Assessment of glycemic control among diabetic residents in nursing homes

Ten-Year Prospective Follow-Up of Institutionalized Patients With Diabetes in a Long-Term Care Home

Clinical practice recommendations advise individualizing diabetes treatment for elderly people, especially those living in long-term care facilities. Elderly patients face one of two main risks: either excessive treatment leading to hypoglycemia or insufficient treatment leading to progression of complications and excess mortality. This article describes a 10-year prospective observational study of people with diabetes in a long-term care home to determine the effect of routine glucose monitoring and monthly evaluation by a diabetes specialist with a goal of improving A1C. Its findings suggest that minimal glucose monitoring and monthly medical follow-up can optimize patient outcomes and help to maintain quality of life without over-medicalization of older people with diabetes in institutional settings.

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

OBJECTIVE

To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Residents with T2DM and aged ≥60 years living in LTCFs.

MEASURES

Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs.

RESULTS

Fifteen studies were included. Prevalence of potential overtreatment (5%-86%, n = 15 studies) and undertreatment (1.4%-35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%-74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%-14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment.

CONCLUSIONS AND IMPLICATIONS

The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.

Diabetes management of older adults in nursing homes: A retrospective study

AIM

To examine the diabetes management of older adults in nursing homes.

BACKGROUND

Diabetes is an increasing problem in nursing homes, and diabetes care is defined as a neglected clinical area.

METHODS

A retrospective collected data review of 166 older adults with known diabetes from four nursing homes.

RESULTS

65% older than 75 years had HbA1c levels lower than 7.5% (58 mmol/mol), 74% older than 85 years had HbA1c levels lower than 8% (64 mmol/mol). The HbA1c levels were 7.3% (56 mmol/mol) for those who had three and more chronic disorders and 6.8% (51 mmol/mol) for those who had less than three chronic disorders. Individuals treated with insulin had higher HbA1c levels (p < .001) and glycaemia (p = .002). Age was associated with a number of chronic disorders (p = .031), a number of regularly prescribed medications (p = .038) and a number of medications as needed (p = .009).

CONCLUSIONS

More than half to three quarters have diabetes well-managed. Nevertheless, there is still some potential for improving diabetes care, and these findings warrant further research for improving diabetes management of older adults in nursing homes.

IMPLICATIONS FOR NURSING MANAGEMENT

Interventions designed to promote a healthy lifestyle, documenting individuals' target level and regular monitoring of glycaemia and HbA1c levels may help to improve diabetes management, which may result in better well-being and quality of life for older adults with diabetes in nursing homes.

Glycemic control and use of glucose-lowering medications in hospital-admitted type 2 diabetes patients over 80 years

Treatment guidelines for type 2 diabetes (T2D) recommend avoidance of hypoglycemia and less stringent glycemic control in older patients. We examined the relation of glycemic control to glucose-lowering medications use in a cohort of patients aged>80 years with a diagnosis of T2D and a hospital admission in the Capital Region of Denmark in 2012-2016. We extracted data on medication use, diagnoses, and biochemistry from the hospitals' records. We identified 5,172 T2D patients with high degree of co-morbidity and where 17% had an HbA_1c in the range recommended for frail, comorbid, older patients with type 2 diabetes (58-75 mmol/mol (7.5-9%)). Half of the patients (n = 2,575) had an HbA_1c <48 mmol/mol (<6.5%), and a majority of these (36% of all patients) did not meet the diagnostic criteria for T2D. Of patients treated with one or more glucose-lowering medications (n = 1,758), 20% had HbA_1c-values <42 mmol/mol (<6%), and 1% had critically low Hba_1c values <30 mmol/mol (<4.9%), In conclusion, among these hospitalized T2D patients, few had an HbA_1c within the generally recommended glycemic targets. One third of patients did not meet the diagnostic criteria for T2D, and of the patients who were treated with glucose-lowering medications, one-fifth had HbA_1c-values suggesting overtreatment.

Prescription Patterns and Disease Control in Type 2 Diabetes Mellitus Patients in Nursing Home and Home Care Settings: A Retrospective Analysis in Germany

AIM

The aim of this study was to analyze prescription patterns and disease control in patients with type 2 diabetes mellitus (T2DM) in nursing home and home care settings in Germany.

METHODS

The present study is based on data from the Disease Analyzer database (QuintilesIMS). Patients with an initial diagnosis of T2DM and documented HbA1c values between January 2011 and December 2015 were included in the analysis. The index date corresponded to the last documented HbA1c value. Patients in nursing homes were matched (1:1) with patients living at home based on age, gender, and dementia diagnosis. The first outcome of the study was the share of use of several antidiabetic drugs in the two different settings. The second outcome was the mean HbA1c value and the proportion of patients with HbA1c values lower than 7% in the two different groups.

RESULTS

In this study, 4925 individuals lived in nursing homes and 4925 individuals lived at home. The mean age was 80.7 years (SD = 7.7). Prescription patterns differed significantly between nursing home and home care settings: insulin (57.9% vs 41.1%), metformin (46.6% vs 60.5%), sulfonylurea (24.9% vs 34.2%), DPP4 inhibitors (13.4% vs 19.8%), and other antihyperglycemic drugs (7.8% vs 12.1%). In contrast, mean HbA1c values (nursing home: 7.2%; home: 7.2%) and the share of patients with Hb1Ac values lower than 7% (nursing home: 49.1%; home: 50.9%) did not differ significantly between the two groups.

