Structuring Diabetes Mellitus Care in Long-Term Nursing Home Residents

D Fitzpatrick1, ES Ibrahim1, S Kennelly2, M Sherlock 3, D O’Neill2

1Peamount Healthcare, Dublin, Ireland
2Centre for Ageing, Neuroscience and the Humanities, Trinity College Dublin
3Department of Endocrinology and Diabetes, Tallaght Hospital, Dublin

Abstract

Nursing home residents with diabetes have more complex care needs with higher levels of comorbidity, disability and cognitive impairment. We compared current practice in the 44 long-term residents in Peamount hospital with the standards recommended in the Diabetes UK “Good Clinical Practice Guidelines for Care Home Residents with Diabetes”. Of 44 residents, 11 were diabetic. Residents did not have specific diabetes care plans. There were some elements of good practice with a low incidence of hypoglycaemia and in-house access to dietetics and chiropody. However, diabetes care was delivered on an ad-hoc basis without individualised care plans, documented glycaemic targets, or scheduled monitoring for complications and no formal screening for diabetes on admission. National and local policy to guide management of diabetes mellitus should be developed. There should be individualised diabetes care plans, clear policies for hypoglycaemia, hyperglycaemia and long-term diabetes complications, screening on admission and increased uptake of the national retinal screening and foot care programmes.

Introduction
Compared to community dwelling older adults, nursing home residents have more complex care needs with higher levels of comorbidity, disability and cognitive impairment1. Diabetes mellitus is also associated with cognitive deficits, functional dependence and multi-morbidity2,3, making nursing home residents with diabetes a particularly vulnerable cohort. Diabetes and its complications are associated with reduced quality of life4. Nursing home residents are a heterogenous population and require an individualised approach which prioritises quality of life and avoidance of hypoglycaemia over strict metabolic control5. Diabetes mellitus is a disease more common in older age6: the estimated prevalence in adults aged over 60 is 13.8%7. Up to 27% of residents in UK nursing homes have diabetes mellitus (diagnosed and undiagnosed)8. The prevalence in Ireland is not known: a previous Irish study found a 14% prevalence of diagnosed diabetes mellitus in nursing homes in Galway9. There may be a significant proportion of undiagnosed residents with diabetes.

Methods
We audited the screening and management of diabetes mellitus in 44 residents in two long-term residential care wards in Peamount Hospital in Dublin. Peamount Hospital is an independent voluntary organisation, partially funded by the HSE. It provides long term residential care overseen by a consultant geriatrician, inpatient rehabilitation services for older people and people with chronic respiratory disease, and services for patients with neurological and intellectual disability. The long-term care wards in Peamount hospital and the patients residing in them would be generally representative of a typical Irish nursing home. We compared current practice with the standards recommended in the Diabetes UK “Good Clinical Practice Guidelines for Care Home Residents with Diabetes”10. We devised a questionnaire based on these guidelines and based on the questionnaire used for the UK-wide National Care Home Diabetes Audit11, carried out in 2013. We reviewed medical notes, nursing notes, drug prescriptions and we interviewed the clinical nurse managers in charge of the two wards.

Results
General
Of 44 residents, one quarter had diabetes mellitus, six men and five women. All diabetic residents had type 2 diabetes mellitus. The average MMSE score was 15.2/30, while the average Barthel index (performance scale of activities of daily living) was 7/20. Two patients received regular long acting insulin (one of whom was on long-term correctional subcutaneous scale, two patients were taking sulphonylureas (one as monotherapy, one combined with linagliptin and metformin). Five patients were taking metformin either alone or with another agent. Only two patients were receiving a DPP-4 inhibitor. Five patients were on no antidiabetic medications i.e. managed with diabetic diet alone.

Screening
Only one non-diabetic patient had a HbA1c (glycated haemoglobin) sent for screening on admission and only two non-diabetic patients had a HbA1c checked in the last year.

Monitoring glycaemic control
No episodes of hypoglycaemia (blood glucose less than 4 (symptomatic or asymptomatic)) were recorded in any of the diabetic residents in the last 6 months. One patient on long acting insulin alone had a morning blood glucose of four to five on several occasions and was noted to be drowsy.  Glucagon is available on the ward in case of hypoglycaemia. The low number of patients on insulin or sulphonylureas likely contributed to the low incidence of hypoglycaemia. Lab results are documented in residents’ charts. The majority (73%) of residents with diabetes had a HbA1c checked in the last year. There was no documented target HbA1c for each resident and no prescribed schedule of HbA1c monitoring. Three residents had never had a HbA1c checked during their admission. Only one patient had a hbA1c greater than 53. All diabetic residents on insulin had their blood glucose level checked prior to insulin administration. Other residents had weekly capillary glucose monitoring. There was no clear guidance on managing hypoglycaemia, hyperglycaemia and what blood sugar levels should trigger doctor review.

