Management of Diabetes Mellitus in the Nursing Home
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INTRODUCTION
Diabetes mellitus (DM), primarily type 2, is a prevalent, resource-intensive condition in nursing homes (NHs), which may have significant impact on residents’ function and quality of life. Upon admission to a NH, 26.4% of residents have a diagnosis of DM, including short-stay (< 6 months) and long-stay residents (> 6 months), whose placement may be permanent.1 Almost half of residents with DM will become long-stay residents.1 Compared to those admitted without DM, residents with DM have a higher burden of comorbid disease, disability, and cognitive impairment, pain, depression, polypharmacy, and require more nursing care.1 Older adults with DM are at higher risk of developing several geriatric syndromes, including injurious falls,2,3 incident disability,4 cognitive impairment,5 urinary incontinence (UI),6 depression,7 and persistent pain,8 if not already present. While the goals of care for short-stay and long-stay residents may differ, avoiding iatrogenic harm is a major focus for both. This is particularly true for frail NH residents with DM who are at high risk for hypoglycemia or other complications of medical therapy such as postural hypotension.
As a result, management of DM in the long-term care setting requires supreme clinical judgment, taking into account the resident’s care preferences, comorbid conditions, and estimated life expectancy. All of this information must be used to make a realistic assessment of the likely benefits and risks of treatment for DM, and associated conditions consistent with the resident’s short- and long-term goals.
In 2003, an expert panel convened by the California Healthcare Foundation/American Geriatrics Society published Guidelines for Improving the Care of the Older Person with Diabetes Mellitus. The major aim of the guideline was to provide clinicians with a framework for prioritizing recommendations for the management of glycemia, and preventing micro- and macrovascular disease in the population of older adults with DM and heterogeneous health status.9 The guideline noted that while intensive risk management is appropriate for robust older adults with good function, it might be inappropriate in frail older adults with limited life expectancy, where the focus of care often shifts to prevention of symptomatic hyperglycemia and reduction of the burden of medical therapy. Furthermore, the guideline noted that geriatric syndromes might complicate the management of DM or constitute a primary focus of care. As a result, it recommended that healthcare providers screen for and manage geriatric syndromes. The guideline provides the basics of a framework to help clinicians prioritize competing comorbidities. Subsequent guidelines by the American Diabetes Association have included explicit reference to these guidelines and have endorsed its message.10 In addition, process-based quality indicators for long-stay NH residents with DM have been developed in an effort to improve outcomes while keeping the unique needs of this population in mind.11
In addition to these considerations (ie, comorbid illness, geriatric syndromes, reduced life expectancy, and shifting priorities of care), physicians and other healthcare providers practicing in the long-term care setting often find that managing residents with DM is complicated by care transitions, dependency that affects food and water intake, and conditions such as dementia and stroke that interfere with patient-provider communication.
References
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