How well are we managing diabetes in long-term care?
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.
In the absence of specific recommendations for extended-care residents with diabetes, our study evaluated the status of care in this population on the basis of pharmacotherapy and standards of care recommended by the ADA for ambulatory adults with DM.
Methods
Data collection
We reviewed the charts of 245 patients in 14 long-term care facilities in Ohio and West Virginia. All participating facilities signed a letter of agreement to take part in the study. The study was approved by the Ohio University Institutional Review Board.
At each facility, the director of nursing supplied a list of residents with DM. To be eligible for chart review, residents had to have a physician-documented diagnosis of type 1 or type 2 DM and have lived at the facility for at least 3 of the previous 12 months. Residents in both skilled nursing care and assisted living facilities were able to participate; short-term rehabilitation residents were not.
We performed a comprehensive review of each chart, examining the medical diagnoses, medication lists, laboratory reports, and physician and consultation notes for a one-year period. Data collection focused on diabetes-related intermediate outcomes and processes of care. Intermediate outcomes included A1c tests, lipid panels, and BP readings. Processes of care included aspirin therapy, use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, use of statins, eye exams, foot exams, and microalbumin tests. The data collected omitted information identifying the patient, physician, or facility.
We compared the collected data with the 2011 ADA standards of care: blood glucose (fasting 80-120 mg/dL; postprandial 100-140 mg/dL), A1c (<7%), BP (<130/80 mm Hg), and lipid levels (low-density lipoprotein [LDL] <100 mg/dL; high-density lipoprotein [HDL] >40 mg/dL in men and >50 mg/dL in women; triglycerides <150 mg/dL).
Data analysis
We entered the data into an Excel database by type and key format and analyzed results using SPSS software, version 14.0 (SPSS, Chicago, IL). We used percentages and means±standard deviation to describe the data.
Results
TABLE 1 lists characteristics of the patients in the study: 24.5% were male and 75.5% were female; 9 (3.7%) were diagnosed with type 1 DM; 236 (96.3%) had type 2 DM. The mean age was 81±9 years, with a range of 44 to 103 years. Approximately 96% were Caucasian. The residents’ medical care was managed by family physicians (66.1%), internists (25.7%), geriatricians (6.9%), endocrinologists (0.8%), and other physicians (0.4%). The findings that follow are all based on a one-year period unless otherwise specified.
TABLE 1
Study population profile
| Patient characteristic | N (%) |
|---|---|
| Sex Male Female | 60 (24.5) 185 (75.5) |
| Diabetes diagnosis Type 1 Type 2 | 9 (3.7) 236 (96.3) |
| Managing physician specialty Family medicine Internal medicine Geriatrics Endocrinology Other | 162 (66.1) 63 (25.7) 17 (6.9) 2 (0.8) 1 (0.4) |
Diabetes management
Most of the residents (211 [86.1%]) underwent glucose monitoring. The proportion of residents who received specific diabetes interventions is detailed in TABLE 2.
Hypoglycemia. Fifty-two residents (24.6% of those receiving glucose monitoring and 21.2% of the total) experienced a hypoglycemic event; 103 (representing 48.8% of the monitored patients and 42% of the total) had hyperglycemic events. On average, each resident experienced 1±2 mild hypoglycemic episodes per month, with a maximum of 13 mild episodes for one resident. Severe hypoglycemia (< 50 mg/dL) occurred less often, on average 0.24±1 time per resident. One resident had 15 severe hypoglycemic events in a month. The mean low hypoglycemic episode was at a glucose level of 52±16 mg/dL.
Hyperglycemia occurred more often than hypoglycemia (8±14 times per month), with a mean high glucose level of 352±89 mg/dL. This study used a generous range for normal glucose readings (70-249 mg/dL), and 89% of blood glucose readings were within that range. Thirty-seven percent of residents had an A1c <7.0%.
Medication. Thirty-two (13.1%) patients received no oral medication or insulin, and were managed with lifestyle interventions alone. Sixty-four patients (26.1%) used only oral medications, 64 (26.1%) received only insulin, and 85 (34.7%) were treated with both. Of the patients receiving insulin, 108 (72%) were on a sliding scale regimen. Seventy-seven (51.7%) of the patients on insulin experienced hypoglycemia, vs 30 (20%) of those taking oral medication. Twenty-seven (31.8%) patients in the combined therapy group had hypoglycemic events.
TABLE 2
Interventions received by the study population
| Intervention | N (%) |
|---|---|
| Glucose monitoring | 211 (86.1) |
| Blood pressure monitoring | 240 (98.0) |
| Lipids checked | 190 (77.6) |
| Dilated eye exams | 133 (54.3) |
| Foot exams* | 187 (76.3) |
| *170 (69.4%) patients had a consultation with a podiatrist. | |
Preventive care
Foot and eye care. Dilated eye examinations were provided for 133 residents (54.3%). Most (76.3%) received foot examinations, and 69.4% were seen by a podiatrist.
Blood pressure. Of the 240 residents (98%) whose BP was monitored, 107 (43.7%) had readings lower than 125/85 mm Hg, a goal set by a team of diabetologists, endocrinologists, and geriatricians at Ohio University. One hundred residents (40.8%) were taking an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker; 122 (49.8%) were receiving aspirin therapy. In the total population, 110 patients (44.9%) were prescribed a statin.
