Belinda P. Childs, ARNP, MN, CDE, BC-ADM,1 and Sandra Drozdz Burke, PhD, APRN, FAAN2
1Childs is a diabetes nurse specialist at Great Plains Diabetes, Wichita, KS. 2Burke is the academic chair for Upper Division Programs and a professor of nursing with the Goldfarb School of Nursing at Barnes–Jewish College in St. Louis, MO.
The aging of the baby boomer generation has led to what is being called a “silver tsunami.” As of 2014, there were nearly 46 million older adults in the U.S., and 10,000 members of the baby boom generation will turn 65 every day until 2030. By 2040, the number of older adults will surpass 80 million and constitute about 22% of the U.S. population.1 The vast majority of older adults live independently, but about 1.5 million reside in long-term care settings such as nursing homes. As much as 10% of those ≥85 years old live in institutional settings.1 Twenty-six percent of the population >65 years old has diabetes.2 Considering the aging of the population, the increased life expectancy, and the increase in diabetes prevalence, nurses will be asked to provide diabetes care and education in the home as well as in assisted and long-term care facilities. The nurse’s role as advocate, care provider, and educator of staff, patient, and family will be pivotal.
The most recent survey data from the National Study of Long Term Care Providers (NSLTCP) provides data on all aspects of long-term care, including nursing homes. According to the NSLTCP, in 2012, 1,383,700 people resided in the 15,700 nursing homes in the U.S. Among nursing home residents, the prevalence of diabetes ranges from 25% to 34%.3,4 In general, nursing home residents tend to be older and frailer than community-dwelling older adults. Data from the NSLTCP indicate that just >42% of the residents are >85 years old and that nursing home residents likely need assistance with functional activities of daily living (ADLs).
Historically, when compared with residents without diabetes, residents with diabetes show greater limitations in ADLs in terms of their ability to bathe (91.9% vs. 88.7% for diabetes versus no diabetes, respectively), dress (82.4% vs. 78.5%), perform toileting activities (72.9% vs. 68.6%), transfer from bed to chair (70.0% vs. 65.8%), walk (76.1% vs. 71.1%), and control bowel movements (48.4% vs. 44%). The two groups were similar in having difficulty feeding (33%) and controlling urine (42%).4,5
Care of the resident with diabetes is complicated by comorbid conditions, including various geriatric syndromes, the individual’s limitations in ADLs, and diabetes-specific management issues that differ from residents who do not have diabetes.6 Moreover, providing quality care is hampered by staff shortages, staff turnover, poor pay, and lack of education and educational materials on diabetes for residents and staff in the nursing long-term care setting.
Diabetes care in the long-term care facility is carried out primarily by vocational or licensed practical nurses, medication aides, and nurse’s aides. The nurse is responsible for coordination of care and development of care plans for the residents. All staff should have some knowledge of standards of diabetes care. Using a team approach to the delivery of care improves the quality of care.
Undiagnosed Diabetes in the Nursing Home
Some 8.1 million Americans have undiagnosed diabetes. Type 1 diabetes (T1D) and type 2 diabetes (T2D) can be diagnosed at any age. The polyuria of hyperglycemia in an incontinent patient may be overlooked. The polydipsia of hyperglycemia may not be recognized because of decreased thirst sensation in elderly patients. Signs and symptoms of hyperglycemia may go unnoticed. It is important to be alert to the potential for newly diagnosed diabetes in the nursing home setting.
Diabetes care areas that need special attention include glycemic control, diabetes medications, medication interactions, glucose monitoring, medical nutrition therapy (including hydration), acute and chronic complications of diabetes, and self-management education and empowerment of the individual with diabetes (Table 30.1).
Table 30.1—Considerations for Nurses Providing Diabetes Care in Nursing Homes
• Is the oral diabetes medication given on time, before the meal, or with food?
• What are the side effects? Are lab results and signs and symptoms observed routinely?
• Is the type of insulin to be given with or before the meal?
• Is the insulin being stored properly?
• Is a new bottle of insulin opened every 28 days?
• Is there an injection site rotation plan? Is there a way to document?
• Is the injection subcutaneous?
• Review medication list after a hospitalization. Confirm, if medications have been dropped, that they were not to be restarted on return to the facility.
• Review for potential interactions of medications.
• Provide adequate calories, prevent malnutrition.
• Consult the dietitian if problems exist.
• Regular diet is acceptable with consistent carbohydrates in meals and snacks.
• Obtain blood glucose levels 2 h after meals to determine the effect of foods.
• Fats do not need to be restricted in the older population.
• Consider the individual.
