Status of Diabetes Management in the Nursing Home Setting in 2008: A Retrospective Chart Review and Epidemiology Study of Diabetic Nursing Home Residents and Nursing Home Initiatives in Diabetes Management


      Diabetes mellitus (DM) is associated with significant morbidity and mortality, and can present with atypical signs and symptoms in elderly residents of nursing homes who often have altered functional and cognitive capacity representing a particularly challenging population to manage. Researchers conducted this study to better understand the current status of DM management in the long-term care facility from the perspective of the facility (use of guidelines, policies, and so forth) as well as that of a resident.


      Thirteen nursing home facilities in 6 states were studied. A 13-question survey instrument was used to collect data from interviews of the directors of nursing and medical directors. A 26-question data collection form was also used to perform a retrospective chart review of studied residents.


      Data from the interview surveys showed that only 15% of facilities studied had a policy for the use of treatment algorithms to manage residents with DM. In addition, only 1 of 13 facilities had a quality improvement tool to evaluate compliance with current policies. In regard to hemoglobin A1C (A1C) testing, only 7.1% of facilities had a house policy in place. Furthermore, only 1% of studied residents had an established target for their A1C despite American Diabetes Association (ADA), American Geriatrics Society (AGS), and American Medical Directors Association (AMDA) guidelines recommending target values and monitoring frequency for A1C testing. The survey instrument also found that just 30.8% of facilities had a policy in place for blood glucose monitoring. Data from the chart review shows that only 57% of residents in this study were taking aspirin or clopidogel bisulfate, although prevention of cardiovascular disease (CVD) is recommended by the American Heart Association (AHA) and ADA in persons with diabetes who are older than 40. Data from this study indicate serious hypoglycemia occurs only occasionally in the nursing home because hypoglycemic episodes requiring hospitalization occurred in only 1% of studied residents. Furthermore, researchers found each of these residents were sent to the hospital only once in the preceding 6 months. One unanticipated finding of the study reports the incidence of delusions from patients’ Minimum Data Set (MDS) was 87.63% compared with the national average of 3.7%.


      Data obtained through this study demonstrates numerous opportunities for improvement in the quality of care for nursing home residents with DM. A multidisciplinary approach is required to properly manage this complex disease in a challenging elderly population. The development of protocols and tools that embrace the latest strategies and treatment algorithms for the management of DM in the geriatric resident are necessary, while implementation of a quality improvement tool can help facilities to further improve on management of DM in the long-term care setting.


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      1. Centers for Medicare and Medicaid Services, MDS Active Resident Information Report: Third Quarter 2007, Avalaible at: Accessed August 8, 2008.

        • Mazza A.D.
        • Morley J.E.
        Update on diabetes in the elderly and the application of current therapeutics.
        J Am Med Dir Assoc. 2007; 8: 489-492
        • McNabney M.K.
        • 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
      2. American Diabetes Association. Standards of medical care in diabetes—2008.
        Diabetes Care. 2008; 31: 12-54
        • Brown A.F.
        • Mangione C.M.
        • Saliba D.
        • et al.
        Guidelines for improving the care of the older person with diabetes mellitus.
        J Am Geriatr Soc. 2003; 51: S265-S280
        • American Medical Directors Association
        Diabetes management in the long-term care setting: Clinical practice guideline.
        AMDA, Columbia, MD2008
        • American Diabetes Association
        Translation of the diabetes nutrition recommendation for health care institutions.
        Diabetes Care. 2004; 27: S55-S57
        • Meyers R.M.
        • Broton J.C.
        • Woo-Rippe K.W.
        • et al.
        Variability in glycosylated hemoglobin values in diabetic patients living in long-term care facilities.
        J Am Med Dir Assoc. 2007; 8: 511-514
        • Zarowtz B.J.
        • Tangalos E.G.
        • Hollenack K.
        • O'Shea T.
        The application of evidence-based principles of care in older persons (issue 3): Management of diabetes mellitus.
        J Am Med Dir Assoc. 2006; 3: 234-240
        • American Diabetes Association
        Nutrition recommendations and interventions for diabetes: A position statement of the American Diabetes Association.
        Diabetes Care. 2008; 31: S61-S78
        • Pandya N.
        • Thompson S.
        • Sambamoorthi U.
        The prevalence and persistence of sliding scale insulin use among newly admitted elderly nursing home residents with diabetes mellitus.
        J Am Med Dir Assoc. 2008; 9: 663-669
        • Buse J.B.
        • Ginsberg H.N.
        • Bakris G.L.
        • et al.
        Primary prevention of cardiovascular diseases in people with diabetes mellitus: A scientific statement from the American Heart Association and the American Diabetes Association.
        Circulation. 2007; 115: 114-126
        • Herrington W.G.
        • Levy J.B.
        Metformin: Effective and safe in renal disease?.
        Int Urol Nephrol. 2008; 40: 411-417
        • Warren R.E.
        • Strachan M.W.
        • Wild S.
        • McKnight J.A.
        Introducing estimated glomerular filtration rate (eGFR) into clinical practice in the UK: Implications for the use of metformin.
        Diabet Med. 2007; 24: 494-497
      3. Gold Standard, Inc. Metformin. Clinical Pharmacology [database online]. Available at: Accessed August 18, 2008.

