Original Research

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

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References

Lipid monitoring. Of the 190 residents (77.6%) whose lipids were monitored, only 89 (46.8%) met the LDL goal suggested by the ADA. Fifty-six (29.5%) had triglycerides <150 mg/dL.

The HDL goal recommended by the ADA is >40 mg/dL for men and >50 mg/dL for women. Three of the 24 men and 16 of the 91 women whose lipids were monitored met the HDL goal.

Discussion

Although several components of diabetes management in our study population failed to meet the ADA standards of care for ambulatory adults, some elements of care were well managed. Monthly foot exams were performed on 76.3% of patients; 69.4% were seen by a podiatrist. While the number of residents receiving foot exams had decreased by 10.7% since a previous study by our research group, the number of podiatric consults increased by 11.4%.14

Dilated eye exams were given to 54.3% of residents. More patients should be given the opportunity to have an annual eye exam. Diabetes is the leading cause of new cases of blindness among adults 20 to 74 years of age,15 and impaired vision affects patient activity levels, susceptibility to falls, and quality of life.

In addition to a good record of preventive exams, physicians were proficient in monitoring residents with diabetes with regular testing regimens. Eighty-six percent of patients underwent regular blood glucose monitoring; 84% had had their A1c tested in the past year, and 36.7% achieved the A1c goal of <7%. The average A1c reading was 6.7±1%.

While these A1c values would seem to reflect well-managed diabetes, blood glucose readings tell a different story. A comparison of A1c values and hyperglycemic events revealed a disparity between the estimated average glucose reading and the actual readings. Of the patients who underwent scheduled fingersticks, 24.6% experienced a hypoglycemic event and 48.8% had hyperglycemic events. On average, each patient had 8 hyperglycemic episodes per month. The average highest glucose reading was >350 mg/dL.

A1c is only part of the story. While A1c can be a marker of sustained hyperglycemia, it does not reflect the stability of glycemic control.16 A study by Löfgren and colleagues confirmed that elderly diabetic patients in nursing homes who have low A1c levels often suffer from hypoglycemia.6 Patients receiving insulin therapy are more likely to experience hypoglycemia.7

The mismatch between A1c and glucose readings reveals an important point about the management of diabetes in long-term care patients: A1c values do not tell the entire story about a patient’s blood glucose; thus, a physician cannot look only at A1c to assess a patient’s diabetes management. A previous study demonstrated that when physicians base treatment plans solely on A1c without consulting glucose logs or being familiar with newer treatments, adherence to evidence-based algorithms is unlikely.17

While A1c does provide information about average blood glucose levels, it does not offer perspective on hypoglycemia or glucose variability. It is vital that physicians screen the glucose log for evidence of hypo- and hyperglycemia before adjusting the patient’s treatment plan. Physicians must also keep in mind that A1c may be falsely low in elderly patients who have concomitant anemia, which lowers the value.

Controlling BP and lipids helps prevent complications. In addition to diabetes management, our study evaluated regulation of the complications of diabetes, particularly cardiovascular complications. Evidence suggests that people with DM derive the greatest mortality benefit from a treatment plan centered first on hypertension, then lipids, and finally, glycemic control.18 A renewed focus on the BP and lipid aspects of diabetes care is needed.

Our data demonstrate that, of the 240 patients who met the ADA goal of <130/80 mm Hg, only 100 (40.8%) were taking an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker. Lowering BP to <130/80 mm Hg may provide further benefit in preventing diabetes-related macrovascular complications.8

Lipid levels are a critical gauge of cardiovascular risk. Previous studies of patients with type 2 DM have shown that treating hyperlipidemia can produce a mortality benefit within 2 to 4 years, whereas aggressive glucose management takes approximately 8 years.18

A lipid panel was performed for 77.6% of the patients in our study—an improvement over a previous study by our team in which only 33% of patients received lipid checks.14 In the current study, a mere 2.9% of patients met the ADA’s combined lipid goals (LDL <100 mg/dL; HDL >40 mg/dL in men and >50 mg/dL in women; and triglycerides<150 mg/dL). Considering the LDL goal alone, 46.8% of the 190 patients whose lipids were monitored achieved it.

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