Diabetes in the Nursing Home
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This article reviews and synthesizes the literature pertaining to the identification and care of the nursing home (NH) resident with diabetes. NH residents with diabetes have heavy illness burden with complex medical management of their comorbid conditions including depression and exacerbations of their other chronic conditions. Future research is necessary to determine models of care in the NH, with nurse practitioners driving improvement in standards of care, and how this may improve outcomes such as cognition and functional ability. Future research is also indicated to determine how residents’ conditions and care change over time, as well as how one can assist in the transition of care to end-stage disease with a terminal decline to better serve these residents. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[8]:42-46)
Twenty percent of patients over age 65 have diabetes.1 This number is expected to grow rapidly with the baby boomers’ advancing age. According to the American Diabetes Association (ADA),1 there are no published long-term studies in individuals over age 65 to demonstrate the benefits of tight glycemic control, blood pressure (BP), and lipid control. High rates of premature death, functional disability, and comorbid conditions are more likely in older patients with diabetes than in those without. These persons are also at greater risk for polypharmacy, depression, cognitive impairment, urinary incontinence, injurious falls, and persistent pain.1 Life expectancies in this population are highly variable. It is important that clinicians recognize the prevalence of diabetes in nursing homes (NHs) and to provide appropriate management.
Prevalence of Diabetes in Nursing Homes
The prevalence of diabetes in NHs, obtained predominantly via questionnaires, has been estimated from 8.8-26.7%.2-7 Sinclair et al4 used a more scientific approach by administering an oral glucose tolerance test in addition to collecting fasting blood sugar (FBS) levels. Nearly 15% of the residents had diabetes and an additional 30.2% were diagnosed with impaired glucose tolerance.4 The prevalence rate using information from the Minimum Data Set (MDS) was 26.4%.7
Undiagnosed diabetes is a serious problem because evidence supports a link between diabetes and cognitive impairment.8-12 Targeted screening of elderly residents with dementia may identify the highest rates of undiagnosed diabetes.13 Researchers have estimated that prevalence rates for undiagnosed diabetes in NHs ranged from 13% to 47.2%.6,13,14 Hauner and colleagues6 concluded that undiagnosed diabetes prevalence was 47.2%; this higher prevalence rate may be related to the authors’ stricter definition of diabetes as hemoglobin A1C (HbA1C) value of greater than 6.0%.
Profile of the Older Adult with Diabetes
The composite of available data is from community-dwelling elderly individuals and is not specific to the elderly NH resident with diabetes. Based on this information, elderly persons with diabetes tend to have decreased functional ability8,9 with increased fall rates as compared to elderly persons without diabetes. Increased hospitalizations and admissions are also seen in the diabetic population. Cognitive functional impairment and depression are strongly correlated with HbA1C values.8-10 According to the ADA, glycosylated hemoglobin levels of 6% or lower are desirable and reduce target organ damage.1 Research indicates otherwise for elderly persons with diabetes. In one study, HbA1C levels less than 6% were found to have a deteriorating effect on cognition.8 Hagemann et al8 concluded that participants with HbA1C levels from 6-8% had higher Mini-Mental State Examination (MMSE) scores than those with levels lower than 6% or higher than 8%. These findings seem to suggest that HbA1C levels of 7.5-8% may be acceptable for elderly individuals.
1. American Diabetes Association. Standards of Medical Care in Diabetes. 2009. http://care.diabetesjournals.org/content/32/supplement_1/S13.full. Accessed June 30, 2009.
2. Benbow SJ, Walsh A, Gill GV. Diabetes in institutionalized elderly people: A forgotten population? BMJ 1997;314:1868-1869.
3. Taylor CD, Hendra TJ. The prevalence of diabetes mellitus and quality of diabetic care in residential and nursing homes. A postal survey. Age Aging 2000;29:447-450.
4. Sinclair AJ, Gadsby R, Penfold S, et al. Prevalence of diabetes in care home residents. Diabetes Care 2001;24(6):1066-1068.
5. Centers for Disease Control (CDC). Perspectives in disease prevention and health promotion impact of policy and procedure changes on hospital days among diabetic nursing-home residents – Colorado. MMWR Morb Mortal Wkly 1984;33(44):621-624, 629.
6. Hauner H, Kurnaz AA, Haastert B, et al. Undiagnosed diabetes mellitus and metabolic control assessed by HbA1C among residents of nursing homes. Exp Clin Endocrinol Diabetes 2001;109:326-329.
7. Travis SS, Buchanan RJ, Wang S, Kim M. Analyses of nursing home residents with diabetes at admission. J Am Med Dir Assoc 2004;5:320-327.
8. Hagemann R, Sartory G, Hader C, Kobberling J. Mood and cognitive function in elderly diabetic patients living in care facilities. Dement Geriatr Cogn Disord 2005;19:369-375. Published Online: March 30, 2005.
9. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: Impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 2000;160:3278-3285.
10. Maraldi C, Volpato S, Penninx BW, et al. Diabetes mellitus, glycemic control, and indicent depressive symptoms among 70-to-79-year-old persons: The health, aging, and body composition study. Arch Intern Med 2007;167:1137-1144.
11. Perlmuter LC, Hakami MK, Hodgson-Harrington C, et al. Decreased cognitive function in aging non-insulin-dependent diabetic patients. Am J Med 1984;77:1043-1048.
12. Reaven GM, Thompson LW, Nahum D, Haskins E. Relationship between hyperglycemia and cognitive function in older NIDDM patients. Diabetes Care 1990;13(1):16-21.
13. Aspray TJ, Nesbit K, Cassidy TP, et al. Diabetes in British nursing and residential homes: A pragmatic screening study. Diabetes Care 2006;29(3):707-708.
14. U’Ren RC, Riddle MC, Lezak MD, Bennington-Davis M. The mental efficiency of the elderly person with type II diabetes mellitus. J Am Geriatr Soc 1990;38:505-510.
15. Worrall G, Moulton N, Briffett E. Effect of type II diabetes mellitus on cognitive function. J Fam Pract 1993;36:639-643.
16. Maurer MS, Burcham J, Cheng H. Diabetes mellitus is associated with an increased risk of falls in the elderly residents of a long-term care facility. J Gerontol A Biol Sci Med Sci 2005;9:1157-1162.
17. Shorr RI, Franse LV, Resnick HE, et al. Glycemic control of older adults with type 2 diabetes: Findings from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Geriatr Soc 2000;48(3):264-267.
18. Peyrot M, Rubin RR. Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care 1997;20(4):585-590.
19. McNabney MK, Pandya N, Iwuagwu C, et al. Differences in diabetes management of nursing home patients based on functional and cognitive status. J Am Med Dir Assoc 2005;6:375-382. Published Online: July 22, 2005.
20. Glynn RJ, Monane M, Gurwitz JH, et al. Aging, comorbidity, and reduced rates of drug treatment for diabetes mellitus. J Clin Epidemiol 1999;52(8):781-790.
21. American Medical Directors Association. Managing Diabetes in the Long-Term Care Setting: Clinical Practice Guideline. Columbia, MD: American Medical Directors Association; 2002.
22. Mader SL, Fuglee KA, Allen DS, et al. Development of a protocol for capillary blood glucose testing in nursing home and rehabilitation settings. J Am Geriatr Soc 2006;54:1114-1118.
23. Nicholls H. Improving diabetes care in our residential homes. Journal of Diabetes Nursing 2005;9(10):385-387.
24. Fahey T, Montgomery AA, Barnes J, Protheroe J. Quality of care for elderly residents in nursing homes and elderly people living at home: Controlled observational study. BMJ 2003;326:580-584.
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