Diabetes Management in Long-Term Care

INTRODUCTION

Approximately 1 in 5 skilled nursing facility residents age 55 years and over have been diagnosed with diabetes. In addition to their diabetes, more than 69% have two or more chronic conditions.¹ Quality health care in skilled nursing facilities proves to be challenging due to nurses concomitantly being responsible for the care of more than five residents, common staff shortages, and frequent staff turnover. Minimal staff salaries and nominal staff education regarding specific disease states contribute to the decrease in quality of care. Unfortunately, most direct patient care in nursing facilities is provided by nursing aides.² As a result, diabetes care in skilled nursing facilities is not optimal. The following case will introduce some deficiencies in a resident’s diabetes care.

CASE PRESENTATION

FS is an 81-year-old white female who resides in a local intermediate-care nursing facility, where she was placed due to lack of family care, lack of mobility, and need for assistance with activities of daily living resulting from a cerebrovascular accident (CVA) 5 years previously; she has high cognitive function with no dementia. She is a patient at the primary care office where clinical pharmacists provide disease and medication management services. FS is visiting the office for an overall diabetes assessment, which includes evaluation of achievement of American Diabetes Association (ADA) standards of care. She is well developed but utilizes a wheelchair for mobilization. Past medical history, list of current medications, and laboratory and physical assessment findings are listed in Tables I, II, and III.

Utilizing the American Association of Diabetes Educators AADE 7 assessment and monitoring tool, the following was discovered.

HEALTHY EATING

Findings:
FS’s meals are prepared at the long-term care facility where she is served meals at 8:00 a.m., noon, and 5:00 p.m. Her normal bedtime snack consists of an enteral nutrition formula specifically for patients with diabetes, and a sugar-free candy bar. This snack has 35 grams of carbohydrate.

Recommendations:
An individualized meal plan was developed for FS. Taken into consideration were her current weight of 173 pounds, BMI of 28, immobility due to her CVA, along with her 3 + edema of the extremities, frequent morning hypoglycemia, and dyslipidemia. The long-term care facility’s dietary manager said that concentrated juices and sweets were not given to residents with diabetes, and they do not limit FS’s carbohydrate intake at meals. This, unfortunately, is common for residents with diabetes.³ A recommendation of 45 grams of carbohydrates per meal and 15 grams of carbohydrates for an evening snack was given to the facility, which would utilize 40% of FS’s daily calories from carbohydrates. Education regarding what food items are considered carbohydrates and the potential laxative effect of the sugar-free candy was provided to FS, and will be reviewed with the facility. Examples of snacks containing 15 grams of carbohydrates based on the availability of food items at the facility will be given to the dietary manager.

BEING ACTIVE

Findings:
FS utilizes a wheelchair due to the CVA. INR levels are being monitored and are within therapeutic range, but will not be discussed further in this article.

Recommendations:
Wheelchair activities can be developed with FS to help her retain some upper body mobility and strength.

MONITORING

Findings:
Currently, the facility monitors FS’s blood glucose levels upon rising and before lunch and evening meals. Her A1c of 6.8% is below the ADA’s goal of less than 7%, but may be falsely low due to frequent hypoglycemia. More than 50% of her fasting blood glucose levels fall below 70 mg/dL, and she complains of symptoms consistent with hypoglycemia. Other pre-meal readings ranged from 160-242 mg/dL, indicating inadequate blood glucose control. Since we do not have any postprandial readings, it would be beneficial to know what her blood glucose levels are at this time. Because 70% of the effect on A1c levels in patients with an A1c less than 7.3% can be attributed to postprandial results, it is desired to obtain her postprandial readings.⁴ Her blood pressure is currently stable, and her triglycerides are slightly elevated.

Recommendations:
To properly balance FS’s meals and medications, the facility should monitor FS’s blood glucose upon waking, before her lunch and evening meals, and 2 hours after lunch and the evening meal. If monitoring 2 hours after the meal is not possible, monitoring at a time as close to this as possible would be beneficial. FS’s slightly elevated triglyceride levels should improve with modifications to her meals and medications.

TAKING MEDICATIONS

Findings:
All of FS’s medications are administered by the facility. She is taking insulin glargine, basal insulin, which is consistently being administered at 8:00 p.m. daily. When asked if she knew why she was taking each of her medications, she replied, “Honey, I don’t know, they just give them to me.” Unfortunately, this is a common finding in many patients, whether in long-term care facilities or not. She has 3 + edema, which is being treated with TED hose of 40 mm/Hg compression and furosemide 80 mg given 3 times daily. Upon performing a foot assessment, the edema has not been relieved by the current therapy. She currently takes metoprolol succinate 50 mg twice daily, which could prevent her from detecting some hypoglycemia symptoms.^5,6 She is taking nitrofurantoin prescribed for a urinary tract infection that may be worsening her peripheral neuropathy.

