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.

PURPOSE: 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.
METHODS: 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.
RESULTS: 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%.
CONCLUSION: 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.