How well are we managing diabetes in long-term care?

,; ,; ,; ,; ,

Original Research

How well are we managing diabetes in long-term care?

J Fam Pract. 2012 August;61(8):467-472

By

Brittney M. Vajen, osteopathic medical student IV

Rachel Holt, DO

Tracy Marx, DO

Frank L. Schwartz, MD

Jay H. Shubrook, Jr, DO

The care received by nursing home residents with diabetes does not meet ADA standards for ambulatory adults, this study finds. Nor should it. The frail elderly need new standards that address their particular needs.

PDF Download

References

1. Centers for Medicare and Medicaid Services. MDS active resident information report: third quarter 2010. Available at: https://www.cms.gov/MDSPubQIandResRep/04_activeresreport.asp?isSubmitted=res3&var=I1a&date=32. Accessed February 9, 2011.

2. Zhang X, Decker FH, Luo H, et al. Trends in the prevalence and comorbidities of diabetes mellitus in nursing home residents in the United States: 1995-2004. J Am Geriatr Soc. 2010;58:724-730.

3. Meyers RM, Reger L. Diabetes management in long-term care facilities: a practical guide. J Am Med Dir Assoc. 2009;10:589.-

4. Mayfield J, Deb P, Potter D, et al. Diabetes and long-term care. In: Diabetes in America. 2nd ed. Bethesda, MD: National Diabetes Data Group, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health; 1995:571–586.

5. Ben-Ami H, Nagachandran P, Mendelson A, et al. Drug-induced hypoglycemic coma in 102 diabetic patients. Arch Intern Med. 1999;159:281-284.

6. Löfgren UB, Rosenqvist U, Lindstrom T, et al. Diabetes control in Swedish community dwelling elderly: more often tight than poor. J Intern Med. 2004;255:96-101.

7. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545-2559.

8. Brown AF, Mangione CM, Saliba D, et al. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51:S265-S280.

9. Chalmers J, Beaven D, Sainsburg R. Are high blood sugar levels in the elderly ignored? Aust NZ J Med. 1987;17:485-490.

10. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care. 2011;34(suppl 1):S11-S61.

11. Meyers RM, Broton JC, Woo-Rippe KW, et al. Variability in glycosylated hemoglobin values in diabetic patients living in long-term care facilities. J Am Med Dir Assoc. 2007;8:511-514.

12. Hamman RF, Michael SL, Keefer SM, et al. Impact of policy and procedure changes on hospital days among diabetic nursing-home residents—Colorado. MMWR Morb Mortal Wkly Rep. 1984;33:621-629.

13. Feldman SM, Rosen R, DeStasio J. Status of diabetes management in the nursing home setting in 2008: a retrospective chart review and epidemiology study of diabetic nursing home residents and nursing home initiatives in diabetes management. J Am Med Dir Assoc. 2009;10:354-360.

14. Holt RM, Schwartz FL, Shubrook JH. Diabetes care in extended-care facilities: appropriate intensity of care? Diabetes Care. 2007;30:1454-1458.

15. Centers for Disease Control and Prevention. National diabetes fact sheet, 2007. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed February 10, 2011.

16. Alam T, Weintraub N, Weinreb J. What is the proper use of hemoglobin A1c monitoring in the elderly? J Am Med Dir Assoc. 2006;7(3 suppl):S60-S64.

17. Alam T, Weintraub N, Weinreb J. What is the proper use of hemoglobin A1c monitoring in the elderly? J Am Med Dir Assoc. 2010;11:171-178.

18. Huang ES, Meigs JB, Singer DE. The effect of interventions to prevent cardiovascular disease in patients with type 2 diabetes mellitus. Am J Med. 2001;11:633-642.

19. Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462-467.

ABSTRACT

Purpose Our objective was to compare the management of diabetes mellitus (DM) in residents of extended-care facilities with the American Diabetes Association (ADA) standards of care for ambulatory adults.

Methods We reviewed the charts of 245 residents in 14 extended-care facilities. All had a physician-documented diagnosis of type 1 or type 2 DM and had spent at least 3 of the past 12 months in the facility. We reviewed medical diagnoses, medications, laboratory reports, and consultation notes of one-year duration, then compared our findings with the ADA standards of care.

