Management During Terminal Phases of the Illness: The Elderly Nursing Home Patient

Approximately 3% to 5% of the population over the age of 65 live in nursing homes. One-third of elderly individuals will spend some time in a nursing home. Diabetes prevalence in the nursing home population is about twice that in the general population and has progressively increased since 1964. The 1987 National Medical Expenditure Survey found that diabetic patients in nursing homes had a high prevalence of diseases associated with diabetes, such as heart disease, and a high prevalence of amputations and immobility.

Chronic renal failure, retinopathy, neuropathy, urinary tract infections, and skin infections are also more common among the patients with diabetes than among a similarly aged group of patients without diabetes. In contrast, the prevalence of dementia is low in diabetic nursing home residents.

A significant degree of functional limitation occurs in this population. As life expectancy is markedly reduced for most individuals admitted to nursing homes, the primary goal of therapy is symptom prevention. A recent study of 563 individuals from 24 nursing homes revealed that 75.8% died within 2 years. Poor functional status was a major predictor of mortality.

Control of hyperglycemia in patients in nursing homes is achieved primarily by diet and medication. Exercise does not play a major role. Diet is an important therapeutic option, but weight maintenance may be as important as weight loss for many elderly patients with diabetes in nursing homes.

One study found that more than 20% of patients with diabetes in nursing homes were more than 20% underweight. Malnutrition in this population is common. Patients should be weighed monthly, and active dietary adjustments should be made.

The choice of sulfonylureas or insulin therapy should be based on the level of glycemic control desired. Sulfonylureas are preferable both to the patient and to the nursing home staff. Insulin, however, is needed for those patients for whom glycemic goals cannot be achieved with a sulfonylurea. In the nursing home setting, glucose monitoring may be done more frequently, a major asset in the management of diabetes mellitus, resulting in low levels of glycosylated hemoglobin and few episodes of hypoglycemia.

Nursing home patients are prone to conditions that may be related to, or are exacerbated by, diabetes mellitus, particularly skin and urinary tract infections. Limiting the use of indwelling bladder catheters and ensuring good urinary output through adequate hydration may reduce urinary tract infections in this population.

Skin infections may be prevented by strict pressure ulcer precautions, including frequent turning of immobilized patients, the use of adequate bed and wheelchair cushioning, and the use of heel protectors. The prevalence of all infections is reduced with strict hand-washing regimens.

Treatment of Diabetes - Geriatric Medicine

Treatment of Diabetes - Geriatric Medicine

Annual influenza and 5-year pneumococcal vaccination will protect against epidemics of these illnesses in the nursing home. Immunization and PPD (purified protein derivative) status should be verified and documented for all new admissions to the nursing home. Patients with diabetes who have a positive PPD reaction should be considered for prophylaxis with isoniazid if they have not been treated previously for tuberculosis.

Regular ophthalmologic, dental, and foot care services should continue in the nursing home.

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