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Diabetes Management: The Hidden Challenge of Managing Hyperglycemia in Long-Term Care Settings
Diabetes affects approximately 20% of nursing home residents.1 The impact of diabetes is devastating in these individuals, with 90% of nursing home residents with diabetes having evidence of coronary artery disease, stroke, and/or peripheral vascular disease. These individuals tend to have 6.4 major diagnoses, compared with only 2.4 in residents without diabetes. Much of the research in this area has focused on describing diabetic care behaviors of providers in nursing homes, and conclusions generally indicated that this care has been inadequate.2-5 Guidelines have been developed based on best practices for management of diabetes with older adults;6,7 however, these guidelines are not well disseminated or utilized.8 For residents in long-term care facilities, subsequent micro- and macrovascular disease may not be important to them. Rather, it is the day-to-day impact of diabetes management on functional activities, mood, cognition, and quality of life that is relevant. It is therefore particularly important to consider the daily impact of diabetes on these individuals, as well as the more commonly ignored and neglected problem of hyperglycemia.
IMPACT OF DIABETES
Diabetes can result in serious morbidity and mortality from micro- and macrovascular complications.9 Complications include heart attack, stroke, diabetic retinopathy, end-stage renal failure, peripheral vascular disease, peripheral neuropathy, cognitive impairment, sexual dysfunction, and multiple gastrointestinal, urological, and cardiovascular symptoms.10-12 Repeatedly it has been shown that glucose control can prevent or slow the progression of these devastating microvascular complications of diabetes.13 Specifically, there is a 25-30% reduction in the development of the microvascular complications for every 1% reduction in glycosylated hemoglobin (HbA1c). Unfortunately, 8 years of treatment are needed before the benefits of glycemic control are appreciated.14 Likewise, it takes time (approximately 2-3 years) to reap the benefits of blood pressure and lipid management in type 2 diabetes with regard to microvascular problems.14,15 Glucose control has not been proven to be a significant factor for the prevention of macrovascular disease.14 Hyperglycemia is noted, however, to have significant short-term effects on older adults causing slowed brain function, lethargy, and dehydration.16 Generally, in the long-term care setting, treatment goals are to restore the metabolic abnormalities to as nearly normal as possible, and to adequately control blood pressure and lipids.6,7 The ultimate purpose of the recommended goals is to reduce morbidity, mortality, and patient care costs in individuals with diabetes.
RECOGNITION OF DIABETES AND HYPERGLYCEMIA
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus developed guidelines for the diagnosis of diabetes (Table I).17 These guidelines maintain that a diagnosis of diabetes should be entertained when there is a fasting glucose of greater than 125 mg/dL and an oral glucose tolerance test (2-hour) that results in a glucose level of greater than 199 mg/dL.
There are many factors that influence the development of hyperglycemia and diabetes in older adults, as shown in the Figure.18 Insulin resistance is particularly common in older individuals; however, insulin secretion can likewise be a problem. Impaired beta-cell compensation to age-related insulin resistance may particularly predispose older individuals to develop hyperglycemia and type 2 diabetes.
Traditional signs and symptoms of hyperglycemia are often different in older adults when compared to younger individuals. It is more likely, for example, that an older adult who is hyperglycemic will present with a fall, urinary incontinence, infections, fatigue, lethargy, acute cognitive changes, weight loss, poor wound healing, and visual disturbances, rather than the typical complaints of polydipsia, polyuria, and ketoacidosis. Older individuals who present with diabetes are also more likely to have associated hypertension, hyperlipidemia, and atherosclerotic disease.
