Reported prevalence of diabetes in nursing and residential homes – Residential Care
* Diabetes in the elderly
* Care homes
* Diabetes monitoring
* Staff education
The focus of long-term care of the elderly has shifted from hospital long-stay wards to privately operated nursing and residential homes. We investigated the prevalence of diabetes among care home residents in our health district, and the proportion of residents with secondary complications. We found a high prevalence of diabetes among the elderly residents, with many having secondary complications in eyes and feet. Although diabetes control is usually monitored, most homes do not have a protocol to act upon the results. Few staff had attended a diabetes course, although demand for education was high.
Diabetes mellitus is one of the most common chronic diseases of elderly people. Nevertheless, this section of the diabetes population has long been neglected (Tattersall, 1984; Sinclair et al, 1997). It has been shown that the provision of diabetes care in institutionalised settings may be inadequate (Benbow et al, 1997; Molyneux, 1997), increasing the risk of short- and long-term complications.
A large proportion of the health budget is taken up by diabetes care, in an increasing elderly population (Gerard et al, 1989; Sinclair, 1994, Williams et al, 2001). Tattersall and Page (1998) report on American studies, which found diabetes in 20% of nursing home residents. In the UK, it is predicted that half of such cases remain undiagnosed (Thurman and Moo radian, 1996).
The focus of long-term care has shifted from hospital long-stay wards to privately operated nursing and residential homes, where the need to make a profit may conflict with the delivery of high-quality care (Bowman et al, 1999). The result is often a reduction in staff levels and few opportunities for personal development (O’Kell, 1996; Sinclair et al, 1999).
This study investigated the prevalence of diabetes among care home residents, and the proportion of residents with secondary complications. It was undertaken within our health district, served by a Trust with combined acute and community services.
The study examined all 161 registered care homes in the Burnley, Pendle and Rossendale health district of East Lancashire. A postal questionnaire requested information on the number of residents diagnosed with diabetes, the proportion of residents with secondary complications, established protocols for diabetes care, and the educational experience and needs of staff (Figure 1). Additionally, carers were asked to provide information on each resident with diabetes (Figure 2). Approval was obtained from the local medical ethics committee.
Of the 161 questionnaires sent out, 122 (75.8%) were returned. Ten homes had closed and II questionnaires lacked sufficient information, leaving 101 for analysis.
Of the 2102 residents, 176 (8.4%) were known to have diabetes (Table 1). Data were obtained for 167 residents: 130 women (78%) and 37 men (22%), mean age 80.8[+ or -]9.3 years (n=160, range 37-98 years), mean body mass index (BMI) 23.9[+ or -]5.6kg/[m.sup.2] (n=134, range 11-42 [kg/[m.sup.2]) and mean duration of diabetes 8[+ or -]7 years (n=6l, range 1-38 years).
Overall, 64 (38%) of these residents were treated with diet alone, 76 (46%) with oral hypoglycaemic agents and 22 (13%) with insulin. Glycaemic control was monitored in 93.5% of residents with diabetes: urine analysis in 50 residents (30%); blood monitoring in 52 residents (31%); and a mixture of the two methods in 54 residents (32%). Blood monitoring was usually performed once every 1-2 weeks, whereas urine analysis was more likely to be performed once a week.
Fifty-two residents with diabetes had sight problems: 15 (9%) were blind and 37 (22%) were partially sighted. Most residents (145; 87%) saw an optometrist on a regular basis. Chiropody care was given to 166 (99%) of the residents, and 144 (86%) received this at intervals ranging from 6 weeks to 3 months. Foot disease was reported in 9 (5%) residents with diabetes, although the presence of foot disease was listed as unknown in another 10 (6%) residents. Foot ulcers (6 cases, 4%) and circulatory problems (26 cases, 16%) were also reported.
Of the 2010 staff employed in 101 care homes, only 30 (1.5%) had previously attended a diabetes education course (Table 2). However, demand for education/ training was high, with 78 (77%) of the homes requesting diabetes education for staff (Table 3). Thirty (30%) homes followed a set diabetes protocol, but none mentioned monitoring, acting on blood/urine results or treating hypoglycaemia.
There was a high prevalence of diabetes among elderly residents in the care homes studied. Many of these had secondary complications in eyes and feet. Although the mean BMI was normal, 27 (20%) of the residents were underweight (BMI 11-19kg/[m.sup.2]); these residents were also older (mean age 83 years). The resident with a BMI of had cancer of the bowel. Obesity (BMI [greater than or equal to]30 kg/[m.sup.2] was present in 20 (15%) residents; this is less than the national trend, which is currently 20%. The mean age of the obese group was 77 years. These findings suggest that older residents with diabetes are more likely to be malnourished, and younger residents obese.
Assessing diabetes control via urine analysis and/or blood glucose monitoring was carried out for most residents, but the majority of homes do not have a set protocol to advise on the frequency of monitoring or action to be taken from the results. There is evidence of considerable unsatisfied demand for diabetes education, with few staff having attended courses.
Strengths and weaknesses of the study
The study achieved a high response rate to the postal questionnaire, probably due to the provision of pre-paid response envelopes and follow-up contact with homes. However, information gained from the postal questionnaire is subjective, and provides reported rather than actual diagnoses of diabetes; also, staff could not be expected to identify macrovascular and microvascular complications with complete certainty.