Care plans and policies
There was no local policy for diabetes management or screening. Residents did not have specific diabetes care plans. Most of the residents had some information on their diabetes detailed in a nutrition care plan. There was no policy or algorithm for the management of hypoglycaemia, hyperglycaemia or diabetic complications.

Foot Disease
The national diabetic foot programmed recommends a model of care for diabetic patients with access to multidisciplinary foot care services. We found that residents at risk of diabetic foot disease were not clearly documented. Staff were conscious of the importance of skin care and vigilant for foot ulcers while washing and caring for residents. No diabetic foot ulcers were reported in any of the patients. Chiropody is readily available in-house and any resident staff are concerned about is seen by the visiting chiropodist. However, there is no system of formal screening and monitoring of diabetic foot disease in place.

Diabetic Nephropathy
Of 11 residents with diabetes, 10 had renal profile bloods sent within the last 6 months. One patient refused blood sampling. None had urinary albumin creatinine ratio measured. One resident had stage 3B chronic kidney disease (CKD). Three residents had stage 3A CKD. The remainder had an eGFR >90.

Retinal Screening
The National Diabetic Retinal Screening Programme commenced in 2013 and offers regular screening for diabetic patients over age 12. Only two residents were called for screening, one of whom attended. No patient was seen by domiciliary eye care services.

Nutrition and Diet
All diabetic residents were on a diabetic diet. All residents had been seen by a dietician in the last 6 months. All residents had malnutrition screening using the MUST tool.

Education and Training for Staff
No structured training or education in diabetes was provided for nurses and health care assistants. Nursing staff were not aware of any available online training and education in diabetes.

Access to specialist diabetic services
There was access to advice from a diabetic nurse and diabetic medical team by telephone. Within the last year, 27% of residents had attended the diabetes clinic.

Equipment on ward
There was adequate equipment to manage diabetes on the ward including: glucometers, glucose reagent strips, blood pressure monitors. IM glucagon was always available on the ward. However, there were no ketone meters.

Cognition, ADL’s and mood
All residents had documented cognition status (MMSE) in last six months. Only one had documented mood status in last six months. All residents had a Barthel index documented in the last six months.

Vaccination
All residents were offered the influenza and pneumococcal vaccine at appropriate intervals.

Annual review
There was no dedicated annual review for diabetic residents. Every resident was discussed at an MDT at least every three months. This was not aimed specifically at diabetic management but did include a review of medications and reviewed any other issue of concern for the resident.

Discussion
Nursing home residents are a complex patient population and residents with diabetes are a particularly vulnerable subgroup requiring special consideration. Diabetes mellitus is associated with macrovascular and microvascular complications, increased susceptibility to infections and high levels of cognitive and physical disability12–14. This audit demonstrated some elements of good practice. In-house chiropody was provided. All patients were screened for malnutrition and had access to in-house dietetics. All patients were offered appropriate vaccination against influenza and pneumococcal pneumonia. Cognition and disability were recorded regularly. Apart from the absence of ketone meters, there was adequate equipment and facilities on the ward.

However, significant gaps in the service were identified. There was no formal screening for diabetes on admission or thereafter, despite the high prevalence of the disease. Access to public-funded nursing home care requires geriatrician or old age psychiatrist assessment, and this should include diabetic screening. Care for patients with diabetes tended to be reactive and delivered on an ad hoc basis. There were no diabetes care plans, formally documented glycaemic targets, or scheduled monitoring for complications. There were no algorithms for management of hypoglycaemia or hyperglycaemia. There was low uptake of the national retinal screening programme. There was no formal system for screening/monitoring of diabetic foot disease. No structured training or education in diabetes was provided for nurses and health care assistants.

It can be difficult and impractical to transport nursing home residents to outpatient appointments. In-house access to dietetics, chiropody and other ancillary health services was a significant advantage to residents in Peamount hospital. Extending in-house access to further diabetes services would benefit patients: for example, visits by diabetes nurses and eyecare specialists. A comprehensive study of diabetes management in the nursing homes of County Galway was carried out in 20139. The authors identified similar deficits in the level of screening, education and training, and a need for national clinical guidelines and standards of care specific to long-term care residents. The importance of transport and access to in-house ancillary diabetic services was also apparent in their study.

Nursing home residents are a heterogenous population: they should have individualised diabetes care plans. Individualised targets and monitoring schedules for glycaemic control, in terms of HbA1c and capillary glucose monitoring, should be set out for each resident. Algorithms for hypoglycaemia, hyperglycaemia should be developed, in line with already developed local hospital guidelines. There should also be protocols for special situations such as residents who are fasting, vomiting or at the end of life. Screening for diabetic complications should be formalized with regular diabetic foot examinations, at least annually (in accordance with the HSE model of diabetic foot care15), monitoring of renal function and proteinuria, and annual retinal eye screening. It is usually the responsibility of the patient to contact the retinal screening programme; residents may need someone to do this for them, which should be included in their care plan. Training and access to structured education in the care of diabetic residents should be provided to HCA’s and nurses. Glycaemic control targets and diabetic complications should be discussed for each resident at a three-monthly multidisciplinary review. We should use a modified version of the template care plan provided in the diabetes UK good clinical practice guidelines10.