IDEAL TREATMENT RECOMMENDATIONS FOR MANAGEMENT OF TYPE 2 DIABETES
The guidelines for therapy for diabetes include regular screening for complications, including a dilated eye examination, monitoring renal function via urinary analysis, and regular foot examinations.19 It is recommended that blood pressure be maintained at less than 130/70 mm Hg, low-density cholesterol should be lower than 100 mg/dL, and nicotine intake should be eliminated. The target fasting blood glucose should be less than 120 mg/dL, and postprandial blood glucose should be less than 160 mg/dL with a HbA1c of less than 7%. Non-medication interventions, including diet and exercise, should be the first treatment option.19-21
Non-Medication Treatment Options
Diet and exercise are the foundation of all therapy for individuals with type 2 diabetes. With regard to dietary interventions, current recommendations from the American Diabetes Association and other organizations are that the caloric distribution should be less than 30% total fat with less than 10% saturated fat, 10-20% protein, and 50-55% carbohydrates.22 Efforts should be made to increase monounsaturated fat intake and fiber intake in these individuals. In addition, physical activity should be increased as much as tolerated. Ideally, the activity should include regular planned aerobic exercise (ie, walking, swimming, or biking) at least 3 times per week and resistance activities (ie, muscle strengthening) on the remaining days of the week.23 Alternating aerobic and resistance programs can result in reducing cardiovascular risk from diabetes, lowering glucose and lipid levels, improving function, decreasing the risk of falling, and improving mood and overall sense of well-being.24
Medication Management
Medication management of hyperglycemia may need to be multimodal, as different types of drugs have different sites of actions. Drug groups include insulin sensitizers that work at the muscle level (eg, thiazolidinediones), insulin sensitizers working at the liver level (eg, metformin), secretagogues that impact the pancreas (eg, sulfonylureas, repaglinide, and nateglinide), and insulin sensitizers working at the bowel level (eg, alpha glucosidase inhibitors). There are no clear guidelines as to which class of drugs to initiate treatment with, and this needs to be individualized per patient based on drug accessibility and side-effect profile (Table II). Although these oral medications are often the first line of treatment, it is not unusual for there to be a need for insulin use in older adults to achieve control of hyperglycemia. Unfortunately, there is a tendency among health care providers to avoid insulin use due to concerns that insulin will result in weight gain and hypoglycemia, be too complex for the patient, and/or significantly alter the individual’s lifestyle.25 These concerns are unfounded as treatment with insulin, particularly basal insulin, is safe, simple, and less likely to cause weight gain than other types of treatments.25,26
REALITY-BASED RECOMMENDATIONS FOR OLDER ADULTS IN LONG-TERM CARE
Recommendations for management of diabetes should be tailored to the individual long-term care resident and his or her life expectancy, quality of life related to treatment of diabetes, and what realistically fits into his or her living situation. Walter and Covinsky27 developed a framework for cancer screening that first anchors decisions through quantitative estimates of life expectancy, risk of cancer death, and screening outcomes based on published data. Similarly, this type of framework should be considered for diabetes management. Target HbA1c should be individualized, and a less stringent target of 8% is more likely to be realistic and appropriate for those in long-term care settings.6 As individuals age, the benefit from intensive glucose control decreases (ie, there is no benefit with regard to cardiovascular complications).28 Moreover, not all older adults with diabetes can tolerate the “tight” glucose levels that may generally be recommended for individuals with diabetes. Moreover, more modest goals may be wise in individuals who are unaware of, or can’t articulate to caregivers, the signs and symptoms of hypoglycemia; have evidence of anorexia, gangrene, malignancy, terminal illness, or severe dementia; are particularly fussy or sporadic eaters; and/or are dependent on others for feeding.7
Current medical nutrition therapy (MNT) for diabetes has liberalized the guidelines for dietary management of diabetes in older adults.22 The recommendations are to realistically meet the nutritional and psychosocial needs of these individuals to keep blood glucose and blood lipids as close to normal ranges as possible. Weight loss albeit healthy weight loss should be cautiously considered because restrictive diets in older adults may lead to nutrient deficits. Table sugar (ie, sucrose) has not been shown to increase blood sugar more than the amount of starch that is equal in calories.28 The previously recommended diet of “no concentrated sweets” is therefore not appropriate for these individuals. Sugar and sugar-containing foods do not specifically promote hyperglycemia and should be included in the diet as so desired by the older individual. This is an important quality-of-life issue because the ability to taste sweet things becomes more difficult with age, due to a loss of taste buds; therefore, older individuals actually need more concentrated (ie, sweeter) sweets to experience the taste. The concentrated sugars eaten should simply be considered within the 50-55% of carbohydrates recommended.
Fructose, or fruit sugar, should also be encouraged and allowed among older adults. Some research has actually shown that fructose lowers postprandial blood sugar when substituted for other carbohydrates.28 Snack and dessert options, therefore, should certainly include fruit. Moreover, fruits—particularly those with dietary fiber such as apples, berries, and pears—help maintain bowel function while these diet foods provide necessary vitamins and minerals.
Realistic management of type 2 diabetes in the long-term care setting must involve a comprehensive review with the older adult and/or his or her health care proxy regarding the risks and benefits associated with adherence to an aggressive management regimen focused on tight glucose control. Table III, for example, provides an overview of the dietary recommendations for those in whom strict dietary interventions are clearly inappropriate (ie, generally the old-old, age 90 and over, and those in long-term care facilities), and in those who do not want to adhere to restrictive diabetic diets. Treatment should not be based on aggressive target levels for blood pressure, lipids, or blood glucose. Rather, the health care providers should develop goals with the patient/power of attorney that ultimately enhance quality of life, improve symptoms associated with diabetes such as those that can occur from hyperglycemia, and prevent the development of common geriatric syndromes such as depression, polypharmacy, or urinary incontinence.
