Diabetes care in extended-care facilities: appropriate intensity of care?

Update on the management of diabetes in long-term care facilities

The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.

Diabetes Management According to Health Status in Older Adults with Type 2 Diabetes Staying in Geriatric Care Facilities

BACKGROUND

About 25% of adults >70 years suffer from type 2 diabetes. Due to the heterogeneity of the geriatric population, guidelines emphasize the need to individualize glycemic goals and simplify treatment strategies with the main focus of avoiding hypoglycemia. The aim of this study was to assess glycemic control in patients with type 2 diabetes in geriatric care facilities based on their individual health status.

METHODS

170 medical records of older adults with type 2 diabetes in geriatric care facilities were retrospectively assessed (64.7% female, age 80 ± 9 years; glycated hemoglobin 6.8% ± 3.6% [51 ± 16 mmol/mol]; body mass index 27.9 ± 5.8 kg/m2). Based on the individual health status, patients were allocated to three groups (healthy n = 27, complex n = 86, and poor n = 57).

RESULTS

The overall blood glucose (BG) value was highest in the poor health group with 188 ± 47 mg/dL (poor) vs 167 ± 42 mg/dL (complex) vs 150 ± 34 mg/dL (healthy). BG values of 1.6% (poor) vs 2.8% (complex) vs 1.5% (healthy) of patients were below 90 mg/dL. 36.8% (poor) vs 23.4% (complex) vs 18.5% (healthy) of patients received insulin as the main diabetes therapy, but of these only 14.3% (poor) vs 20% (complex) vs 40% (healthy) were treated with basal insulin.

CONCLUSIONS

Overall, BG values were higher in the poor and complex health group. There were a few low BG values in all groups. Although recommended by international guidelines, basal insulin therapy with its low complexity and low hypoglycemic risk is still underused, especially in the poor health group. Therefore, simplification of diabetes therapy should be considered further.

Mental health care use in men with comorbid diabetes and depression: The role of age and race

Objectives:

Older adults with diabetes have double the normal average risk for depression. While women also report higher rates of depression, men are less likely than women to recognize symptoms and seek assistance for mental health treatment. Racial disparities in mental health care use among men have also been identified. While age and gender differences in mental health care use have been accounted for in adults with comorbid diabetes and depression little is known about within group differences among men. The purpose of this study was to examine the influence of age and race on mental health service use in a sample of men with comorbid diabetes and depression.

Methods:

This study utilized secondary data from a large health care delivery system serving in a Midwestern urban city and included 335 Black, and non-Latino White men with comorbid type 2 diabetes and depression.

Results and Discussion:

Findings indicate that men under the age of 55 were less likely to experience a 6-month or more delay in receiving a psychiatric medication prescription after their initial depression diagnosis. Black men over 55 years of age were significantly more likely to experience a delay of over six months to receiving psychiatric medication. More research is needed to explore preferred depression treatment methods for older Black men with type 2 diabetes, in addition to any issues with access to pharmacological medications to treat depression.

A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial

OBJECTIVES

Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities.

DESIGN

This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM.

SETTINGS

Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia.

PARTICIPANTS

A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%.

INTERVENTION

Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL.

MEASUREMENTS

Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers.

RESULTS

Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations.

CONCLUSION

Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.

Adherence to national diabetes guidelines through monitoring quality indicators--A comparison of three types of care for the elderly with special emphasis on HbA1c

AIM

To compare adherence to Swedish guidelines for diabetes care between elderly people living at home with or without home health care, and residents of nursing homes.

METHODS

Medical records of 277 elderly people aged 80 and older, with known diabetes in a Swedish municipality, were monitored using quality indicators to evaluate processes and outcomes.

RESULTS

Monitoring, in accordance to diabetes guidelines, of HbA1c, lipids, blood pressure and foot examinations was lower among residents of nursing homes (p < 0.001). The HbA1c value of ≤ 6.9% (52 mmol/mol) was achieved for 48% of those in nursing homes with medication, 35% and 39%, for those living at home with or without home health care, respectively. Insulin was used to a greater extent in nursing homes. Metformin was frequently used, even at reduced e-GFR. Systolic BP ≤ 140 mmHg was achieved by 71% vs 80% and 85% of those living at home, those with home health care and residents of nursing homes in the respective groups.