Results Of the 245 patients, 211 (86.1%) had their glucose monitored; 36.7% had a hemoglobin A1c (A1c) below 7%. Fifty-two residents (21.2%) experienced hypoglycemic events; 103 (42%) had hyperglycemic events. Of the 240 patients (98%) whose blood pressure (BP) was monitored, 107 (43.7%) met the ADA goal. Lipids were checked in 190 residents (77.6%), 89 (46.8%) of whom met the goal for low-density lipoprotein (LDL). Dilated eye examinations were provided to 133 patients (54.3%). Foot examinations were performed on 187 residents (76.3%); 170 (69.4%) had a consultation with a podiatrist.

Conclusions Our chart review demonstrates that the management of diabetes in extended-care facilities does not meet the recommended ADA standards of care for ambulatory adults. Although 36.7% of patients met the A1c goal, the A1c did not account for glucose variability. Only 46.8% of patients met the recommended LDL goal. Our results suggest the need for new standards of care for patients with diabetes residing in nursing facilities. These standards should take into account the particular needs of this patient population, specifically with regard to hypoglycemic risk, cardiovascular risk factors, and quality of life.

A surge in elderly patients with diabetes has placed a large burden on extended-care facilities. According to the Centers for Medicare and Medicaid Services, the prevalence of diabetes among nursing home residents is 33.3%.¹ Between 1995 and 2004, the estimated number of long-term care residents with diabetes mellitus (DM) grew by 7.1%, from approximately 242,000 to 329,000.² The increase adds to the challenge extended-care facilities face in attempting to provide high-quality care to patients with diabetes. No well-accepted management guidelines exist for nursing home residents with DM.³

Frail older adults with DM are more likely to suffer from cardiovascular conditions than younger patients, and are at greater risk for hypoglycemic coma and serious hyperglycemia.^4,5 A high frequency of hypoglycemia, especially nocturnal hypoglycemia, has been reported among nursing home residents with diabetes.⁶ Intensive insulin therapy is associated with hypoglycemia and increased mortality.⁷ However, hyperglycemia also must be considered because it significantly impairs quality of life. Uncontrolled hyperglycemia causes osmotic diuresis, leading to polyuria, nocturia, aggravated incontinence, and disrupted sleep, as well as contributing to dehydration.⁴ All of these problems have serious implications for quality of life and overall health.

FAST TRACK

Although poor glycemic control and hypertension are major problems facing nursing home patients with diabetes mellitus, little research has examined how therapies targeting these problems help the elderly.

Although studies have identified poor glycemic control and hypertension as the major problems facing nursing home patients with DM,^2,6 little research has examined how therapies targeting these problems help the elderly. Solid evidence supports the effectiveness of controlling hyperglycemia, lipid levels, and blood pressure (BP), along with aspirin therapy, in preventing microvascular disease, but does not reflect research involving older patients.⁸

A study of nursing homes found that health care teams did not respond to half of all significantly abnormal laboratory test results.⁹ Physicians who are aware of the problems associated with DM in elderly patients may hesitate to treat them because of the lack of guidelines for this patient population or concerns about adverse effects. Because of the deficiency of clinical trial data in elderly patients and the heterogenicity of the population, the American Diabetes Association (ADA) suggests that “less stringent treatment goals” may be appropriate.¹⁰

A central conflict in diabetes care for nursing home residents revolves around the need for guidelines that are both generalizable and easily individualized. Some studies support the need for individualized care, particularly with regard to A1c goals, because residents vary greatly in both disease burden and frailty.^8,11 Yet individualized treatment could increase the complexity of care for nurses who must manage many patients, potentially having a negative effect on patient care.

FAST TRACK

Frail older adults with diabetes are more likely to suffer from cardiovascular conditions than younger adults and are at greater risk for hypoglycemic coma and serious hyperglycemia.

Implementation of a treatment protocol for residents with DM is associated with a decrease in the number of hospital days for acute and chronic complications,¹² but one study found that only 15% of nursing homes had such a protocol.¹³ Ultimately, long-term care facilities may benefit from an approach that strikes a balance between individualized care and generalized goals and does not closely mimic either acute hospital care or outpatient management of diabetes.³