In the Republic of Ireland, 2.8% and 11% of the population is comprised of people aged ≥ 80 years and ≥ 65 years respectively.¹ These values are projected to increase by 2030 to 4.3% and 16%.¹ It is estimated that about one-third of residents that are admitted to nursing homes have type 2 diabetes² and approximately 4,000 patients > 65years of age currently reside in long-term care in the Republic of Ireland.¹

Diabetes presents specific complex issues. It is a multisystemic chronic disease that results in microvascular and macrovascular complications such as retinopathy, renal disease, neuropathy, stroke, coronary artery disease, and peripheral vascular disease.³

Older people with increased frailty and comorbidity are more susceptible to diabetic complications. Hence, the management of type 2 diabetes in the elderly residents in nursing homes can pose a unique challenge. Current guidelines advocate for individualised care plans and an interdisciplinary team approach in this population.^4,5

In this article, the complexity of type 2 diabetes management in the elderly population in nursing homes and the need for individualised care plans is discussed. In addition, a case study highlighting this complexity is presented and the existing guidelines are described.

The complexity of diabetes in frail elderly and those resident in nursing homes

Type 2 diabetes is complex in the elderly population as it is characterised by increased risk of comorbid diseases, functional deterioration and clinical frailty.⁴ Comorbidities are more common in the elderly with studies showing that 40% have at least three illnesses.⁴

This cohort is more susceptible to the adverse effects of drug interactions and polypharmacy. Residents admitted to nursing homes frequently present with type 2 diabetes and one or more acute illnesses, such as congestive cardiac failure, infections, fractures, stroke and pulmonary diseases. Therefore, they are at increased risk of short-term and atypical complications of diabetes, such as falls, dehydration, poor wound healing, skin ulcers, weight loss, urinary incontinence, and pain syndromes, all of which can result in poor quality of life and poor health outcomes.^2,6

Cognitive impairment is more prevalent in elderly patients. In a cohort study in 2010, people with dementia were found to have mortality rates increased three-fold  compared to those without dementia in the first year after diagnosis and increased two-fold from the second to the sixth year after diagnosis.⁷

Patients with cognitive impairment are three times more likely to develop severe hypoglycaemia.⁸  Dementia is progressively being linked to type 2 diabetes as a cause and complication.⁶ As a result, it plays an important part in determining the optimum diabetes care plan for the affected person. 

A quarter of elderly patients with type 2 diabetes are frail.⁴ Frailty is a syndrome characterised by loss of energy, cognition, physical ability and health that results in vulnerability.⁹ Clinical frailty can be used in the development of interventions and services an individual may require. In addition, it can aid in the prediction of mortality risk and need for long-term care.⁹

The Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale is a 7-point scale that evaluates frailty taking into account comorbidity, functional disability and cognitive impairment.^9,10

This scale can be utilised in establishing degree of frailty which in turn will aid in creating an individualised diabetes care plan.

This Clinical Frailty Scale can be utilised in establishing degree of frailty which in turn will aid in creating an individualised diabetes care plan. 

Managing the elderly population with type 2 diabetes

Several studies have demonstrated the range of comorbidities and functional impairment in older adult populations. They highlighted significant characteristics which include increased risk of hypoglycaemia, recurrent hospitalisation and development of cognitive impairment and frailty. 

These features were taken into consideration in the recommendations of the clinical guidelines for type 2 diabetes management in the older population by the International Diabetes Federation.⁴ The guidelines recommend individualised care plans tailored to the specific features of the elderly patient with type 2 diabetes and the employment of an interdisciplinary approach.

Patients have been stratified into three main categories: 

• Category 1 is functionally independent (full mental capacity to self-manage their diabetes and reasonably healthy)

• Category 2 is functionally dependent (have some loss of function) 

• Category 3 is end of life care. 

The functionally dependent category 2 is further divided into subcategory A – frail and subcategory B – dementia (those with some degree of cognitive impairment and who are unable to self-manage their diabetes). 

The emphasis of management of diabetes in older people is on achieving glycaemic levels that prevent and reduce vascular complications as well as reducing the risk of hypoglycaemia. Glycaemic targets should be individualised based on comorbidities, functional status, history of risk of hypoglycaemia, presence of micro/macrovascular complications and cognitive impairment. Table 1 shows the glycaemic targets based on functional category. 

 (click to enlarge)

A recently published article by Day et al² on a quality improvement study on the management of diabetes in nursing home residents demonstrated improved outcomes in this population when a co-ordinated diabetes disease management (CDDM) model was used. The co-ordinated interdisciplinary diabetes care approach resulted in significant reductions in hypoglycaemic episodes and inappropriate use of oral medications with increased resident-centred care and better screening for chronic kidney disease.⁴

The American Medical Directors Association (AMDA) currently known as The Society for Post-Acute and Long-Term Care Medicine evidenced-based guidelines were utilised in clinical decision-making for this patient-centred care.⁴ Benetos et al¹¹ and Sinclair et al¹² have proposed practical approaches to applying individualised diabetes management in older persons in long-term care.  These approaches also take into consideration the complexity of this population with type 2 diabetes.^11,12

Case study – 86-year-old Ms JB

Ms JB, an 87-year-old woman who had been a resident in a nursing home for two years, was referred with increasing agitation, refusal to eat, weight loss and recurrent falls. She had a history of type 2 diabetes diagnosed 20 years ago, osteoporosis, vascular dementia, hypertension and recurrent urinary tract infections. Ms JB’s medications included: 

• Metformin 1,000mg twice daily orally

• Insulin glargine 14 IU mane subcutaneously

• Amlodipine 5mg once daily orally

• Memantine 20mg once daily

• Aspirin 75mg once daily

• Calcium carbonate 500mg twice daily

• Alprazolam 250µg twice daily

• Zolpidem 5mg nocte

• Risendronate 35mg once weekly

• Esomeprazole 40mg once daily. 