Acute complications of diabetes
• Observe for signs of DKA, HHS, LA, hypoglycemia.
• Contact the health-care provider immediately with signs of DKA, HHS, or LA.
• Protocols for treatment of hyperglycemia and hypoglycemia are valuable.
• Be cautious not to overtreat hypoglycemia.
• Recheck blood glucose 15–20 min after treatment; repeat treatment if needed.
• Try to problem solve why acute complication occurred in order to decrease the risk of a recurrence.
Chronic complications of diabetes
• Follow the ADA Standards of Medical Care in Diabetes4 to reduce risks for blindness, strokes, and amputations.
Foot and skin care
• Daily inspection for individuals who cannot inspect their own feet
• Weekly nurse examination of feet
• Careful skin care, prevention of ulcers and skin tears
• Referral to podiatrist for foot care/footwear
• The resident should always wear shoes and socks whether walking or in a wheelchair.
• Respect the individual’s history of living with diabetes.
• Provide choices whenever possible.
• Include the family in care.
DKA, diabetic ketoacidosis; HHS, hyperglycemic hyperosmolar syndrome; LA, lactic acidosis.
Various organizations have published guidelines for management of diabetes in long-term care settings.7–9 All guidelines suggest that target blood glucose levels for the older adult should be individualized. Glycemic goals depend on several factors, including age, life expectancy, presence of chronic complications, and geriatric syndromes, including frailty and cognitive impairment. Goals should be focused on the prevention of hypoglycemia and avoidance of persistent hyperglycemia. Aging is associated with alterations in renal function, metabolism, and hormonal functioning. These and any conditions that reduce appetite and nutritional intake can lead to episodic hypoglycemia in the resident taking insulin or insulin secretagogues. The frail elder may not have typical symptoms of hypoglycemia. Nursing staff should be alert to changes in cognitive status, such as confusion and delirium. Advanced age, recent hospitalization, and polypharmacy are known to be strong predictors of hypoglycemia.6
On the other end of the spectrum of glycemic control is hyperglycemia. Acute or persistent hyperglycemia can lead to an increased risk for dehydration, infection (in particular, skin and urinary tract), greater sensitivity to pain, urinary incontinence, and decreased visual acuity and cognition. Target blood glucose levels should be designed to control hyperglycemia and prevent symptoms and acute complications. Fasting and premeal glucose targets in the range of 100 mg/dL to 200 mg/dL are reasonable for the long-term care and assisted living resident, although individualization of targets is a key aspect of care.6 Medical treatment options are improving, allowing for safer management of glucose levels. If one regimen is not achieving the identified glucose targets, then alternative medication strategies are indicated.
Long-term care residents may be on insulin, oral agents, or a combination. Key considerations with diabetes medications include appropriate timing of the medication administration and monitoring for side effects. It is important to properly administer the medication(s). Time constraints make the administration of multiple medications to residents a challenge for the nurse who must administer medications to several patients in a timely fashion. Inappropriate administration of diabetes medication can mean the difference between hypoglycemia, euglycemia, and hyperglycemia. Inconsistent timing of medication, especially insulin, also can lead to variable patterns in blood glucose levels. The health-care provider who reviews the blood glucose records must be astute in asking the right questions before making dosage adjustments. The health-care provider and long-term care staff also should consider the timing of snacks. Consult Chapter 6, Table 6.2, Insulin Action Times, when considering times for snacks, glucose monitoring, and increased activity. Consumption of snacks should be timed to match the peak activity of insulin. Increased physical activity, including physical therapy, should be avoided during peak insulin action. If activity is increased, blood glucose levels can be monitored to determine the need for an extra snack.
Despite being listed as a potentially inappropriate medication for older adults on the Beers Criteria for Potentially Inappropriate Medical Use in Older Adults, sliding-scale insulin (SSI) continues to be commonly used in nursing home settings.6,10,11 Even though residents receiving SSI are subject to frequent blood glucose (fingerstick) tests, they experience erratic blood glucose levels and overall poorer glycemic control.11 When insulin is needed, a better approach is to use basal or basal-bolus insulin therapy (see Chapter 26). Strategies to convert from SSI to basal bolus will vary depending on how SSI is being used.6
Storage and administration of insulin should be reviewed. Insulin is injected subcutaneously. Injection sites should be rotated, and hypertrophied or scarred areas should not be used to administer insulin. Attention should be given to the technique of insulin administration. A nurse may inadvertently administer the insulin in the muscle in a lean individual, which will cause the insulin to peak sooner, reducing its duration of action and placing the patient at risk for hypoglycemia. Using shorter-length needles (4 mm or 5 mm) can largely prevent injection into muscle.12 Insulin becomes less effective when it is outdated. Insulin bottles should be dated and discarded when they have exceeded the usage limit, which varies according to the type of insulin but is typically 28 days.13,14
Many antihyperglycemic oral agents should be used cautiously in older adults. Selecting agents with low hypoglycemia risk and a low side-effect profile is in the best interest of the resident. In all cases, it is important to monitor for potential side effects from antihyperglycemic oral agents. If residents taking thiazolidinediones develop edema or increasing congestive heart failure or if residents taking metformin have an increase in serum creatinine level, the health-care provider should be notified. Renal function may deteriorate with age, making this an important consideration in medication use and dosage. Chapter 7, Therapy for Type 2 Diabetes, reviews the potential side effects of oral agents and recommended monitoring techniques.