Unlike other studies that use the sample approach, this work sought precise information from all registered homes within a single health district. Its weakness is that there was no comparison with a control group, such as elderly people with diabetes living in their own homes.
Implications of the study
This study and its findings provide insight into possible solutions to a serious, expensive and increasing national problem. The pressures on NHS resources due to diabetes and related conditions are large (Keen et al, 1995; Williams et al, 2001). Care home residents with diabetes are more frequently admitted to hospital and require more visits from their GPs (Benbow et al, 1997).
Previous research has suggested that the incidence of diabetes is under-recorded and growing (Richmond, 1994; Meneilly et al, 1996; Sinclair et al, 1999). Approximately 20% of the population are over 65 years of age (Meneilly and Tessier, 1995), and the incidence of diabetes is forecast to double by the year 2010 (Amos et al, 1997). This suggests that for every resident with diagnosed diabetes there could be another, as yet undiagnosed, resident receiving no monitoring or treatment.
Questions and future research
Further work needs to be undertaken to include residents with diabetes in any local audit of diabetes care by listing them on district diabetes registers. Research is also required to deliver and evaluate diabetes education programmes to care home staff.
The study has shown a high prevalence of diabetes within institutionalised care. The percentage of residents with diabetes and secondary complications has been difficult to assess, but the incidence of blindness and foot ulceration has been shown to be higher than the national average for a non-diabetes elderly population. However, most residents with diabetes in this study were receiving regular eye and foot care. Malnutrition may be a serious problem, with 20% of residents with diabetes being clinically underweight.
Although diabetes control is generally monitored, few results are acted upon, and protocols, when they do exist, tend to be ambiguous and non-specific. Most carers work part-time and have little expertise in this area. Demand for diabetes education is high, but the lack of financial resources and staff time are impediments to progress.
We would like to thank Tina Clark (Diabetes Register Facilitator) for assisting in the formulation of the questionnaires. Grateful thanks also to all of the care home staff for their contribution to this study.
Prevalence of diabetes within the study care homes.
Type of No. of No. of %
home residents with residents
All 176 2102 8.4
Nursing 36 360 10.0
Residential 94 1051 8.9
Dual registered 46 691 6.7
Care home staff attendance on diabetes courses
Type of home No. of staff Total no. %
who attended of staff
All 30 2010 1.5
Nursing 9 437 2.1
Residential 11 1052 1.0
Dual registered 10 521 1.9
Education topics requested for care home staff
Topics No. of %
Diet 69 68
Medication 41 41
Insulin 32 32
Hypoglycaemic episodes 60 59
Eye disease 53 52
Foot disease 56 55
Blood testing 35 35
Annual review screening 48 48
Questionaire sent to nursing and care homes within the study area.
Burnley, Pendle and Rossendale Diabetes Care Team Questionnaire
1. Are you: a nursing home a residential home dual registered?
Name of home (optional) ____________
2. How many residents do you have? ____________
3. How many residents have diabetes? ____________
4. Please fill in one of the attached sheets for each resident with
(See Figure 2, below.)
5. How many staff work at the home? _____ Full-time? _____
6. Have any staff been on diabetes education courses? If yes, please
state number _____
7. Does the home follow a set protocol for diabetes care? If yes, give
8. Please indicate (by ticking) which of the following (if any) you
would like further
* insulin and devices
* prevention and management of hypoglycaemia
* eye disease
* foot disease
* blood testing
* annual screening for complications.
Information requested for each resident with diabetes from the care
homes in the study area.
Please complete one sheet per resident with diabetes
About the resident: Male/female _____
Is he/she: Confused? _____
Year of diagnosis _____ Currently treated by:
Does he/she receive: Normal diet
Diabetes control Blood testing
monitored by: Urine testing
Is he/she: Registered blind? _____
Can he/she: Read? _____
Does he/she receive Yes, optometist
regular eye checks? visits home
Other (please state) _____
Does he/she have foot Yes
disease currently? No
Can he/she: Walk? _____
Does he/she receive If yes, how often? _____
regular chiropody? If no, foot care by:
About the resident: Age (years) _____
Is he/she: Responsive to
diabetes education? _____
Year of diagnosis _____ Diet alone
Does he/she receive: Low sugar diet
Diabetes control How often? _____
monitored by: How often? _____
Is he/she: Partially sighted? _____
Can he/she: Watch television? _____
Does he/she receive Yes, attends community
regular eye checks? optometrist
Does he/she have foot Deformity (e.g. bunion)
Can he/she: Climb stairs? _____
Does he/she receive
regular chiropody? Patient
About the resident: Height _____ Weight _____
Is he/she: Comments _____
Year of diagnosis _____ Diet and tablets Diet and Insulin
Does he/she receive: Tube feeding Supplements
Diabetes control No monitoring
Is he/she: Due to (if known) _____
Can he/she: Comments _____
Does he/she receive Yes, attends hospital No, does not have
regular eye checks? eye department eyes checked
Does he/she have foot Ulcer(s) Poor circulation
Can he/she: Comments _____
Does he/she receive
regular chiropody? Relatives Home staff
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Trudi A Deakin is Diabetes Specialist Research Dietitian and Malcolm D Littley is Consultant Physician, Diabetes Unit, Burnley General Hospital, Lancashire.
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