Diabetes in institutionalised elderly people: a forgotten population?

Introduction

Diabetes mellitus is one of the commonest chronic diseases of elderly people. Nevertheless, this section of the diabetic population has long been neglected,1 which was emphasised again more recently.2 We report what we believe to be one of the first large studies of the patterns of care and levels of complications and resource usage of diabetic residents in residential or nursing homes. These people are possibly the most vulnerable section of the aged population.

Subjects, methods, and results

One hundred and nine residents with known diabetes mellitus were randomly selected from 19 nursing, 16 residential, six elderly mentally infirm, and three dual registered homes in the catchment area of one hospital in north west England. Controls were sex and nearest age matched non-diabetic residents in the same homes. All residents were interviewed by a research nurse, who completed a comprehensive questionnaire and examined each subject during six months from January 1995. Hospital and general practice records were subsequently reviewed.

Of all 1611 residents in the 44 homes, 159 (9.9%) had diabetes. There were no significant differences between the 109 diabetic subjects studied and the controls in age (mean 80.9 (SD 7.6) v 81.7 (7.0) years), sex (male to female ratio 34:75 v 31:76), or durations of stay in the homes (median 2.0 (range 0.3-17.0) v 2.0 (0.1-10.0) years). In the diabetic group 45 (41%) subjects were treated by diet, 42 (39%) with oral hypoglycaemic agents, and 22 (20%) with insulin. Monitoring of diabetic control in the homes was done by urine analysis in 11 (10%) cases, home blood glucose monitoring in 21 (19%) cases, and both methods in 48 (44%) cases. Twenty nine patients (27% of the group) were not being monitored for diabetic control. One third of these subjects were in nursing homes. Seventy eight (72%) diabetic residents were regularly weighed. There was a significantly greater prevalence of lower limb amputation, past or present foot ulceration, foot deformity, peripheral vascular disease, and catheterised subjects in the diabetic group than among controls (table 1).

Fifteen (14%) diabetic residents received diabetic care solely from their general practitioner and 27 (25%) received care from a hospital clinic. Seventy (64%) patients had no record of anyone being medically responsible for diabetes review and management the previous year. Diabetic residents in elderly mentally infirm homes were significantly less likely to be receiving formal diabetic care than residents in any of the other three types of home (P<0.05). Within the previous year 78 (72%) diabetic residents had seen an optician or had their eyes examined at a medical clinic, 20 (18%) had their feet medically examined, 36 (33%) had their glycated haemoglobin concentration and 31 (28%) their renal function checked, and 32 (29%) had their blood pressure measured. Within the previous four months 97 (89%) diabetic residents had seen a chiropodist (non-state registered in a quarter of cases), though payment for this was made by 68 (62%).

Within the previous year significantly more of the diabetic group had been admitted to hospital for any reason (47/109 subjects v 27/107; P<0.01) and the total number of admissions was greater (median 0 (range 0-2) v 0 (0-1); P<0.01) than among controls. Diabetic residents had also been seen by their general practitioner significantly more often than controls (3 (0-16) occasions v 1 (0-11); P<0.05).

Comment

The provision of care for this vulnerable group of diabetic residents was inadequate despite their high morbidity levels and greater use of health service resources. Many residents had no medical team responsible for their diabetic care and had not been assessed for the presence or risk of diabetic complications.3 Improved staff training, closer cooperation between primary and secondary care in the management of institutionalised diabetic residents, and individual care plans for these residents are needed. The role of a diabetes specialist nurse with particular responsibility for elderly patients requires evaluation. At a district level guidelines and standards for the management of residents with diabetes are urgently needed.