ASSESSMENT OF GLYCEMIC CONTROL AMONG ... - Ipab di Vicenza

NOTICE: this is the author’s version of a work that was accepted for publication in Diabetes Research and Clinical Practice. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in Diabetes Res Clin Pract. 2012 Jun;96(3):e80-3. Epub 2012 Mar 23. doi:10.1016/j.diabres.2012.02.026

ASSESSMENT OF GLYCEMIC CONTROL AMONG DIABETIC RESIDENTS IN NURSING HOMES Alfonso Basso^, MD, Pierpaolo Peruzzi°, MD, Maria Cecilia Carollo°, Giuseppina Improta°, Ugo Fedeli*, MD

^ Fondazione Maria Teresa Mioni Onlus. ° I.P.A.B. Vicenza. Contrà San Pietro 60, 36100 Vicenza (Italy) * SER – Epidemiological Department, Veneto Region. Passaggio Gaudenzio 1, 35131 Padova (Italy)

Correspondence to: Ugo Fedeli SER – Epidemiological Department, Veneto Region Passaggio Gaudenzio, 1 35131 Padova (Italy) Phone: +39 049 877 8251 Mail: [email protected]

ABSTRACT We assessed hemoglobin A1c (HbA1c) among 88 diabetic residents in three Italian nursing homes, and compared figures with current guidelines and reports in the literature. Mean HbA1c was 6.5%; this paper from Southern Europe confirms recent findings in nursing homes on HbA1c values well below recommended targets.

Keywords: diabetes mellitus; hemoglobin A1c; long term care facilities

Accepted author manuscript. A definitive version has been published in Diabetes Res Clin Pract. 2012 Jun;96(3):e80-3.

Introduction Each diabetic resident in nursing homes should have a individualized diabetes care plan including glycemic targets. According to the guidelines of the American Diabetes Association, glycemic goals for older adults not functionally and cognitively intact, or with reduced life expectancy, should be relaxed with respect to the standard of hemoglobin A1c (HbA1c) 8.5%). Discussion To our knowledge, this is the first report from Southern Europe on HbA1c levels among diabetic residents in long term care facilities. Although limited to three facilities and to pharmacologically treated patients, the study showed a very tight glycemic control: three out four subjects were below the target range set by European guidelines for older diabetics, and the great majority were below the relaxed target range set for frail dependent elderly. In the Veneto region priority of admission to nursing homes is based on poor health status, low autonomy, and lack of social support; nursing homes subjects are mainly supported by paramedical staff, with overall fewer resources than in traditional health care settings. These constrains add to the difficulties in the management of diabetes in elderly subjects who are malnourished, have irregular food intake, are treated with many drugs for multiple comorbidities, and have high levels of disability [20]. However, some authors reported that strict glycemic control can be achieved in most nursing home residents, without any serious adverse effect from hypoglycemia [14, 16]; others concluded that the control of diabetes in this population is too thigh [17], and that the withdrawal or the reduction of diabetes medications is safe [15]. Recent clinical trials found that intensive glycemic control had a beneficial effect on various microvascular outcomes, but not on the risk of major cardiovascular events; moreover, intensive therapy increased the frequency of severe hypoglycemia [21]. According to a 3-month period chart review of residents included in the present study, 31% had hypoglycemic events requiring an intervention recorded in medical records, although none was hospitalized. Symptoms of hypoglycemia in elderly patients might be misinterpreted as being manifestations of other diseases, especially in patients with low cognitive function; furthermore hypoglycemia might be particularly deleterious in patients with cardiovascular disorders. In view of the above, overtreatment of diabetic residents must be regarded as a patient safety issue in nursing homes, and a individualized target range for HbA1c should be identified with the priority to avoid hypoglycemic episodes. Until mid-2000s, sparse data were available on HbA1c levels measured in nursing home residents with diabetes. In more recent years, a number of papers has been published showing that HbA1c levels are shifted toward low values, irrespective of study design or facility location. The present report extends previous findings on low HbA1c in nursing home residents, and underlines the distance between evidence available from clinical trials and the reality of diabetes management in nursing homes, where staff usually care for very elderly diabetics with HbA1c values well below the targets recommended by current guidelines.

Conflict of interest statement The authors declare they have no conflict of interest. Acknowledgements The study was funded by “Fondazione Maria Teresa Mioni” ONLUS.


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Table 1. HbA1c levels by clinical characteristics of diabetic patients: mean and standard deviation (SD) of study groups, and p value for the Student t test or one-way analysis of variance. Study variable

Mean HbA1c (SD)

p

Age