The role of nursing home admission and dementia status on care for diabetes mellitus

Emergency department visits and associated factors among people with dementia residing in nursing homes in Taiwan: a one-year cohort study

BACKGROUND

Residing in a nursing home (NH) may increase emergency department (ED) utilization in patients with dementia; however, evidence regarding the status of and predictors for ED utilization of NH residents with dementia remains unclear, especially in Asia. This study aimed to assess the incidence density of ED visits and associated factors for the risk of ED utilization among NH residents with dementia.

METHODS

This one-year cohort study followed 6595 NH residents with dementia aged ≧ 40 years from Taiwan's National Health Insurance Research Database between 2012 and 2014. The Andersen-Gill extension of Cox regression analysis with death as a competing risk was applied to investigate the association of the risk of all causes and the most common causes of ED utilization with the predisposing, enabling, and need factors as defined by the Andersen model.

RESULTS

All participants encountered 9254 emergency visits in the 5371.49 person-years observed, representing incidence densities of ED visits of 1722.80 per 1000 person-years. Among them, respiratory disease was the most common cause of ED visits. The significant predictors for the risk of all-cause and respiratory-cause ED visits included: (1) predisposing factors (i.e., age and gender); (2) enabling factors (i.e., regional variables); and (3) need factors (i.e., prolonged ventilator dependence and comorbidity status).

CONCLUSIONS

Predisposing, enabling, and need factors could influence ED visits among studies patients. NH providers should consider these factors to develop strategies for reducing ED utilization.

How to manage comorbidities in people with dementia: A scoping review

BACKGROUND

People with dementia experience a high prevalence of comorbidities that seriously affect patient outcomes. The aim of this study was to map the evidence and components related to comorbidity management, including interventions to facilitate and support the practice of management.

METHODS

A scoping review was conducted. In June 2022, PubMed, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The National Institute of Health and Care Excellence (NICE), Open grey, and the Cochrane Library were searched to identify relevant literature. The inclusion criteria were outlined to identify studies on comorbidity management in people with dementia.

RESULTS

We found 43 items that met the inclusion criteria. The majority of the studies were published since 2010. Most research focused on medication management, health care service use and provision, and comorbidity-related monitoring and management; there were a small number of studies that involved decision-making. Only 6 studies developed interventions to support dementia care, which included comorbidity management. Studies involving the comorbidity management process were mainly based on qualitative methods, which make it difficult to quantify the impact of these processes on comorbidity management.

CONCLUSIONS

Given the serious impact of dementia on managing comorbidities, there is a need to develop systematic interventions targeting the management of comorbidities.

The influence of primary care quality on nursing home admissions in a multimorbid population with and without dementia in Germany: a retrospective cohort study using health insurance claims data

Background

Multimorbidity poses a challenge for high quality primary care provision for nursing care-dependent people with (PWD) and without (PWOD) dementia. Evidence on the association of primary care quality of multimorbid PWD and PWOD with the event of a nursing home admission (NHA) is missing. This study aimed to investigate the contribution of individual quality of primary care for chronic diseases in multimorbid care-dependent PWD and PWOD on the duration of ongoing residence at home before the occurrence of NHA.

Methods

We conducted a retrospective cohort study among elderly care-dependent PWD and PWOD in Germany for six combinations of chronic diseases using statutory health insurance claims data (2007–2016). Primary care quality was measured by 21 process and outcome indicators for hypertension, diabetes, depression, chronic obstructive pulmonary disease and heart failure. The primary outcome was time to NHA after initial onset of care-dependency. Multivariable Cox proportional hazard models were used to compare the time-to-event between PWD and PWOD.

Results

Among 5876 PWD and 12,837 PWOD 5130 NHA occurred. With the highest proportion of NHA for PWD with hypertension and depression and for PWOD with hypertension, diabetes and depression. Average duration until NHA ranged from 6.5 to 8.9 quarters for PWD and from 9.6 to 13.5 quarters for PWOD. Adjusted analyses show consistent associations of the quality of diabetes care with the duration of remaining in one’s own home regardless of the presence of dementia. Process indicators assessing guideline-fidelity are associated with remaining in one’s home longer, while indicators assessing complications, such as emergency inpatient treatment (HR = 2.67, 95% CI 1.99–3.60 PWD; HR = 2.81, 95% CI 2.28–3.47 PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 PWD; HR = 2.81, 95% CI 1.94–4.08 PWOD) in PWD and PWOD with hypertension and diabetes, increase the risk of NHA.

Conclusions

The quality of primary care provided to care-dependent multimorbid PWD and POWD, influences the time individuals spend living in their own homes after onset of care-dependency before a NHA. Health care professionals should consider possibilities and barriers of guideline-based, coordinated care for multimorbid care-dependent people. Further research on quality indicator sets that acknowledge the complexity of care for multimorbid elderly populations is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02731-8.