There is a need for the development of national and local policy to guide management of diabetes mellitus in long-term care residents in Ireland. In the interim, doctors and nurses in Irish nursing homes should follow the recommendations given in the “Good Clinical Practice Guidelines for Care Home Residents with Diabetes” provided by Diabetes UK. The clinical practice guidelines provide a template from which a local policy can be developed. A national audit of diabetes care in nursing homes would highlight gaps in the service on a national level: inclusion of diabetes care in the nursing home regulatory process would be supportive in the development of appropriate care paradigms.

Conflicts of Interest:
None

Correspondence
Prof Desmond O’Neill, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin D24 NR0A, Ireland:
Email doneill@tcd.ie
Tel +35314143215

References
1. Falconer M, O’Neill D. Profiling disability within nursing homes: a census-based approach. Age Ageing [Internet]. 2007 Jan 25 [cited 2017 Mar 11];36(2):209–13. Available from: https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afl185
2. Kodl CT, Seaquist ER. Cognitive dysfunction and diabetes mellitus. Endocr Rev [Internet]. 2008 Jun [cited 2017 Mar 11];29(4):494–511. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18436709
3. Gregg EW, Beckles GL, Williamson DF, Leveille SG, Langlois JA, Engelgau MM, Narayan KM. Diabetes and physical disability among older U.S. adults. Diabetes Care [Internet]. 2000 Sep [cited 2017 Mar 11];23(9):1272–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10977018
4. Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab Res Rev [Internet]. 1999 May [cited 2017 Apr 25];15(3):205–18. Available from: http://doi.wiley.com/10.1002/%28SICI%291520-7560%28199905/06%2915%3A3%3C205%3A%3AAID-DMRR29%3E3.0.CO%3B2-O
5. Munshi MN, Florez H, Huang ES, Kalyani RR, Mupanomunda M, Pandya N, Swift CS, Taveira TH, and Haas LB. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care [Internet]. 2016 [cited 2017 Apr 25];39(2). Available from: http://care.diabetesjournals.org/content/39/2/308
6. Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS. Diabetes in older adults. Diabetes Care [Internet]. 2012 Dec [cited 2017 Mar 12];35(12):2650–64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23100048
7. All-Ireland Diabetes Prevalence Working Group. Making Diabetes Count [Internet]. 2007 [cited 2017 Mar 11]. Available from: http://www.publichealth.ie/files/file/LFahy Diabetes Nursing and Midwifery 11 Oct 07.pdf
8. Sinclair AJ, Gadsby R, Penfold S, Croxson SC, Bayer AJ. Prevalence of diabetes in care home residents. Diabetes Care [Internet]. 2001 Jun [cited 2017 Mar 11];24(6):1066–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11375372
9. Hurley L, O’Donnell M, O’Caoimh R, Dinneen SF. Investigating the management of diabetes in nursing homes using a mixed methods approach. Diabetes Res Clin Pract [Internet]. 2017 May [cited 2017 Jun 15];127:156–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28371686
10. Sinclair AJ, Task and Finish Group of Diabetes UK. Good clinical practice guidelines for care home residents with diabetes. Diabet Med [Internet]. 2011 Jul [cited 2017 Apr 30];28(7):772–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21672001
11. Sinclair A (Institute of D for OP, Walton C( A of BCD. England-wide Care Home Diabetes Audit [Internet]. 2014 [cited 2017 Mar 6]. Available from: http://www.diabetologists-abcd.org.uk/Audits/Care_Home_Diabetes_Audit.pdf
12. Benbow SJ, Walsh A, Gill G V. Diabetes in institutionalised elderly people: a forgotten population? BMJ [Internet]. 1997 Jun 28 [cited 2017 Mar 12];314(7098):1868–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9224129
13. Ott A, Stolk RP, van Harskamp F, Pols HA, Hofman A, Breteler MM. Diabetes mellitus and the risk of dementia: The Rotterdam Study. Neurology [Internet]. 1999 Dec 10 [cited 2017 Mar 12];53(9):1937–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10599761
14. Klein R. Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care [Internet]. 1995 Feb [cited 2017 Mar 12];18(2):258–68. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7729308
15. National Diabetes Programme HSE. Model of Care for the Diabetic Foot [Internet]. 2011 [cited 2017 Mar 13]. Available from: http://www.hse.ie/eng/about/Who/clinical/natclinprog/diabetesprogramme/modelofcarediabetes.pdf

(P711)