CONCLUSIONS

Adherence to guidelines was deficient particularly in nursing homes. Clearer guidelines and interventions aimed at the improvement of quality in diabetes care in elderly people and sustainable coordination between health care providers is needed.

A randomized controlled trial comparing treatment with oral agents and basal insulin in elderly patients with type 2 diabetes in long-term care facilities

BACKGROUND

Managing hyperglycemia and diabetes is challenging in geriatric patients admitted to long-term care (LTC) facilities.

METHODS

This randomized control trial enrolled patients with type 2 diabetes (T2D) with blood glucose (BG) >180 mg/dL or glycated hemoglobin >7.5% to receive low-dose basal insulin (glargine, starting dose 0.1 U/kg/day) or oral antidiabetic drug (OAD) therapy as per primary care provider discretion for 26 weeks. Both groups received supplemental rapid-acting insulin before meals for BG >200 mg/dL. Primary end point was difference in glycemic control as measured by fasting and mean daily glucose concentration between groups.

RESULTS

A total of 150 patients (age: 79±8 years, body mass index: 30.1±6.5 kg/m(2), duration of diabetes mellitus: 8.2±5.1 years, randomization BG: 194±97 mg/dL) were randomized to basal insulin (n=75) and OAD therapy (n=75). There were no differences in the mean fasting BG (131±27 mg/dL vs 123±23 mg/dL, p=0.06) between insulin and OAD groups, but patients treated with insulin had greater mean daily BG (163±39 mg/dL vs 138±27 mg/dL, p<0.001) compared to those treated with OADs. There were no differences in the rate of hypoglycemia (<70 mg/dL) between insulin (27%) and OAD (31%) groups, p=0.58. In addition, there were no differences in the number of hospital complications, emergency room visits, and mortality between treatment groups.

CONCLUSIONS

The results of this randomized study indicate that elderly patients with T2D in LTC facilities exhibited similar glycemic control, hypoglycemic events and complications when treated with either basal insulin or with oral antidiabetic drugs.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01131052.

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.

Diabetes in long-term care facilities

With the aging of the population and longer life expectancies, the prevalence of population with multiple chronic medical conditions has increased. Difficulty managing these conditions as people age (because of changes in physical, functional, or cognitive abilities and the complexity of many treatment regimens), has led to more individuals with multiple medical conditions admitted to the long-term care facilities. Older adults with diabetes residing in the long-term facilities represent the most vulnerable of this cohort. Studies that specifically target diabetes management in older population are lacking and those that target diabetes management in the long-term care facilities are even fewer. The lack of knowledge regarding the care of the elderly residing in long-term care with diabetes may lead to treatment failure and higher risk of hyperglycemia, as well as hypoglycemia. In aging populations, hypoglycemia has the potential for catastrophic consequences. To avoid this, the management of older population with diabetes and other medical comorbidities residing in long-term care facilities requires a more holistic approach compared with focusing on individual chronic disease goal achievement.

Challenges in managing elderly people with diabetes in primary care settings in Norway

OBJECTIVE

To explore the experiences and clinical challenges that nurses and nursing assistants face when providing high-quality diabetes-specific management and care for elderly people with diabetes in primary care settings.

DESIGN

Focus-group interviews.

SUBJECTS AND SETTING

Sixteen health care professionals: 12 registered nurses and four nursing assistants from nursing homes (10), district nursing service (5), and a service unit (1) were recruited by municipal managers who had local knowledge and knew the workforce. All the participants were women aged 32-59 years with clinical experience ranging from 1.5 to 38 years.

RESULTS

Content analysis revealed a discrepancy between the level of expertise which the participants described as important to delivering high-quality care and their capacity to deliver such care. The discrepancy was due to lack of availability and access to current information, limited ongoing support, lack of cohesion among health care professionals, and limited confidence and autonomy. Challenges to delivering high-quality care included complex, difficult patient situations and lack of confidence to make decisions founded on evidence-based guidelines.

CONCLUSION

Participants lacked confidence and autonomy to manage elderly people with diabetes in municipal care settings. Lack of information, support, and professional cohesion made the role challenging.

Implementing diabetes care guidelines in long term care

OBJECTIVE

The objectives of this article are to (1) describe the outcomes of a diabetes care program in a long term care facility dedicated to diabetes excellence and (2) compare the relevant outcome variables of research published between 2007 and 2012 with the results found in the studied facility.