Comparison of the Quality of Chronic Disease Management Between Adults With and Without Dementia

Importance

Adults with dementia may experience poorer quality of chronic disease management because of the difficulty in reporting symptoms and engaging in shared decision-making associated with cognitive impairment.

Objective

To compare the quality of chronic disease management received by adults with and without dementia.

Design, Setting, and Participants

For this cross-sectional study, nationally representative data from noninstitutionalized patients 65 years or older were obtained from the 2002-2015 Medical Expenditure Panel Survey. The control group comprised adults of similarly limited life expectancy without dementia comprised . Data analysis was performed in June 2020.

Exposures

Dementia diagnosis.

Main Outcomes and Measures

Quality of chronic disease management based on 14 individual quality indicators. The association between dementia status and the quality of chronic disease management (3 composite categories: preventive care, diabetes care, and medication treatment) was examined using multivariable linear regression models. Survey weights, sampling strata, and primary sampling unit variables were used to produce national estimates adjusted for nonresponse.

Results

This study included 2506 adults (mean [SD] age, 81.4 [4.7] years; 1259 [49.3%] female; 1243 [50.7%] male), of whom 1335 (53.3%) had a diagnosis of dementia and 1171 (46.7%) did not have a diagnosis of dementia. After adjusting for potential confounders, adults with dementia received lower-quality preventive care compared with adults of similar life expectancy without dementia (adjusted absolute difference [aAD], -6.1 percentage points [pp]; 95% CI, -9.7 to -2.5 pp; P = .001). We found no evidence that the quality of care differed in diabetes care (aAD, 1.7 pp; 95% CI, -4.5 to 7.9 pp; P = .59) and medication treatment (aAD, 1.0 pp; 95% CI, -5.0 to 7.0 pp; P = .75).

Conclusions and Relevance

In this cross-sectional study, the quality of chronic disease management for adults with dementia was not substantially different from that for those without dementia despite potential barriers. Future studies are warranted to gain a better understanding of the underlying mechanism of these findings for preventive care.

Fingerstick Glucose Monitoring in Veterans Affairs Nursing Home Residents with Diabetes Mellitus

BACKGROUND/OBJECTIVE

Guidelines recommend less intensive glycemic treatment and less frequent glucose monitoring for nursing home (NH) residents. However, little is known about the frequency of fingerstick (FS) glucose monitoring in this population. Our objective was to examine the frequency of FS glucose monitoring in Veterans Affairs (VA) NH residents with diabetes mellitus, type II (T2DM).

DESIGN AND SETTING

National retrospective cohort study in 140 VA NHs.

PARTICIPANTS

NH residents with T2DM and older than 65 years admitted to VA NHs between 2013 and 2015 following discharge from a VA hospital.

MEASUREMENTS

NH residents were classified into five groups based on their highest hypoglycemia risk glucose-lowering medication (GLM) each day: no GLMs; metformin only; sulfonylureas; long-acting insulin; and any short-acting insulin. Our outcome was a daily count of FS measurements.

RESULTS

Among 17,474 VA NH residents, mean age was 76 (standard deviation (SD) = 8) years and mean hemoglobin A1c was 7.6% (SD = 1.5%). On day 1 after NH admission, 49% of NH residents were on short-acting insulin, decreasing slightly to 43% at day 90. Overall, NH residents had an average of 1.9 (95% confidence interval (CI) = 1.8-1.9) FS measurements on NH day 1, decreasing to 1.4 (95% CI = 1.3-1.4) by day 90. NH residents on short-acting insulin had the most frequent FS measurements, with 3.0 measurements (95% CI = 2.9-3.0) on day 1, decreasing to 2.6 measurements (95% CI = 2.5-2.7) by day 90. Less frequent FS measurements were seen for NH residents receiving long-acting insulin (2.1 (95% CI = 2.0-2.2) on day 1) and sulfonylureas (1.7 (95% CI = 1.5-1.8) on day 1). Even NH residents on metformin monotherapy had 1.1 (95% CI = 1.1-1.2) measurements on day 1, decreasing to 0.5 (95% CI = 0.4-0.6) measurements on day 90.

CONCLUSION

Although guidelines recommend less frequent glucose monitoring for NH residents, we found that many VA NH residents receive frequent FS monitoring. Given the uncertain benefits and potential for substantial patient burdens and harms, our results suggest decreasing FS monitoring may be warranted for many low hypoglycemia risk NH residents.