Polypharmacy is a common geriatric syndrome. It can be especially problematic for individuals with diabetes. Control of the multiple complications requires treatment with multiple medications. Chapter 25 discusses the issues of polypharmacy.
Diligent review of medications and observation by the nurse can prevent a resident from experiencing serious side effects. Each time a resident returns to the facility after a hospitalization, a careful review of medications should occur. Medication reconciliation involves a comparison of the resident’s medication list before hospitalization and the discharge list on return to the facility. Medications may have been discontinued during the hospitalization that should be restarted on return to the nursing home facility (e.g., medications for pain, sleeping, or antiplatelet therapy). Do not assume that just because a medication is not on the discharge list that it was discontinued. It may have been overlooked, changed, or discontinued. Verify the orders with the health-care provider.
To achieve optimal glycemic control, glucose monitoring is important, regardless of the location of care. Glucose monitoring is necessary to determine the effects of food and medication as well as activity, stress, and illness. Glucose monitoring can be important in determining whether the resident’s symptoms are related to hyperglycemia or hypoglycemia. This monitoring is an important tool in the management of the resident with diabetes. The frequency of monitoring for nursing home residents should be individualized and based on regimen complexity and the resident’s risk of hypoglycemia (see Chapter 8, Self-Management Practices: Problem Solving).6
Following are important considerations for glucose monitoring for nursing home staff:
1. The resident’s hands should be washed in warm water to improve circulation and remove any food residue or lotions.
2. Avoid using alcohol to cleanse the skin. Elderly patients have dry skin and alcohol increases dryness.
3. When obtaining blood from the finger, drop the resident’s hand to the side to improve blood flow before sticking the finger.
4. Use the sides of the finger rather than the tips to prevent tenderness.
5. Try not to squeeze the finger (squeezing leads to bruising and soreness).
6. If you suspect hypoglycemia or hyperglycemia, test the patient’s blood glucose level for verification.
Medical Nutrition Therapy
Providing adequate nutrition is a primary concern for residents of long-term care facilities.15 Prevention of malnourishment and malnutrition are key considerations. Frail elders, particularly those with cognitive impairment or depression, are at risk for poor nutrition, weight loss, and even failure to thrive.6 Restrictive diets are no longer recommended. Rather, it is appropriate to serve residents regular menus with consistent amounts of carbohydrates at each meal and for snacks. The caveat is that patients must receive consistent amounts of carbohydrates to ensure that the same amount is given each day and distributed throughout the three meals and snacks in a consistent manner. Glucose monitoring and notation of foods eaten will assist in adjusting medication to keep blood glucose levels within target ranges.
Two other aspects of poor nutrition are worth consideration: 1) eating meals alone discourages appetite and 2) dentition issues may deter patients from eating protein foods or raw fruits and vegetables that are difficult to chew. Because eating is generally a social behavior, appetite can increase when patients eat in a common dining room or have companionship while eating. Spending time with residents during a meal can help the nurse cue in on their food preferences in type and preparation style. Substitutions then can be made that will encourage nutritional balance.
Consultation with a registered dietitian is essential, and individual needs and preferences should be considered when developing a nutritional plan. If the dietitian suggests changes in daily intake, the health-care provider should be notified of these changes. If the individual’s appetite, quantity of food, or types of food change, increased glucose monitoring should occur, and the health-care provider should be notified; the antihyperglycemic medication may need to be adjusted.
Other Key Nutrition Considerations
1. Fat restriction generally is not needed in this population.
2. Residents on pureed or softened foods should receive adequate calories for nutrition.
3. Adequate hydration is essential in the nursing home environment. Older adults may be less keenly aware of feeling thirsty. It is necessary to promote the intake of fluids even when the resident does not request fluids.
