Differences in Diabetes Management of Nursing Home Patients Based on Functional and Cognitive Status

doi:10.1016/j.jamda.2005.05.012

Journal of the American Medical Directors Association

Volume 6, Issue 6, November–December 2005, Pages 375-382

https://doi.org/10.1016/j.jamda.2005.05.012 Get rights and content

Objectives

To describe practice patterns regarding diabetes management among nursing home (NH) physicians and to identify variation in this practice based on patient characteristics.

Design

Mailed survey.

Participants

Nursing home physicians from the American Medical Directors Association (AMDA) Foundation Long-Term Care Research Network (n = 142), as well as other members of AMDA who were Certified Medical Directors (CMD) (n = 68) and members who were not CMD certified (n = 45). Response rates to the survey were 51%, 33%, and 23%, respectively.

Measurements

Physician and facility characteristics were queried. Responses to 12 items pertaining to diabetes management and 5 items pertaining to use of specific oral diabetes medications were evaluated in the context of 3 different patient profiles that reflected different combinations of functional and cognitive impairment. Responses were based on the physicians’ perception of how they manage diabetes under these specified patient profiles.

Results

Responses from members of the Research Network indicated highly significant variability (P < .01) between the 3 patient profiles for all of the 12 management items. Ordering a special diet, monitoring lipid panel, and ordering routine ophthalmology was less likely for the patient profile with both functional and cognitive impairment (P < .01). These differences among the patient profiles for these 3 interventions were present in the responses from all 3 categories of physicians (Research Network, CMD, and non-CMD members of AMDA). There was no statistically significant variability among the 3 patient profiles for any of the 3 physician groups regarding the likelihood of using of any of the 5 classes of oral diabetic medications. Non-CMD physicians were more likely to have less NH experience; otherwise, there were no differences among the 3 physician groups.

Conclusions

Nursing home physicians appear to alter the approach to diabetes management based on the functional and/or cognitive status of the patient. This was particularly true for those physicians who were members of the AMDA Foundation Research Network. These findings have implications for initiatives designed to guide clinical practice as well as efforts by regulatory bodies to evaluate appropriate care. Further research is needed to measure the actual impact of different approaches to diabetes management on relevant outcomes in this population.

Section snippets

Methods

We mailed the survey to a total of 683 NH physicians believed to represent the full spectrum of clinical management styles in nursing homes. In addition to the 276 members of the AMDA Foundation Research Network, surveys were also distributed to random samples of 208 AMDA members who were Certified Medical Directors (CMD) and 199 members who were not CMD. The potential pool of study participants included 1635 CMD and 6830 non-CMD members of AMDA. Because this was a project of the AMDA

Results

Of the 683 surveys mailed, 255 (37%) were returned. This included 51% (n = 142) from the members of the Research Network, 33% (n = 68) of CMD and 23% (n = 45) of non-CMD members of AMDA. Demographic data on all respondents are listed in Table 1. With the exception of years of NH experience, there were no differences in demographic characteristics among the 3 groups of physicians. There was a statistically significant (P < .05) greater likelihood that physicians without CMD had fewer years of NH

Discussion

The major finding of this study is that physicians report that they manage NH patients with diabetes differently based on the functional and cognitive status of the resident. For each of the 3 physician groups studied, monitoring and prescribing for diabetes was less aggressive for those NH patients who were both cognitively and functionally impaired. This has significant implications with regard to the continued use and revision of existing clinical practice guidelines. It also raises

Conclusions

Physicians report a less aggressive approach to diabetes management for NH patients who are both functionally and cognitively impaired. There are many possibilities for this variation in practice. Physicians did not report a variation in likelihood of using a particular type of oral diabetes medication for the different types of NH patients.

Acknowledgments

The Diabetes Workgroup of the AMDA Foundation Long-Term Care Research Network included the following members: Conn Foley, MD, CMD; Cletus Iwuagwu, MD, CMD; Vicki James, MD, CMD; Paul Katz, MD, CMD; Matthew McNabney, MD, CMD; Naushira Pandya, MD, CMD; Meenakshi Patel, MD, CMD; David Smith, MD, CMD; and Matthew Wayne, MD, CMD. All members of this group contributed to the original design and planning of this project.

