Annals of Long Term Care

INTRODUCTION

Approximately 1 in 5 skilled nursing facility residents age 55 years and over have been diagnosed with diabetes. In addition to their diabetes, more than 69% have two or more chronic conditions.1 Quality health care in skilled nursing facilities proves to be challenging due to nurses concomitantly being responsible for the care of more than five residents, common staff shortages, and frequent staff turnover. Minimal staff salaries and nominal staff education regarding specific disease states contribute to the decrease in quality of care. Unfortunately, most direct patient care in nursing facilities is provided by nursing aides.2 As a result, diabetes care in skilled nursing facilities is not optimal. The following case will introduce some deficiencies in a resident’s diabetes care.

CASE PRESENTATION

FS is an 81-year-old white female who resides in a local intermediate-care nursing facility, where she was placed due to lack of family care, lack of mobility, and need for assistance with activities of daily living resulting from a cerebrovascular accident (CVA) 5 years previously; she has high cognitive function with no dementia. She is a patient at the primary care office where clinical pharmacists provide disease and medication management services. FS is visiting the office for an overall diabetes assessment, which includes evaluation of achievement of American Diabetes Association (ADA) standards of care. She is well developed but utilizes a wheelchair for mobilization. Past medical history, list of current medications, and laboratory and physical assessment findings are listed in Tables I, II, and III.

Utilizing the American Association of Diabetes Educators AADE 7 assessment and monitoring tool, the following was discovered.

HEALTHY EATING
Findings:
FS’s meals are prepared at the long-term care facility where she is served meals at 8:00 a.m., noon, and 5:00 p.m. Her normal bedtime snack consists of an enteral nutrition formula specifically for patients with diabetes, and a sugar-free candy bar. This snack has 35 grams of carbohydrate.

Recommendations:
An individualized meal plan was developed for FS. Taken into consideration were her current weight of 173 pounds, BMI of 28, immobility due to her CVA, along with her 3 + edema of the extremities, frequent morning hypoglycemia, and dyslipidemia. The long-term care facility’s dietary manager said that concentrated juices and sweets were not given to residents with diabetes, and they do not limit FS’s carbohydrate intake at meals. This, unfortunately, is common for residents with diabetes.3 A recommendation of 45 grams of carbohydrates per meal and 15 grams of carbohydrates for an evening snack was given to the facility, which would utilize 40% of FS’s daily calories from carbohydrates. Education regarding what food items are considered carbohydrates and the potential laxative effect of the sugar-free candy was provided to FS, and will be reviewed with the facility. Examples of snacks containing 15 grams of carbohydrates based on the availability of food items at the facility will be given to the dietary manager.

BEING ACTIVE
Findings:
FS utilizes a wheelchair due to the CVA. INR levels are being monitored and are within therapeutic range, but will not be discussed further in this article.

Recommendations:
Wheelchair activities can be developed with FS to help her retain some upper body mobility and strength.

MONITORING
Findings:
Currently, the facility monitors FS’s blood glucose levels upon rising and before lunch and evening meals. Her A1c of 6.8% is below the ADA’s goal of less than 7%, but may be falsely low due to frequent hypoglycemia. More than 50% of her fasting blood glucose levels fall below 70 mg/dL, and she complains of symptoms consistent with hypoglycemia. Other pre-meal readings ranged from 160-242 mg/dL, indicating inadequate blood glucose control.