Hospital Admissions in People With Alzheimer's Disease or Senile Dementia According to Type 2 Diabetes Status: An Observational 10-Year Study

We aimed to describe admission rates and outcomes of hospitalized people with Alzheimer's disease (AD) or senile dementia stratified by type 2 diabetes (T2D) in Spain, 2004 to 2013 (N = 541 858, 143 501 [26.5%] of whom had T2D). We excluded alternative causes of dementia. Hospitalization rates were higher in people with T2D (130.5 vs 91.5 cases/105 people). People older than 84 years and comorbidity increased over time. Crude inhospital mortality (IHM) decreased over time both in people with and without T2D (all P values <.001). Time trend analyses, 2004 to 2013, showed an overall adjusted incidence rate ratio (95% confidence interval [95% CI]) of hospitalization of 1.41 (1.40-1.42) for T2D (men, 1.32 [1.30-1.33]; women, 1.46 [1.45-1.48]). In logistic regression analyses, IHM decreased over time (odds ratio, OR [95% CI] = 0.97 [0.96-0.98]) and T2D was not associated with a higher IHM (OR [95% CI] = 0.99 [0.98-1.01]). In conclusion, admission rates were higher in patients with T2D. Inhospital mortality decreased over time. Diabetes did not predict IHM in patients with AD or senile dementia.

Effects of Nursing Home Residency on Diabetes Care in Individuals with Dementia: An Explorative Analysis Based on German Claims Data

Aims

This claims data-based study compares the intensity of diabetes care in community dwellers and nursing home residents with dementia.

Methods

Delivery of diabetes-related medical examinations (DRMEs) was compared via logistic regression in 1,604 community dwellers and 1,010 nursing home residents with dementia. The intra-individual effect of nursing home transfer was evaluated within mixed models.

Results

Delivery of DRMEs decreases with increasing care dependency, with more community-living individuals receiving DRMEs. Moreover, DRME provision decreases after nursing home transfer.

Conclusion

Dementia patients receive fewer DRMEs than recommended, especially in cases of higher care dependency and particularly in nursing homes. This suggests lacking awareness regarding the specific challenges of combined diabetes and dementia care.

Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

OBJECTIVE

The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality.

METHODS

This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study.

RESULTS

Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions.

CONCLUSIONS

This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Nursing home patients with diabetes: prevalence, drug treatment and glycemic control

AIMS

Determine prevalence of diabetes, and describe use of blood glucose lowering (BGL) drugs and glycemic control in Norwegian nursing homes.

METHODS

In this cross-sectional study we collected details of BGL drugs, capillary blood glucose measurements (CBGM) in the last four weeks and HbA1c measurements in the last 12 months from the medical records of patients with diabetes, within a population of 742 long-term care patients from 19 randomly selected nursing homes in Western Norway. Descriptive statistics were applied, and Pearson's chi-squared (P≤0.05) or non-overlapping 95% confidence intervals were interpreted as significant effects.

RESULTS

116 patients (16%) had diabetes, 100 of these gave informed consent and medical data were available. BGL treatment was as follows: (1) insulin only (32%), (2) insulin and oral antidiabetics (OADs) (15%), (3) OADs only (27%) and (4) no drugs (26%). Patients with cognitive impairment were less likely to receive medical treatment (P=0.04). CBGM and HbA1c measurements were performed for 73% and 77% of patients, respectively. Mean HbA1c was 7.3% (57 mmol/mol), 46% of patients had an HbA1c <7.0% (53 mmol/mol), and CBGM consistent with risk of hypoglycemia was found for 60% of these patients.

CONCLUSIONS

Prevalence of diabetes and BGL treatment in Norwegian nursing homes is comparable to other European countries. Although special care seems to be taken when choosing treatment for patients with cognitive impairment, there are signs of overtreatment in the population as a whole. The strict glycemic control unveiled may negatively affect these frail patients' quality of life and increase the risk of early death.

Receipt of monitoring of diabetes mellitus in older adults with comorbid dementia

OBJECTIVES

To examine the extent to which receipt of recommended monitoring of diabetes mellitus (DM) differed for participants with and without comorbid dementia, as well as the effect of other comorbidities on monitoring of DM in individuals with comorbid dementia.

DESIGN

Retrospective cohort study.

SETTING

Secondary analysis of 2005/2006 claims and enrollment data for a 5% national random sample of Medicare beneficiaries.

PARTICIPANTS

Two hundred eighty-eight thousand eight hundred five Medicare fee-for-service beneficiaries with a diagnosis of DM before 2006, 44,717 (16%) of whom had evidence of comorbid dementia in claims.

MEASUREMENTS

Established algorithms were used to determine whether patients received at least one glycosylated hemoglobin (HbA1c) test, one low-density lipoprotein cholesterol (LDL-C) test, and one annual eye examination in 2006 and to construct variables representing comorbidities common in DM, sociodemographic characteristics, and patterns of healthcare utilization.

RESULTS

In unadjusted and fully adjusted models, the presence of dementia reduced the likelihood of receiving HbA1c tests, LDL-C tests, and eye examinations, with effects being smallest for HbA1c tests. The effects of other comorbidities on DM monitoring in participants with dementia varied according to the nature of the comorbidity and the specific test.