DESIGN

Three-year retrospective chart review of the facility's residents with comparison to extant literature.

PARTICIPANTS

A total of 224 resident charts within the studied facility were reviewed. Residents with a diagnosis of diabetes, or who were on diabetes medications, or whose fasting blood sugars exceeded 126 mg/dL on 2 occasions, and whose length of stay exceeded 6 months, were tracked for adherence to diabetes guidelines (n = 48). Participant outcomes from relevant studies in the literature were compared to these 48 participants' outcomes.

INTERVENTION

All levels of staff in the studied facility were educated in general diabetes care. A nurse practitioner was contracted to provide medical care for all diabetic residents (with primary care provider approval). A scorecard for adherence to diabetes guidelines was completed by the nurse practitioner. Over a 3-year period following the education program and scorecard implementation, a chart review of all residents was completed by a consulting diabetes educator/nurse practitioner/nurse faculty member and 6 undergraduate nursing students.

RESULTS

In general, the nursing home in the present study compared favorably with other relevant studies, demonstrating lower A1C levels, tracking blood sugars more regularly, monitoring blood pressure and lipids more regularly, having a greater percentage of patients on lipid-lowering medications among those in need, more appropriate use of sliding scale insulin, greater adherence to recommendations regarding diet, and had more patients who fit criteria on preventive anticoagulation.

DISCUSSION

The results for the studied facility were very similar, often better, when compared with the most current nursing home literature. Areas of weakness provided focused strategic planning for the facility. Regrettably, the research is sparse, and evidence supporting guideline adherence data is often missing, making data comparison difficult. This model of care, linking health care agencies with academia, could offer a supportive and affordable method for identifying responses to evidence-based care guidelines.

CONCLUSION

This narrative review points to the need for continued work in the application of evidence-based guidelines in long term care, specifically in the area of interventions that must be adjusted to the needs of the nursing home population, with increased awareness in maintaining or improving quality of life.

Use of telemedicine to improve glycemic management in a skilled nursing facility: a pilot study

The objective of this study was to evaluate the feasibility of using telemedicine to improve glycemic control (reduce episodes of hypoglycemia and severe hyperglycemia) for residents with diabetes in a skilled nursing facility. This randomized pilot study enrolled residents with diabetes (n=23; mean age, 83 years; 91% insulin-treated) and compared usual care (control; n=11) with usual care plus weekly/biweekly teleconsultations with an endocrinologist (n=12) for up to 6 months. A nurse and dietitian from the skilled nursing facility were at all televisits. Residents who were able and willing attended the televisits. Family members were also invited and occasionally were present. The endocrinologist reviewed glucose levels from point-of-care glucose meter downloads, dietary intake, medications, and medical status and recommended changes in glycemic therapy as needed. Measurements included glucose levels from point-of-care glucose meter downloads, hemoglobin A1c (A1c) levels, and a nurse satisfaction survey. Results showed that 7 of 10 insulin-treated intervention subjects had basal doses reduced (18-69%) compared with 2 of 11 control subjects (reduced 10% and 25%, respectively). There was a decrease in percentage of intervention participants with episodes of hypoglycemia (<80 mg/dL) over the previous month from baseline (42%) to end of study (22%) versus a rise in the control group (from 36% to 45%) and less hyperglycemia (>400 mg/dL) (intervention, from 33% to 22%; control, from 22% to 55%). There were no end-of-study A1c values >8.0% in the intervention group versus 44% in controls. Nursing staff at the skilled nursing facility expressed high satisfaction. Results suggest that telemedicine diabetes consultations to skilled nursing facilities can improve glycemic management.

Assessment of glycemic control among diabetic residents in nursing homes

We assessed hemoglobin A1c (HbA1c) among 88 diabetic residents in three Italian nursing homes, and compared figures with current guidelines and reports in the literature. Mean HbA1c was 6.5%; this paper from Southern Europe confirms recent findings in nursing homes on HbA1c values well below recommended targets.

