The Role of Nursing Home Admission and Dementia Status on Care for Diabetes Mellitus

More than 24 million people in the United States have diabetes mellitus, and this number will grow by 1 million per year due to population aging and other factors.1,2 The risk of diabetes mellitus increases dramatically with age, and the devastating effect of diabetes mellitus is particularly evident in elderly and institutionalized people. Whereas 5.6% of noninstitutionalized Americans have diabetes mellitus, up to one-quarter of America's 1.5 million nursing home (NH) residents have diabetes mellitus.2–4 NH residents with diabetes mellitus have higher rates of cardiovascular disease, visual problems, foot conditions, kidney failure, urinary incontinence, depression, cognitive impairment, injurious falls, nutritional deficiencies, and pain than residents without diabetes mellitus.2,3 As the population ages, the burden of the costs of and care for diabetes mellitus will fall heavily on the U.S. long-term care system. Following intensive regimens for the management of diabetes mellitus is essential to delaying or avoiding its many negative health consequences. Standard diagnostic and preventive procedures include periodic dilated eye examinations, lipid profiling and testing of glycosylated hemoglobin (HbA1c), fasting plasma glucose, and serum creatinine. The American Geriatrics Society (AGS) provides guidelines for older persons with diabetes mellitus,5 and guidelines for institutionalized elderly adults have also been offered.6 Unfortunately, many elderly persons with diabetes mellitus, whether in the community or residing in an NH, do not receive the level of diagnostic and preventive care prescribed by these guidelines.7–12 An important question for researchers and clinicians alike pertains to the relationship between NH admission and quality of care for diabetes mellitus. Although the structured care environment of the NH might lead to better care, priority may be given to more-urgent health concerns in people newly admitted to the NH, or the goals of care for diabetes mellitus may change as the costs and expected benefits of procedures are considered.3,5,11,13,14 Care may also change as NH physicians, rather than endocrinologists, direct care.15 Drawing inferences about this question from existing studies of community- and NH-dwelling elderly persons with diabetes mellitus is not possible because of widely varying sample demographics, data collection time frames, geographic locations, and inclusion and exclusion of short-stay NH patients. Additionally, it is likely that community-dwelling persons with diabetes mellitus admitted to an NH differ from those remaining in the community in the severity of their diabetes mellitus and other comorbidities.14 To examine the relationship between NH admission and quality of care for diabetes mellitus, care provided to a single sample of NH residents before and after NH admission must be examined. Because of its prevalence and relationship to care practices, evaluations of care of diabetes mellitus in the NH should also take dementia into account. Approximately half of all NH residents have dementia.16 A wide range of studies have documented a connection between cognitive impairment and the provision of less-aggressive care related to diabetes mellitus,12–15,17 although these studies did not consider the role of NH admission or did not examine diabetes mellitus care practices across a wide spectrum of quality indicators. Thus, a resident's status with regard to dementia is an important factor to consider when examining how admission to an NH relates to care for diabetes mellitus. Because diabetes mellitus is a disease for which the parameters of good care are relatively well defined, comparing the provision of procedures related to the care of diabetes mellitus to those with and without dementia also yields insights into the quality of care for patients with dementia. For five basic diagnostic and preventive procedures related to diabetes mellitus, the current study asks whether care is provided at higher rates in the 12-month period before or after NH admission and for those with or without dementia. Interactions between dementia status and place of residence were also looked for, and rates of receiving these procedures in each setting were examined. For each procedure, basic rates and rates adjusted for variables that may affect the amount or type of care received by people newly admitted to the NH, including resident demographics, health status, and the previous year's healthcare utilization, were examined.