CONCLUSION

Dementia reduces the likelihood that individuals with DM will receive recommended annual monitoring for DM. More research is needed to understand reasons for lower monitoring in this subgroup and how this affects functioning, adverse events, and quality of life.

Efficacy and tolerability of self-titrated biphasic insulin aspart 70/30 in patients aged >65 years with type 2 diabetes: an exploratory post hoc subanalysis of the INITIATEplus trial

BACKGROUND

The Initiation of Insulin to reach A1C Target (INITIATEplus) trial studied the effect of self-titrating biphasic insulin aspart 70/30 (BiAsp 30) twice daily during 24 weeks in insulin-naïve patients with type 2 diabetes who were poorly controlled by oral medication, and originally randomized according to frequency of dietary counseling interventions.

OBJECTIVE

The purpose of this study was to compare the efficacy and tolerability of biphasic insulin aspart 70/30 (BIAsp 30, NovoLog Mix 70/30) in INITIATEplus patients ≤65 versus >65 years old, irrespective of dietary counseling frequency, and to test the hypothesis that self-titrating BIAsp 30 in patients >65 years old could be well-tolerated and effective in this age group.

METHODS

An exploratory post hoc subanalysis, using standard statistical methods, was performed on patients stratified according to age. Data collected from 3492 patients in the intent-to-treat population who were ≤65 years old and 716 patients who were >65 years old compared glycosylated hemoglobin (HbA(1c)) and plasma glucose changes from baseline. Hypoglycemia rates and adverse event (AE) incidence were compared for the tolerability population of 4007 patients ≤65 years old and 805 patients >65 years old.

RESULTS

Baseline-adjusted HbA(1c) changes for patients ≤65 versus >65 years old were -2.38% versus -2.73% (P < 0.0001), with final HbA(1c) achieving 7.55% and 7.06%, respectively. Thirty-nine percent of patients ≤65 years old achieved HbA(1c) ≤7% compared with 51% of patients >65 years old. Baseline-adjusted fasting plasma glucose decreases were greater for the >65 year old population (85.2 vs 91.2 mg/dL; P = 0.004; ≤65 vs >65 years old, respectively). Minor hypoglycemia was reported in 9.7% and 7.7% of patients ≤65 versus >65 years old, respectively (0.52 vs 0.41 episodes per patient per year [ppy]; P = 0.01). Major hypoglycemia occurred in 1.5% and 3.1% of patients (0.05 vs 0.14 episodes ppy, ≤65 vs >65 years old, respectively; P < 0.0001). Nocturnal major hypoglycemia was reported for 0.4% and 0.6% of patients (P = 0.0028), whereas nocturnal minor hypoglycemia was reported for 3.8% and 2.6% (P = 0.007) of patients ≤65 and >65 years old, respectively. AEs were reported for 24% and 28% of patients ≤65 and >65 years old, respectively, serious AEs were reported for 4% and 9% of patients, respectively, and AE-related withdrawals were reported for 1.3% and 2% of patients, respectively.

CONCLUSIONS

Self-titrated biphasic insulin aspart 70/30 was found to be well-tolerated and effective in type 2 diabetes patients >65 years old, as well as in patients ≤65 years old. HbA(1c) and fasting plasma glucose decreases were significantly (P < 0.05) higher for patients >65 years old versus patients ≤65 years old. Tolerability was indicated by major and minor hypoglycemia rates at or below <0.5 episodes ppy in both age groups. Overall rates of AE and serious AEs were higher among patients > 65 years; withdrawals related to AEs were 2% compared with 1.3% in the younger age group.

Diabetes Management in the Nursing Home

Purpose

Diabetes mellitus is a disease with debilitating potential. Growing numbers of elderly individuals are being admitted to under-resourced nursing homes with this often complicated, time-intensive, and costly diagnosis. The purpose of this systematic review of the literature was to determine the trends in diabetes management in nursing homes over the last decade including the use of clinical practice guidelines and the evaluation of management outcomes.

Methods

Ten medical, nursing, psychological, legal, and business databases were searched for articles written in English between 2000 and 2010 addressing diabetes management in nursing homes or long-term care settings. They were analyzed to determine diabetes management characteristics, use of clinical practice guidelines, resident outcomes associated with different regimens, and implications for improved management and outcomes.

Results

A total of 20 studies from 6 countries, primarily the United States, including both qualitative and quantitative designs and a combined sample of 779 707 residents, met the inclusion criteria. The majority of the studies described frequencies of various management practices and found rare clinical practice guideline adherence.

Conclusion

A severe lack of research relating management practices to health and quality-of-life outcomes was evident as was a lack of the voice of the resident in determining the diabetes regimen. Clear implications were found for improvement in diabetes management education for residents, families, and all health care providers in this setting.