Good clinical practice guidelines for care home residents with diabetes: an executive summary

A Task and Finish Group of Diabetes UK was convened over 14 months to undertake a systematic review of the original 1999 British Diabetic Association guidance on care home diabetes, incorporate new research findings and produce a set of recommendations that are evidenced-based, practical and implementable within UK care home settings. The anticipation of Diabetes UK is that these guidelines will represent a national policy of good clinical practice for diabetes care within care homes. This executive summary demonstrates how the full guidelines should provide a framework of assessment of the quality of diabetes care within care homes, for use by regulatory bodies who have responsibility for this provision of diabetes care. This document is primarily based on recommendations for adults living within British care home environments and its focus, by virtue of the nature and characteristics of residents, is on older adults. Improvements in diabetes care within residential and nursing homes are likely to follow a sustained commitment by health and social care professionals to ensure that the well-being of residents with diabetes is paramount, that high-quality policies of diabetes care are implemented and monitored and effective diabetes education is a mandatory and integral part of care home staff training.

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.

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

PURPOSE

Diabetes mellitus (DM) is associated with significant morbidity and mortality, and can present with atypical signs and symptoms in elderly residents of nursing homes who often have altered functional and cognitive capacity representing a particularly challenging population to manage. Researchers conducted this study to better understand the current status of DM management in the long-term care facility from the perspective of the facility (use of guidelines, policies, and so forth) as well as that of a resident.

METHODS

Thirteen nursing home facilities in 6 states were studied. A 13-question survey instrument was used to collect data from interviews of the directors of nursing and medical directors. A 26-question data collection form was also used to perform a retrospective chart review of studied residents.

RESULTS

Data from the interview surveys showed that only 15% of facilities studied had a policy for the use of treatment algorithms to manage residents with DM. In addition, only 1 of 13 facilities had a quality improvement tool to evaluate compliance with current policies. In regard to hemoglobin A1C (A1C) testing, only 7.1% of facilities had a house policy in place. Furthermore, only 1% of studied residents had an established target for their A1C despite American Diabetes Association (ADA), American Geriatrics Society (AGS), and American Medical Directors Association (AMDA) guidelines recommending target values and monitoring frequency for A1C testing. The survey instrument also found that just 30.8% of facilities had a policy in place for blood glucose monitoring. Data from the chart review shows that only 57% of residents in this study were taking aspirin or clopidogel bisulfate, although prevention of cardiovascular disease (CVD) is recommended by the American Heart Association (AHA) and ADA in persons with diabetes who are older than 40. Data from this study indicate serious hypoglycemia occurs only occasionally in the nursing home because hypoglycemic episodes requiring hospitalization occurred in only 1% of studied residents. Furthermore, researchers found each of these residents were sent to the hospital only once in the preceding 6 months. One unanticipated finding of the study reports the incidence of delusions from patients' Minimum Data Set (MDS) was 87.63% compared with the national average of 3.7%.

CONCLUSION

Data obtained through this study demonstrates numerous opportunities for improvement in the quality of care for nursing home residents with DM. A multidisciplinary approach is required to properly manage this complex disease in a challenging elderly population. The development of protocols and tools that embrace the latest strategies and treatment algorithms for the management of DM in the geriatric resident are necessary, while implementation of a quality improvement tool can help facilities to further improve on management of DM in the long-term care setting.

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

OBJECTIVES

To study the role of nursing home (NH) admission and dementia status on the provision of five procedures related to diabetes mellitus.

DESIGN

Retrospective cohort study using data from a large prospective study in which an expert panel determined the prevalence of dementia.

SETTING

Fifty-nine Maryland NHs.

PARTICIPANTS

Three hundred ninety-nine new admission NH patients with diabetes mellitus.

MEASUREMENTS

Medicare administrative claims records matched to the NH medical record data were used to measure procedures related to diabetes mellitus received in the year before NH admission and up to a year after admission (and before discharge). Procedures included glycosylated hemoglobin, fasting blood glucose, dilated eye examination, lipid profile, and serum creatinine.

RESULTS

For all but dilated eye examinations, higher rates of procedures related to diabetes mellitus were seen in the year after NH admission than in the year before. Residents without dementia received more procedures than those with dementia, although this was somewhat attenuated after controlling for demographic, health, and healthcare utilization variables. Persons without dementia experience greater increases in procedure rates after admission than those with dementia.

CONCLUSION

The structured environment of care provided by the NH may positively affect monitoring procedures provided to elderly persons with diabetes mellitus, especially those without dementia. Medical decisions related to the risks and benefits of intensive treatment for diabetes mellitus to patients of varying frailty and expected longevity may lead to lower rates of procedures for residents with dementia.