Diabetes Care in Nursing Homes: What Should We Expect?

In 1995, a 69-year-old man with type 2 diabetes was referred to me. Carl had been taking insulin for 12 years, and his main problem was recurrent hypoglycemia and hypoglycemia unawareness to the point where he required assistance on a regular basis. The problem was a bit unusual because his frequent emergency room visits are more commonly seen in patients with type 1 diabetes, not insulin-resistant people with type 2 diabetes. Yet Carl was not a usual patient, and his family came to me asking for help to deal with this difficult problem.

Going back to his initial clinic note, I saw he was on an insulin regimen common in the mid-1990s: morning NPH and regular insulin, predinner regular insulin, and bedtime NPH insulin. At my initial visit, we increased his home blood glucose monitoring to premeals and bedtime, in addition to making an important change in his insulin regimen: I decreased the morning NPH and added a prelunchtime injection of regular insulin. Insulin analogs were not introduced until the following year with the approval of insulin lispro (Humalog, Eli Lilly), and by fall 1996, we replaced Carl's regular insulin with insulin lispro. A few years later, the NPH was replaced with insulin glargine and, until 2006, Carl was treated with the “gold standard” of basal bolus therapy, a rapid-acting analog with a long-acting basal insulin analog. Importantly, at no time since 1995 did he have another episode of severe hypoglycemia (requiring the assistance of another person), a clinical finding supported by the literature of these newer insulins.¹ Equally important, he has been able to enjoy a full and rewarding life, traveling to Europe on several occasions and watching his grandson grow up.

The problem now is that Carl is 84 years old, and he has developed numerous medical conditions, including vertebral osteomyelitis, neurogenic bladder with urinary incontinence, and early dementia. During a recent hospital visit, his overall blood glucose control on the subcutaneous insulin algorithm was quite good, with no hypoglycemia and only rare glucose levels above 180 mg/dl. Unfortunately, whereas Carl's 23 years on insulin have served him well, for the most part allowing him to avoid many of the problems from his diabetes, he is no longer able to care for himself. Like many of our patients in this situation, he now requires some type of nursing home assistance. Carl's family, with the aid of a medical social worker, found an appropriate facility close by so that his wife can visit frequently, and he was transferred there for long-term care.

All of this sounds like an appropriate progression of events, given the unfortunate but not uncommon circumstances in this elderly man. But there is one problem: The nursing home will allow Carl to receive only two daily insulin injections. I am told that this nursing home (with an excellent reputation in the community) under no circumstances has the staffing to allow any patient to receive more than two injections. And although this was not mentioned, I'm sure it would be even more preferable for the facility's staff if we could work out a regimen for him to receive only one daily shot.

So I have a patient with severe insulin deficiency, who 11 years ago suffered from frequent severe hypoglycemia on three daily insulin injections. He has done well on a basal-bolus regimen of four shots each day, and he likely is even more insulin-deficient than when we met in 1995. Although I've never had reason to measure his C-peptide level, his glycemic variability on his meter downloads over the years confirms to me his endogenous insulin secretion is more like that of someone with type 1 diabetes. (With the growth of type 2 diabetes in our youth, my guess is this type of situation will become common over the next few years.)

I also have to acknowledge I have no real expertise in geriatric medicine (other than my internal medicine and general endocrinology training), and thus maybe this situation is common to those physicians who regularly care for this population. However, it seems unusually paradoxical that someone like Carl—with an active osteomyelitis and doing well with his current diabetes therapy—will need to change therapy due to poor nursing home staffing. If nothing else, his risk of life-threatening hypoglycemia should concern any nursing home administrator. I'm sure there are good financial reasons for not providing more aggressive care, but this type of decision seems unjustified and even illegal, if not immoral.

Why should we knowingly deliver substandard care? The American Diabetes Association (ADA) has position statements about diabetes care in the school and day care setting, diabetes care at diabetes camps, and diabetes management in correctional institutions. Inpatient diabetes has received much attention the past few years and is now an important part of the ADA practice guidelines.² These statements for children, prisoners, and inpatients are mostly based on expert opinion and common sense. It seems to me, as the baby boomers are aging and diabetes prevalence is exploding, we need a statement to remind nursing home administrators what constitutes reasonable diabetes care. This is especially true if we think about the numbers of people with type 1 diabetes who will require this kind of care over the next few decades.

I decided to prescribe Carl twice-daily pre-mix analog insulin mostly because it is a bit safer than the alternatives, and the nursing home staff is familiar with pre-mix insulin for most of their residents. It is far from ideal since it is not appropriate for someone with such severe insulin deficiency. But it is the best tool I have, given the circumstances.

It is my hope that, as this problem grows, we will have better systems in place to provide our patients the most efficacious and safest therapy available. ▪