Recommendations:
Several changes in her medications were suggested to her physician. Discontinuation of her oral hypoglycemic medications, glyburide, and metformin was suggested to prevent morning hypoglycemia and to simplify therapy. Another reason to suggest medication changes is her low creatinine clearance, which became evident when we calculated her glomerular filtration rate. This may lead to some of the hypoglycemia and may make her more susceptible to adverse reactions with metformin. Changing her insulin glargine to a premixed intermediate-acting insulin and rapid-acting insulin administered twice daily was recommended. The rapid-acting mixture was chosen to allow her insulin to be administered just before her meal. This regimen would minimize insulin administration timing errors, such as delayed meal delivery or insulin being administered after a meal. A starting dose of 25 units of premixed insulin given just before the morning meal and 10 units given just before the evening meal should prevent the morning hypoglycemia and lower her readings throughout the day. A recommendation to increase the dose of furosemide until edema resolved or stabilized was made.

Several other medication changes were recommended, but due to space limitation, they will not be discussed here. Even though metoprolol succinate may prevent a patient from detecting some of the symptoms of hypoglycemia, such as rapid heartbeat, the benefits of taking it for her blood pressure and other cardiovascular disease outweigh the risks. Changing her nitrofurantoin to another antibiotic will be recommended.

PROBLEM SOLVING

Findings:
The facility does not make any medication dosing changes or perform sliding scale insulin administration.

Recommendations:
Have the facility fax daily blood glucose readings to the primary care office until morning hypoglycemia is resolved. Adjustments in her insulin levels could be recommended weekly based on patterns in fasting and post-meal glucose levels.

HEALTHY COPING

Findings:
FS is a pleasant lady who does not seem to be distraught about her medical or social condition. She “just follows orders.”

Recommendations:
Monitor for signs and symptoms of depression or agitation, which may adversely affect her diabetes and other medical conditions.

REDUCING RISKS

Findings:
Her foot screening indicates the need for immediate toenail care. Although she states that a podiatrist comes to the facility every 6 weeks, she has long, thick toenails that need to be thinned and cut. She has lost sensation in both feet, and has recently experienced urge urinary incontinence. Fasting hypoglycemia occurs frequently and needs to be addressed.

Recommendations: Neuropathy
Longstanding uncontrolled diabetes and duration of diabetes can lead to peripheral and autonomic neuropathy, as well as other acute and chronic complications (eg, cardiovascular disease, coronary artery disease). The loss of sensation in her feet is prevalent in people with peripheral neuropathy. Afferent autonomic fibers transmit signals to indicate bladder fullness. Other nerves control sphincter tone and bladder contraction. FS should be assisted to the bathroom every 2 hours or more frequently to prevent urinary incontinence, frequent urinary tract infections, and other skin breakdown, which will continue to occur if not corrected. She is currently taking extended-release tolterodine tartrate 2 mg twice daily, which is appropriate for urge incontinence. Daily Kegel exercises for the pelvic muscles, have been recommended to the patient in the past. Dry skin, especially when found on the feet, is another sign and symptom of autonomic neuropathy, due to decreased sweating mechanism. Since nitrofurantoin may be contributing to her peripheral neuropathy, a recommendation to change this medication will be made.

Hypoglycemia/Hyperglycemia
Discontinuing the glyburide and metformin, and changing insulin glargine to pre-mixed intermediate-acting/rapid-acting insulin should correct the hypoglycemia. Monitoring blood glucose levels before each meal and 2 hours after the lunch and evening meals will give a better indication of how high her post-meal blood glucose levels actually are and allow for titration of insulin doses to prevent high and low blood sugar levels.

Foot Care
Toenail care needs to be performed at least four times a year with proper thinning and trimming of the nails by a skilled professional. The dryness in FS’ feet also needs to be addressed with moisturizing lotions applied at least daily, without application between the toes.

Eye Care
FS does wear glasses, but currently does not have any cataracts, retinopathy, or macular degeneration. She has an annual appointment with a local ophthalmologist.

Dental Care
FS wears dentures that fit properly. She has no other gum problems. She cleans her dentures daily.

CONCLUSION

Persons with suboptimal diabetes care who reside in long-term care facilities, such as the case patient, are common. Multiple patient medications, comorbid medical conditions, and untrained staff, can complicate not only diabetes, but other medical conditions of residents. Suboptimal health care can also lead to unnecessary hospitalizations and decreased quality of life. Staff in-servicing on the importance of administering medications at proper times, serving prescribed and consistently-timed meals, and having residents—even those confined to a wheelchair —perform daily physical activities (within the scope of the patient’s ability) is key to maintaining the health of residents in long-term care facilities. To improve residents’ quality of care, skilled nursing facilities should also properly monitor blood glucose, take action when blood glucose levels are either below or above target, and notify the primary care physician of frequent blood glucose fluctuations.

The authors report no relevant financial relationships.