        • Shaw J.S.
        • Wilmot R.L.
        • Kilpatrick E.S.
        Establishing pragmatic estimated GFR thresholds to guide metformin prescribing.
        Diabet Med. 2007 Oct; 24: 1160-1163
      4. Food and Drug Administration. Glucophage/Glucophage XR. Available at: Accessed January 28, 2009.

        • Bertoni A.G.
        • Anderson G.F.
        • Krpo J.S.
        • Brancati F.L.
        Diabetes-related morbidity and mortality in a national sample of US elders.
        Diabetes Care. 2002; 24: 471-475
      5. Centers for Medicare and Medicaid Services. MDS Active Resident Information Report: Third Quarter 2007. Available at: Accessed August 18, 2008.

        • Briscoe V.J.
        • Davis S.N.
        Hypoglycemia in type 1 and type 2 diabetes: Physiology, pathophysiology, and management.
        Clinical Diabetes. 2006; 24: 115-121
        • Kamel H.K.
        Managing urinary tract infections in the nursing home: Myths, mysteries, and realities.
        The Internet Journal of Geriatrics and Gerontology. 2004; 1
        • Del Rio R.A.
        • Goldman M.
        • Kapella B.K.
        • et al.
        The accuracy of minimum data set diagnoses in describing recent hospitalization at acute care facilities.
        J Am Med Dir Assoc. 2006; 7: 212-218
        • Jónsson P.V.
        • Finne-Soveri H.
        • Jensdóttir A.B.
        • et al.
        Co-morbidity and functional limitation in older patients under reported in medical records in Nordic acute care hospitals when compared with the MDS-AC instrument.
        Age Ageing. 2006; 35: 433-437
        • Bharucha A.J.
        • Vasilescu M.
        • Dew M.A.
        • et al.
        Prevalence of behavioral symptoms: Comparison of the minimum data set assessments with research instruments.
        J Am Med Dir Assoc. 2008; 9: 244-250
        • Mader S.L.
        • Fuglee K.A.
        • Allen D.S.
        • 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
        • Huang E.S.
        • Meigs J.B.
        • Singer D.E.
        The effect of interventions to prevent cardiovascular disease in patients with type 2 diabetes mellitus.
        Am J Med. 2001; 11: 633-642
        • Alam T.
        • Weintraub N.
        • Weinreb J.
        What is the proper use of hemoglobin a1c monitoring in the elderly?.
        J Am Med Dir Assoc. 2005; 6: 200-204
        • Cox D.J.
        • Kovatchev B.P.
        • Gonder-Frederick L.A.
        • et al.
        Relationships between hyperglycemia and cognitive performance among adults with type 1 and type 2 diabetes.
        Diabetes Care. 2005; 28: 71-77
        • Hass L.B.
        Optimizing insulin use in type 2 diabetes: Role of basal and prandial insulin in long-term care facilities.
        J Am Med Dir Assoc. 2007; 8: 502-510
        • Holt R.M.
        • Schwartz F.L.
        • Shubrook J.H.
        Diabetes care in extended-care facilities: Appropriate intensity of care?.
        Diabetes Care. 2007; 30: 1454-1458
        • Holstein A.
        • Plaschke A.
        • Egberts E.H.
        Clinical characteristics of severe hypoglycemia—a prospective population-based study.
        Exp Clin Endocrinol Diabetes. 2003; 111: 364-369
        • Ben-Ami H.
        • Nagachandran P.
        • Mendelson A.
        • Edoute Y.
        Drug-induced hypoglycemic coma in 102 diabetic patients.
        Arch Intern Med. 1999; 159: 281-284
        • Amiel S.A.
        • Dixon T.
        • Mann R.
        • Jameson K.
        Hypoglycaemia in type 2 diabetes.
        Diabet Med. 2008; 25: 245-254
        • Boyko E.J.
        • Fihn S.D.
        • Scholes D.
        • et al.
        Diabetes and the risk of acute urinary tract infection among postmenopausal women.
        Diabetes Care. 2002; 25: 1778-1783
        • Midthun S.
        • Paur R.
        • Bruce A.W.
        • Midthun P.
        Urinary tract infections in the elderly: A survey of physicians and nurses.
        Geriatr Nurs. 2005; 26: 245-251

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