She had lost 8kg over a two-month period and weighed 44kg at presentation. Her haematological investigation revealed raised white cell count indicative of an infection that was confirmed on urinalysis. Biochemical investigation showed raised urea 17mmol/l (2.5-6.5mmol/l) with a creatinine of 245µmol/l (50-120µmol/l). 

Her estimated glomerular filtration rate (eGFR) using the Cockcroft-Gault equation¹³ for calculation of creatinine clearance was significantly decreased and was less than 45ml/min. 

Ms JB was also dehydrated. Her glycosylated haemoglobin (HbA1c) level was 44mmol/mol. Her blood glucose levels (BGL) by finger-prick testing, was monitored over a 24-hour period. She experienced several hypoglycaemic episodes of < 4mmol/l and the highest BGL during the 24-hour period was 12mmol/l. This suggested that she was under tight glycaemic control and targets resulting in frequent hypoglycaemic events.  

Ms JB presented with a clinical picture of delirium. Hypoglycaemia is an established cause of delirium. Other important causes using the ‘PINCH ME’ mnemonic are: pain, infection, nutrition (malnutrition), constipation, hydration, medications (any, but particularly drugs with anticholinergic properties and psychoactive drugs) and environment (ward transfer or lack of watch/clock).^14,15

The risk factors for hypoglycaemia include tight glycaemic control, nursing home residency, aged 80 years and over, malnutrition, insulin or sulphonylurea treatment and polypharmacy.¹⁶ Hypoglycaemia leads to falls, cognitive impairment, hospital admissions, further poor nutrition and weight loss, decreased adherence to treatment and decreased ADLs.¹⁶

All of these result in frailty with worse clinical outcomes, increased disability, further risk of hypoglycaemia and premature death. Therefore, hypoglycaemia and frailty have a relationship that is bidirectional.¹⁶

As part of Ms JB’s management, metformin was discontinued, as eGFR was < 45ml/min and the insulin dose was reduced. The engagement of the nursing home staff regarding her management of diabetes led to an overall dose reduction of > 50%. 

The urinary tract infection was treated with antibiotics, she received fluid supplementation and pain control was optimised. There was also rationalising of the rest of her medications. She had a dramatic turnaround in overall clinical condition and significant improvement in psychological symptoms. 

This case study highlights the complexity of diabetes management in frail elderly persons in nursing homes. In using an individualised management plan for Ms JB, tailored to her specific needs, her clinical outcomes were much improved. 

Individualised diabetes care

There is complexity in the management plan of type 2 diabetes in the elderly population and in Irish nursing homes. This is due to the heterogeneity of elderly persons with type 2 diabetes. 

Factors such as comorbidities, functional status, clinical frailty and cognitive impairment play significant roles in determining the management plan for elderly residents in nursing homes. Current guidelines recommend individualised diabetes care plans for elderly people with an interdisciplinary approach that has been shown to improve clinical outcomes. In addition, as demonstrated in our case study, hypoglycaemia is a risk factor as well as a consequence of frailty. 

It is important to establish the precipitating factors of delirium using the “PINCH ME” mnemonic and institute the appropriate management.

Acknowledgement: 

Special thanks to Melissa Ryan, liaison nurse, Older Person Assessment Service, Outreach Programme Nursing Home Facilities, Community Liaison Team, Connolly Hospital, Blanchardstown.

Contact Diabetes Ireland at 1850 909 909 for information on their now accredited residential home diabetes education programme

References

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2. Day C, Kimble S, Cheng AL. Improving Outcomes Through a Coordinated Diabetes Disease Management Model. Annals of Long Term Care, 2014; 22(9)
3. Singhal A, Segal AR, Munshi MN. Diabetes in Long-Term Care Facilities. Current Diabetes Reports, 2014; 14(3) doi:10.1007/s11892-013-0464-y
4. International Diabetes Federation (IDF). Managing older people with type 2 diabetes: Global guideline. 2013
5. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M. European Association for the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 2012; 35(6): 1364-1379. doi:10.2337/dc12-0413
6. Leung MCF. Diabetes and the Frail Elderly in Long-term Care. Canadian Journal of Diabetes, 2009; 33(11): 114-121 doi:10.1016/S1499-2671(09)32008-0
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9. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A.  A global clinical measure of fitness and frailty in elderly people. Cmaj, 2005; 173(5): 489–495. doi:10.1503/cmaj.050051
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11. Benetos A, Novella JL, Guerci B, Blickle JF, Boivin J-M, Cuny P, Weryha G. Pragmatic diabetes management in nursing homes: individual care plan. Journal of the American Medical Directors Association, 2013; 14(11): 791-800. doi:10.1016/j.jamda.2013.08.003
12. Sinclair A, Morley JE. How to manage diabetes mellitus in older persons in the 21st century: Applying these principles to long term diabetes care. Journal of the American Medical Directors Association, 2013; 14(11): 777-780. doi:10.1016/j.jamda.2013.09.001
13. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron, 1976; 16(1): 31-41
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16. Abdelhafiz AH, Rodríguez-Manas L, Morley JE, Sinclair AJ. Hypoglycemia in Older People - A Less Well Recognized Risk Factor for Frailty. Ageing and Disease, 2015; 6(2): 156-167