In addition, the authors would like to pay tribute to Matthew Tayback, PhD, who

References (15)

J. Spooner et al.
Pharmacologic treatment of diabetes in long-term care
J Clin Epidemiol
(2001)
R. Glynn et al.
Aging, comorbidity and reduced rates of drug treatment for diabetes mellitus
J Clin Epidemiol
(1999)
S.S. Travis et al.
Analyses of nursing home residents with diabetes at admission
J Am Med Dir Assoc
(2004)
M.I. Harris et al.
Prevalence of diabetes mellitus, impaired fasting glucose tolerance in US adults. The Third National Health and Nutrition Examination Survey
Diabetes Care
(1998)
Department of Health and Human Services, Centers for Disease Control and Prevention. Data and Trends, National Diabetes...
J. Reinstock
Management of type 2 diabetes mellitus in the elderly
Drugs & Aging
(2001)
National Center for Health Statistics. The National Nursing Home Survey 1997—Summary for the United States. Vital and...

There are more references available in the full text version of this article.

Cited by (31)

Continuous Glucose Monitoring-Guided Insulin Administration in Long-Term Care Facilities: A Randomized Clinical Trial
2024, Journal of the American Medical Directors Association
To evaluate the efficacy of real-time continuous glucose monitoring (rt-CGM) in adjusting insulin therapy in long-term care facilities (LTCF).
Prospective randomized clinical trial.
Insulin-treated patients with type 2 diabetes (T2D) admitted to LTCF.
Participants in the standard of care wore a blinded CGM with treatment adjusted based on point-of-care capillary glucose results before meals and bedtime (POC group). Participants in the intervention (CGM group) wore a Dexcom G6 CGM with treatment adjusted based on daily CGM profile. Treatment adjustment was performed by the LTCF medical team, with a duration of intervention up to 60 days. The primary endpoint was difference in time in range (TIR 70-180 mg/dL) between treatment groups.
Among 100 participants (age 74.73 ± 11 years, 80% admitted for subacute rehabilitation and 20% for nursing home care), there were no significant differences in baseline clinical characteristics between groups, and CGM data were compared for a median of 17 days. There were no differences in TIR (53.38% ± 30.16% vs 48.81% ± 28.03%, P = .40), mean daily mean CGM glucose (184.10 ± 43.4 mg/dL vs 190.0 ± 45.82 mg/dL, P = .71), or the percentage of time below range (TBR) <70 mg/dL (0.83% ± 2.59% vs 1.18% ± 3.54%, P = .51), or TBR <54 mg/dL (0.23% ± 0.85% vs 0.56% ± 2.24%, P = .88) between rt-CGM and POC groups.
The use of rtCGM is safe and effective in guiding insulin therapy in patients with T2D in LTCF resulting in a similar improvement in glycemic control compared to POC-guided insulin adjustment.
How to manage comorbidities in people with dementia: A scoping review
2023, Ageing Research Reviews
People with dementia experience a high prevalence of comorbidities that seriously affect patient outcomes. The aim of this study was to map the evidence and components related to comorbidity management, including interventions to facilitate and support the practice of management.
A scoping review was conducted. In June 2022, PubMed, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The National Institute of Health and Care Excellence (NICE), Open grey, and the Cochrane Library were searched to identify relevant literature. The inclusion criteria were outlined to identify studies on comorbidity management in people with dementia.
We found 43 items that met the inclusion criteria. The majority of the studies were published since 2010. Most research focused on medication management, health care service use and provision, and comorbidity-related monitoring and management; there were a small number of studies that involved decision-making. Only 6 studies developed interventions to support dementia care, which included comorbidity management. Studies involving the comorbidity management process were mainly based on qualitative methods, which make it difficult to quantify the impact of these processes on comorbidity management.
Given the serious impact of dementia on managing comorbidities, there is a need to develop systematic interventions targeting the management of comorbidities.
The Impact of Dementia on Diabetes Control: An Evaluation of HbA<inf>1c</inf> Trajectories and Care Outcomes in Linked Primary and Specialist Care Data
2022, Journal of the American Medical Directors Association
Citation Excerpt :
Individuals with dementia had a greater odds of macrovascular complications and diabetes foot morbidity but were less likely to have had routine retinal screening or foot examination than those without dementia, particularly in those with more advanced dementia. Other studies have also reported less frequent diabetes monitoring and an increased risk of diabetes complications in those with dementia compared to those without dementia,25,26 including a survey of US nursing home medical directors that reported less routine diabetes monitoring in nursing home residents with cognitive impairment than residents without.27 In our study, patients with dementia had significantly more health care encounters around the time of dementia diagnosis than the nondementia group; thus, dementia may serve as a competing demand in the lead up to dementia diagnosis to the detriment of diabetes management,28 particularly in those with more cognitive impairment.
Diabetes self-care may become increasingly challenging as cognition declines. We sought to characterize glycated hemoglobin A_1c (HbA_1c) trajectories, markers of diabetes-related management, health care utilization, and mortality in people with preexisting type 2 diabetes (T2D) with and without dementia and based on the extent of cognitive impairment at the time of dementia diagnosis.
