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REVIEW

Managing diabetes in nursing and care homes

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One in four people in residential homes has diabetes. However, a national audit has found the condition is not being identified, monitored and treated adequately

Abstract

The England-wide Care Home Diabetes Audit, published earlier this year, revealed a lack of assessment, monitoring and specialist care for people with diabetes who live in nursing and care homes. Many homes are not systematically screening residents for diabetes nor monitoring the blood glucose levels of those with the condition. Staff education and training is patchy and patients are at risk of hypoglycaemia and diabetic foot complications. The Institute of Diabetes for Older People, which conducted the audit, has called for tighter regulation to improve care.

Citation: Anderson P (2014) Managing diabetes in nursing and care homes. Nursing Times; 110; 34/35, 20-21.

Author: Pat Anderson is a freelance healthcare writer and editor.

Introduction 

A national audit of diabetes care in nursing and care homes has revealed significant gaps in care for vulnerable patients (Institute of Diabetes in Older People, 2014). The audit was conducted by the IODP in collaboration with the Association of British Clinical Diabetologists, with the support of organisations including the Royal College of Nursing.

A total of 2,043 homes took part in the audit; of the 48,978 people living in these homes, 5,087 (10.4%) were reported as having diabetes. The IODP points out that this finding is at odds with research showing that diabetes is becoming increasingly prevalent in care homes, with 27% of care home residents having the condition (IODP, 2014).

The report says further investigation is needed to understand whether this disparity is to do with problems in diagnosis, recording of key medical data or staff awareness of the condition.

Assessing and managing diabetes

Screening and self-medication

Almost two-thirds (65%) of the homes responding to the audit had no policy on screening for diabetes. The report points out that this means residents could have undiagnosed diabetes, and therefore be missing opportunities for early treatment.

A total of 17% of care homes said they had no system to check whether residents who self-medicated for diabetes had taken their medication. The report says it is important to evaluate residents’ ability to self-medicate on admission and at regular intervals, as failure to do so could mean they are left untreated or exposed to complications because of medication errors.

Hypoglycaemia: a medical emergency

Only 53% of the homes audited said that they assessed knowledge of hypoglycaemia among their residents with diabetes using a standard protocol. The report says homes that are not doing this could be missing vital information and would find it difficult to design a care plan to meet individual needs.

More than one-third of homes (37%) admitted that they did not have a written policy for managing hypoglycaemia. The report emphasises that hypoglycaemia is a medical emergency and a clear written policy is in the interests of the home and the staff as well as the residents.

More than one-third of homes (34%) reported that they did not assess whether their residents with diabetes knew the signs and symptoms of hypoglycaemia. The report points out that almost 60% of care home residents are aged over 85, and hypoglycaemia is one of the most important complications affecting older people with diabetes. Hypoglycaemia:

  • Is a key factor in hospitalisation;
  • Is associated with falls and decreased cognitive function;
  • Can have fatal consequences if undetected.

The report stresses that hypoglycaemia can be minimised by modifying medication or diet.

Staff responsibility, training and guidelines

Nearly two-thirds (63%) of homes did not have a designated staff member with responsibility for diabetes management. According to the report, protocols, policies and guidance are the foundations of high-quality diabetes care, and a designated person would be “of great value to provide leadership and take responsibility for the quality of care”.

One-third of homes (33%) did not have direct access to any NHS training to support diabetes care. The report says that staff training forms the foundation of good-quality diabetes care, and should focus on ongoing care as well as emergencies like hypoglycaemia.

Nearly half of homes (47%) were unaware of Diabetes UK’s care home guidelines (Diabetes UK, 2010).

Tests of cognitive function and mood

Homes said that a quarter of residents (25%) had not been given a documented test of cognition in the last 12 months, so there was no up-to-date record of their cognitive state. The report says knowing residents’ cognitive ability is important to assess their care needs accurately and their ability to self-medicate and report symptoms of hypoglycaemia. It adds that monitoring cognitive function is particularly important in people with diabetes, because they are at increased risk of dementia.

Two-thirds (68%) of homes reported that residents had undergone a documented test of mood status in the previous 12 months. The report highlights that older people with diabetes are at an increased risk of developing low mood and depression, which could impair their ability and motivation to self-medicate.

Test results and annual review reports

Only 34% of homes were able to confirm that they received an annual review report from GPs for all residents; the report says this means that information including that on medication, glycaemic control and treatment targets is not readily available to the home. In addition, only 44% of homes kept documented evidence of residents’ most recent HbA1c levels from GPs, and only 40% kept documented evidence of residents’ most recent kidney function tests.

The report says it would be “very valuable” if homes were regularly informed of HbA1c levels as they are key partners in residents’ lifestyle choices, and that knowledge of renal function is useful when choosing medication and when dehydration is suspected.

Risk of foot problems

The report highlights that more than half (53%) of care home residents with diabetes may be at moderate or high risk of foot problems. This means they could develop foot ulcers, which can result in amputation, particularly if care home staff are unaware of this risk and the potential speed at which deterioration can occur.

The report stresses that foot assessment should be part of daily routine care, and that the development of a foot ulcer should be seen as a medical emergency.

Urgent safety concerns

The IODP says that the audit findings “highlight several areas of urgent concern around the safety of residents and their day-to-day health”.

It says that by addressing diabetes care, homes could make significant improvements to residents’ quality of life, and that all care homes should be aware of the Diabetes UK good clinical practice guidelines (Diabetes UK, 2010) and base their care and policies on these as far as possible. All homes should have a screening policy for diabetes, which should be used on admission, and should assess residents’ know-ledge, especially regarding hypoglycaemia.

The report also emphasises that each care home should have a designated member of staff responsible for diabetes management, and that care home staff should be given access to training and education on diabetes. Other key recommendations are summarised in Box 1.

Box 1. Recommendations for care homes

Clinical care and monitoring - Care and residential homes should:

  • Have a policy for managing hypoglycaemia, with staff trained to deliver care in line with that policy, and a hypoglycaemia treatment kit available
  • Make foot assessment part of daily routine
  • Monitor the ability of residents with diabetes to self-medicate at regular intervals
  • Assess residents’ cognitive function on admission and at regular intervals
  • Assess mood on admission and at regular intervals

Communication with primary care - Care and residential homes should:

  • Liaise with GPs and community teams to ensure that annual reviews and other scheduled checks take place
  • Document HbA1c levels received from primary care so they can take a more active role in disease management
  • Document kidney function test results and understand their implications

Next steps

The IDOP aims to repeat the audit at two-yearly intervals and to extend it to other settings. With the Joint British Diabetes Societies, it will campaign for greater regulation of diabetes care in care homes through the Care Quality Commission, and for the Diabetes UK good practice guidelines to be taken into account during inspections.

The institute plans to work with the Association of British Clinical Diabetologists to develop an accreditation system backed up with training resources so that homes can improve their diabetes care. Homes that provide high-quality diabetes care will receive recognition.

Key points

  • Up to 27% of nursing and care homes residents have diagnosed or undiagnosed diabetes
  • A national audit has shown that 65% of homes have no policy on screening for diabetes
  • More than one third of homes have no written hypoglycaemia policy and only 44% keep evidence of residents’ HbA1c test results
  • Two-thirds of homes do not have a designated staff member who is responsible for diabetes management
  • More than half of care home residents with diabetes may be at moderate or high risk of diabetic foot complications
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