IDENTIFICATION AND MANAGEMENT OF HYPERGLYCEMIA IN LONG-TERM CARE SETTINGS
Regardless of how the resident with diabetes is managed (ie, whether or not strict guidelines for glucose control are adhered to), these individuals are particularly at risk for hyperosmolar hyperglycemia and associated complications because of underlying infections, dehydration, cardiovascular problems, medications, and cognitive and functional impairment. Unfortunately, prevention of hypoglycemia has traditionally been the focus of concern in these settings, as the signs and symptoms of hypoglycemia are often easier to identify than hyperglycemia. The challenges to identification and management of hyperglycemia are compounded by three issues: (1) assessment skills related to recognition of hyperglycemia; (2) knowledge deficits and myths; and (3) system-related challenges. These challenges are described individually below, and interventions to address each challenge are provided in Table IV.
Assessment Skills
There is a tendency for staff in long-term care facilities to focus exclusively on fasting blood sugars and to neglect or ignore blood sugars that are obtained after eating. Care providers may not routinely assess for the underlying cause of the hyperglycemia, and may not know how to evaluate residents for associated complications (eg, orthostatic hypotension indicative of dehydration, urinary tract infections, or fungal infections all associated with hyperglycemia). Foot and oral hygiene evaluations are not always routinely completed, nor are focused evaluations for evidence of polydipsia, polyuria, dehydration, infections, renal function, lower-extremity ulcers, or dry mouth.
Knowledge Deficits and Old World Beliefs
The current guidelines for management of diabetes specifically developed and written for older adults6,7 are not well disseminated or used in long-term care settings. Consequently, care providers in these sites may not be familiar with currently recommended treatment options. Behavioral interventions and the important impact of exercise should be reviewed, as should age-appropriate dietary interventions and treatment of complications. Routine interventions for residents with diabetes should focus on providing a regular diet that is varied, and incorporation of exercise for at least 30 minutes daily. Exercise activities and intensity will vary based on the ability of the individual.29 Education for caregivers in long-term care settings should also focus on end-of-life diabetes management, in which the goals of management should be comfort and avoidance of polydipsia, polyuria, and other associated symptoms of hyperglycemia.
System-Related Challenges
There is often little focus on diabetic management and no specific plan for coordinated care within the facility. Poor communication and lack of a team effort between all disciplines can result in serious consequences and significant deficiencies on state surveys.30 For example, there are no clear guidelines on when to call the primary care provider for blood glucose levels, how to manage hypo- or hyperglycemia, and/or appropriate protocols for fingersticks and use of associated equipment. Medical directors and/or nurse practitioners within these facilities can serve as important leaders in the development of such guidelines.
A particularly important area of system-related management is the use of equipment to perform fingersticks and infection control during this procedure. A retrospective study in long-term care noted that there was an association between diabetic management (via either fingersticks or insulin administration) and acute incidences of hepatitis B virus despite appropriate techniques for fingerstick testing and insulin administration.31 Given this risk, and weighing the risks/benefits of testing, it is prudent for facilities to clean supplies carefully, encourage self-monitoring by the individual, prepare medications in a clean area, change gloves after each patient, and avoid extra or unnecessary fingersticks.
MONITORING THE FACILITY
Optimal management of diabetes, and particularly of hyperglycemia in long-term care facilities, can best be achieved through careful monitoring of the facility. This process is most successful when there is an identified or self-selected diabetes champion and/or a designated individual responsible for quality assurance who takes responsibility for oversight of diabetes management and care. Monitoring should include evaluation of HbA1c levels, the incidences of hyperglycemia that occur, the number of hospitalizations that are related to diabetes mellitus and associated hyperglycemia, and the incidences of lower-extremity ulcers and infections. Other outcomes to monitor include evidence of eye, foot, and oral evaluations, cardiovascular risk monitoring, monitoring of renal function, and evidence of appropriate dietary and exercise interventions. Areas in which there is no evidence that screening or interventions are appropriately being implemented should be addressed, and barriers or challenges related to implementation considered.
Diabetes management and care in the long-term care setting is certainly challenging. Health care providers have the opportunity, however, to optimize quality of life for these individuals. Optimal care is best achieved by being familiar with the current guidelines for management of type 2 diabetes for older adults, particularly those in long-term care settings, and by addressing hyperglycemia and the associated signs and symptoms of hyperglycemia. In so doing, the older adults in these settings will be helped to achieve and maintain optimal quality of life.
