
• Block testing (monitoring at different times of the day to identify patterns, e.g., checking fasting glucose on some days, prelunch or predinner on other days) to provide pattern without multiple daily checks
• Increase glucose monitoring during acute mental status or behavior changes
• Switch to a long-acting form of oral medications that can be given once daily or to crushed or liquid formulation
• Switch to mixed insulin to decrease daily injections, although hypoglycemia risk will remain high
Depression• Not interested in activities
• Weight loss, refusal to eat
• Excessive intake of sugary foods
• Assess and treat depression
• Encourage physical activity as possible
• Encourage socialization, especially during meals
Physical disability• Unable to exercise
• High risk of deconditioning and pressure ulcers
• Require assistance with food and fluid intake
• High risk of functional disability
• Encourage activity that patient can perform, e.g., exercise pedals for non–weight-bearing patients
• Assessment for pressure ulcers
• Encourage ADL independence
Excessive skin problems, e.g., infections, ulcers, delayed wound healing• Causes hyperglycemia
• Anorexia, poor dietary intake
• May decrease physical activity
• Nutrition consult
• More frequent glucose monitoring and temporary regimen intensification
• Exercises appropriate for non–weight-bearing patients
• Regular skin checks and foot assessments by nursing staff
Hearing and vision problems• Decreased hearing can lead to isolation and depression
• Low vision has large impact on quality of life
• Continue hearing and vision screening and preventive strategies if feasible
Oral health problems, teeth decay, dry mouth• High risk of infection
• Weight loss due to loss of chewing ability
• Loss of taste sensation
• Regular oral health evaluations and cleaning
• Ensure appropriate daily oral care
  • ADL, activities of daily living (such as bathing, toileting, eating, dressing, transferring).