Diabetes Management: The Hidden Challenge of Managing Hyperglycemia in Long-Term Care Settings

Fri, 9/5/08 - 4:54pm
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Author(s):

Barbara Resnick, PhD, CRNP, FAAN, FAANP

Diabetes affects approximately 20% of nursing home residents.1 The impact of diabetes is devastating in these individuals, with 90% of nursing home residents with diabetes having evidence of coronary artery disease, stroke, and/or peripheral vascular disease. These individuals tend to have 6.4 major diagnoses, compared with only 2.4 in residents without diabetes. Much of the research in this area has focused on describing diabetic care behaviors of providers in nursing homes, and conclusions generally indicated that this care has been inadequate.2-5 Guidelines have been developed based on best practices for management of diabetes with older adults;6,7 however, these guidelines are not well disseminated or utilized.8 For residents in long-term care facilities, subsequent micro- and macrovascular disease may not be important to them. Rather, it is the day-to-day impact of diabetes management on functional activities, mood, cognition, and quality of life that is relevant. It is therefore particularly important to consider the daily impact of diabetes on these individuals, as well as the more commonly ignored and neglected problem of hyperglycemia.

IMPACT OF DIABETES

Diabetes can result in serious morbidity and mortality from micro- and macrovascular complications.9 Complications include heart attack, stroke, diabetic retinopathy, end-stage renal failure, peripheral vascular disease, peripheral neuropathy, cognitive impairment, sexual dysfunction, and multiple gastrointestinal, urological, and cardiovascular symptoms.10-12 Repeatedly it has been shown that glucose control can prevent or slow the progression of these devastating microvascular complications of diabetes.13 Specifically, there is a 25-30% reduction in the development of the microvascular complications for every 1% reduction in glycosylated hemoglobin (HbA1c). Unfortunately, 8 years of treatment are needed before the benefits of glycemic control are appreciated.14 Likewise, it takes time (approximately 2-3 years) to reap the benefits of blood pressure and lipid management in type 2 diabetes with regard to microvascular problems.14,15 Glucose control has not been proven to be a significant factor for the prevention of macrovascular disease.14 Hyperglycemia is noted, however, to have significant short-term effects on older adults causing slowed brain function, lethargy, and dehydration.16 Generally, in the long-term care setting, treatment goals are to restore the metabolic abnormalities to as nearly normal as possible, and to adequately control blood pressure and lipids.6,7 The ultimate purpose of the recommended goals is to reduce morbidity, mortality, and patient care costs in individuals with diabetes.

RECOGNITION OF DIABETES AND HYPERGLYCEMIA

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus developed guidelines for the diagnosis of diabetes (Table I).17 These guidelines maintain that a diagnosis of diabetes should be entertained when there is a fasting glucose of greater than 125 mg/dL and an oral glucose tolerance test (2-hour) that results in a glucose level of greater than 199 mg/dL.

There are many factors that influence the development of hyperglycemia and diabetes in older adults, as shown in the Figure.18 Insulin resistance is particularly common in older individuals; however, insulin secretion can likewise be a problem. Impaired beta-cell compensation to age-related insulin resistance may particularly predispose older individuals to develop hyperglycemia and type 2 diabetes.

Traditional signs and symptoms of hyperglycemia are often different in older adults when compared to younger individuals.

References:

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