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-morbidity^2,3, 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 disability^12–14. 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 [email protected]
Tel +35314143215

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