CONCLUSION

Overall, the differences in prescription patterns between nursing homes and home care were not associated with significant differences in the management of T2DM.

HYPERGLYCEMIA AND HYPOGLYCEMIA IN PATIENTS WITH DIABETES IN SKILLED NURSING FACILITIES

OBJECTIVE

Endocrinologists are faced with a growing elderly patient population with diabetes mellitus (DM), some of whom are in skilled nursing facilities (SNFs). Efforts at managing their DM is hampered by concerns for hypoglycemia. This study aimed to determine the frequency of hypo- and hyperglycemia in SNFs, and associated factors.

METHODS

We reviewed medical records of 200 consecutive residents admitted to two SNFs in the Cleveland area in 2014 with documented DM, aged ≥65 years. Data collected included blood glucose (BG) levels and DM regimens. Frequency of hyper- and hypoglycemic events was noted. Since patients had different frequencies of BG checks, event-days were calculated.

RESULTS

Mean age, BG, and glycated hemoglobin (±SD) were as follows: 80.2 ± 8.2 years, 172.4 ± 40.3 mg/dL, and 7.5 ± 1.9% (59 mmol/mol), respectively. Seventy-one percent were on insulin alone, 15.5% on insulin and oral diabetes agents, and 13.5% on oral diabetes agent on admission. Patients with at least one event were as follows: 38% hypoglycemia, 3.5% severe hypoglycemia, 90.5% hyperglycemia, and 15% severe hyperglycemia. Event-days were: 3.4% hypoglycemia and 52.4% hyperglycemia. Risk of hypoglycemia was highest with concomitant sulfonylurea and prandial or sliding-scale insulin. Hyperglycemia risk was high in basal insulin-containing regimens.

CONCLUSION

Hypoglycemia was seen in one-third of patients, and hyperglycemia was common despite insulin use. Concomitant use of sulfonylurea and prandial or sliding-scale insulin is best avoided in this fragile population with hypo- and hyperglycemia.

ABBREVIATIONS

ADA = American Diabetes Association BG = blood glucose DM = diabetes mellitus GLP-1 = glucagon-like peptide 1 HBA1c = glycated hemoglobin LOS = length of stay NPH = neutral protamine Hagedorn SNF = skilled nursing facility SSI = sliding-scale insulin.

Severe hypoglycemia is associated with antidiabetic oral treatment compared with insulin analogs in nursing home patients with type 2 diabetes and dementia: results from the DIMORA study

OBJECTIVES

Severe hypoglycemia is associated with cognitive decline and dementia in older persons with type 2 diabetes. The role of antidiabetic treatments on severe hypoglycemia is unknown in dementia. The aims were to determine the prevalence of severe hypoglycemic events and investigate associations among severe hypoglycemic and specific antidiabetic treatments (classes of oral agents and types of insulin analogs) in a large sample of nursing home patients with diabetes according to dementia status.

DESIGN

Cross-sectional observational study.

SETTING

A total of 150 nursing homes across Italy.

PARTICIPANTS

A total of 2258 patients with type 2 diabetes (dementia = 1138, no dementia = 1120).

MEASUREMENTS

Diagnosis of dementia before nursing home admission. Data were collected regarding functional status, glycemic control, antidiabetic treatments, comorbidities, and biochemical and clinical measurements. Logistic regression models with severe hypoglycemia as the dependent variable were used to test associations with antidiabetic agents.

RESULTS

Patients had a mean age (SD) of 82 (8) years, body mass index (BMI) of 25.4 (4.8), fasting plasma glucose (FPG) of 7.5 (3.0) mmol/L, postprandial glucose (PPG) of 10.3 (3.6) mmol/L, HbA1c of 7.1% (54 mmol/L), and impairments in activities of daily living (ADLs) of 3.7 (2.1). Severe hypoglycemia was more prevalent in patients with dementia (18%) compared with patients without dementia (8%). Patients with dementia were older, showed greater ADL impairments, greater number of comorbidities, lower FPG, and higher PPG compared with those without dementia. Adjusted logistic regression models in patients with dementia showed that rapid- and long-acting insulin analogs were associated with reduced odds ratio (OR) (OR 0.333; 95% confidence interval [CI] 0.184-0.602; OR 0.248, 95% CI 0.070-0.882, respectively), whereas sulphonylureas and combined metformin + sulphonylurea were associated with increased ORs (OR 8.805, 95% CI 4.260-18.201; OR 6.639; 95% CI 3.273-14.710, respectively) of experiencing severe hypoglycemia. No correlations were found in patients without dementia.

CONCLUSION

In older nursing home patients with type 2 diabetes, severe hypoglycemia was significantly higher in dementia. Our findings suggest that sulphonylureas should be used with caution, whereas rapid- and long-acting insulin analogs seem safer.

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.