Acute Complications of Diabetes
Hyperglycemia, including diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, and hypoglycemia are the most common acute complications of diabetes. The symptoms and management of these acute complications are addressed in Chapter 9, Acute Complications of Diabetes. It is most important to try to prevent acute complications by recognizing symptoms and identifying the problem early so that treatment can be initiated as soon as possible.
The long-term care population is at increased risk for lactic acidosis. Lactic acidosis results from inadequate oxygen delivery or utilization in individuals with serious underlying disease. The accumulation of lactic acid indicates that the balance between lactate production and utilization has been disturbed. Metformin has been associated with lactic acidosis and primarily occurs in patients with severe renal insufficiency or other concomitant conditions associated with poor renal perfusion or hypoxia. These conditions include congestive or acute heart failure, septicemia, severe respiratory insufficiency, chronic obstructive pulmonary disease, and age >80 years.16The guidelines for the use of metformin recently changed. Serum creatinine levels should be monitored regularly. Nausea and vomiting and failure to offer adequate fluids may lead to dehydration and subsequently to lactic acidosis. An individual’s health status may change, necessitating a reevaluation of their medication and safety issues.
Lactic acidosis will be difficult to differentiate from the other forms of critical illness. Conscious monitoring and notifying the health-care provider of any changes in hydration, oxygen perfusion, and mental orientation may prevent an acute crisis from occurring in the nursing home.
Chronic Complications of Diabetes
The focus of diabetes management in nursing home residents involves prevention of acute complications and preservation of quality of life. Screening for long-term complications is recommended so that problems can be detected and treated early. The American Diabetes Association’s guidelines recommend that screening be individualized, with particular attention paid to those complications that can develop over short periods of time or that would significantly impair one’s functional status.7 An annual dilated eye examination may contribute to the prevention of blindness. Assessing visual acuity and fitting with proper eyewear may prevent falls, increase quality of life, and reduce sensory deprivations. Management of hypertension reduces the incidence of strokes and kidney disease.
Foot and Skin Care
Early recognition and management of independent risk factors for foot ulcers and amputations can prevent or delay the onset of adverse outcomes.17 Individuals with diabetes are taught to do daily foot examinations, and it would seem appropriate that this recommendation be carried out in the nursing home. If the individual or a family member is unable to perform this exam, then the nursing home staff should conduct a visual inspection daily. Many facilities have access to podiatric services and should recommend that all individuals with diabetes receive these services, particularly for nail care. Evaluation for appropriate footwear should be done by a professional. The individual should always wear shoes when walking or when riding in a wheelchair to prevent foot injuries; this is especially critical for those with sensory loss.
Prevention and management of other skin ulcers and tears is also critical. Skin yeast infections are common in this population.18,19 Red rashy areas in the skinfolds or groin, especially if the resident is incontinent, may indicate yeast infections. In the 2004 nursing home survey, nearly 14% and 9.4% of residents with and without diabetes had a pressure ulcer at the time of the survey, yielding 56% higher odds of ulceration among residents with diabetes.4 Strategies to maintain skin integrity include making frequent assessments of pressure points, keeping the skin dry, assisting the resident to change position frequently, and turning the bedridden frequently.
Empowerment and Self-Management
Nursing home residents usually depend on others for the majority of their care. All but the cognitively impaired, however, can benefit from simple or new information. Residents and their family members deserve the opportunity to learn about their disease and have control over procedures whenever possible.
Caregivers should recognize that residents may have lived with and successfully managed diabetes for many years. Thus, it is important to listen to residents to learn important details related to daily management. Conversely, the diagnosis of diabetes may be new and the resident may not understand the medications, the need for glucose testing, or the symptoms of hypoglycemia. Allowing residents with diabetes to have some control over what and when they eat, to determine how often they engage in physical activity, and to have some say over their medications preserves their autonomy. For example, a cognitively intact resident may wish to direct the timing, location, and administration of the insulin injection. Encourage residents to be as physically active as they are able, and assess physical activity areas for safety. Include the family in the treatment plan and listen to them. They may have insight into the resident’s likes and dislikes. Older individuals with diabetes should be screened for depression and cognitive impairment.19
Nurses need to recognize the characteristics, challenges, and barriers related to the population with diabetes living in assisted living and long-term care facilities. These settings offer an opportunity to provide quality diabetes care and education to the individual with diabetes and to improve their quality of life. It is important to provide regular opportunities for continuing education for the staff. Nurses should guide the development and implementation of protocols for care—following the Association’s Standards of Care—and ensure that a trained staff is providing daily assistance for all individuals with diabetes living in nursing homes and long-term care facilities.
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