Retrospective matched cohort study.
Using a linkage between a primary care (Lambeth DataNet) and a secondary mental healthcare database, up to 5 individuals aged ≥65 y with preexisting T2D without dementia were matched to each individual with dementia based on age, sex, and general practice.
Comparisons were made for HbA_1c trajectories (linear mixed effects models), markers of diabetes-related management and severity at dementia diagnosis (logistic regression), mortality (Cox regression), and health care utilization (multilevel mixed effects binomial regression).
In 725 incident dementia and 3154 matched comparators, HbA_1c trajectories differed by dementia status; HbA_1c increased over time for mild dementia and non-dementia, but the increase was greater in the mild dementia group; for those with moderate-severe dementia, HbA_1c decreased over time. Despite individuals with dementia having increased health care utilization around the time of dementia diagnosis, they were less likely to have had routine diabetes-related management. Patients with dementia had a higher prevalence of macrovascular complications and diabetes foot morbidity at dementia diagnosis and a higher mortality risk than those without dementia; these relationships were most marked in those with moderate-severe dementia.
Our study has highlighted important differences in the monitoring, management, and control of diabetes in people with dementia. The effects of frailty and the extent of cognitive impairment on the ability to self-manage diabetes and on glycemic control may need to be considered in treatment guidelines and by primary care.
A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial
2018, Journal of the American Medical Directors Association
Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities.
This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM.
Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia.
A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%.
Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL.
Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers.
Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations.
Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.
Type 2 diabetes mellitus in elderly institutionalized patients
2014, Revista Clinica Espanola
Una mujer de 93 años de edad ingresa en una planta de hospitalización convencional por una infección respiratoria aguda. La paciente tiene diabetes mellitus tipo 2 de unos 15 años de evolución y no presenta otras comorbilidades asociadas, salvo progresiva dependencia por senescencia y un ingreso hospitalario previo por neumonía hace 6 meses; actualmente vive en una residencia asistida. En un análisis reciente tenía una HbA1c de 7,8%, con una creatinina sérica de 1,3 mg/dl (MDRD: 45 ml/min). Su tratamiento habitual consistía en glibenclamida 5 mg al día y metformina 850 mg cada 12 h. ¿Qué pauta debemos seguir una vez hospitalizada? ¿Precisa de alguna modificación de su tratamiento al alta?
A 93-year-old woman is admitted to a conventional hospital ward for an acute respiratory infection. The patient has type 2 diabetes mellitus of approximately 15 years evolution and has no other associated comorbidities, except for progressive dependence due to senescence and a previous hospitalization for pneumonia 6 months ago. She is currently in an assisted-living residence. A recent laboratory test revealed an HbA1c level of 7.8%, with a serum creatinine level of 1.3 mg/dl (MDRD, 45 ml/min). Her standard treatment consists of 5 mg of glibenclamide a day and 850 mg of metformin every 12 hours. What regimen should we follow once she is hospitalized? Does she require any change in her treatment at discharge?
Nursing home patients with diabetes: Prevalence, drug treatment and glycemic control
2014, Diabetes Research and Clinical Practice
Citation Excerpt :
A lack of decisional capacity is associated with impaired cognitive function [42], and differences in diabetes management due to impaired cognitive function have been reported [43–45]. However, in contrast to our findings, McNabney et al. report no difference in choice of oral agents between nursing home patients with different levels of both functional and cognitive impairment, and do find lower intensity of both CBGM and HbA1c measurements [45]. Less frequent HbA1c measurements for patients with dementia is also reported by Quinn et al. and Thorpe et al. [43,44].
Determine prevalence of diabetes, and describe use of blood glucose lowering (BGL) drugs and glycemic control in Norwegian nursing homes.
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.
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.
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.

View all citing articles on Scopus

: Partial grant support provided by Glaxo-Smith-Kline, Research Triangle Park, NC.

View full text

Original studyDifferences in Diabetes Management of Nursing Home Patients Based on Functional and Cognitive Status

Objectives

Design

Participants

Measurements

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgments

J Clin Epidemiol

J Clin Epidemiol

J Am Med Dir Assoc

Prevalence of diabetes mellitus, impaired fasting glucose tolerance in US adults. The Third National Health and Nutrition Examination Survey

Diabetes Care

Management of type 2 diabetes mellitus in the elderly

Drugs & Aging

Original study
Differences in Diabetes Management of Nursing Home Patients Based on Functional and Cognitive Status