Diabetes in care homes : Special emphasis on medicines and blood glucose measurements

Diabetes mellitus (DM) is prevalent among older adults and leads to disability, frailty, and dependency. In care homes, multimorbidity and polypharmacy may further complicate the management of DM and increase the risk of adverse events. This thesis aims to investigate the prevalence and management of DM in care homes, with special emphasis on medicines and blood glucose measurements. Paper I was a cross-sectional study of 742 residents from 19 Norwegian nursing homes (NHs). We found a DM prevalence of 16 % (n=116), and that 74 % of residents with DM used blood glucose-lowering medicines. CBGM the last four weeks was registered for 73 % of the residents, frequency varied from daily to monthly. Six out of ten residents had at least one blood glucose reading <6.0 mmol/L. An HbA1c value the last twelve months was recorded for 77 % of residents, with a mean of 57 mmol/mol (7.3 %) and a range of 28-112 mmol/mol (4.7-12.4 %). Paper II was a retrospective study of 826 residents from 30 English care homes, using baseline data from the CAREMED study. For residents with type 2 DM (T2DM), we described comorbidities and prescriptions, and identified potentially inappropriate medicines (PIMs). Of the 106 residents with T2DM, 76 % used blood glucoselowering medicines. The number of comorbidities, prescriptions, and residents using ≥5 medicines was higher among residents with T2DM compared to residents without DM. We identified 346 PIMs, and nine out of ten residents with T2DM had at least one PIM. Of the 67 PIMs in the 20 % resident sample for validation, a care home physician agreed that 26 and 40 of them could be directly discontinued or considered discontinued, respectively. Paper III was a qualitative study exploring the perspectives of NH staff on the use and usefulness, procedures, and potential challenges of CBGM in Norwegian NHs. We conducted three profession-specific focus groups, including five physicians, four registered nurses, and three auxiliary nurses, using a semi-structured interview guide. All professional groups found CBGM necessary when caring for residents with DM,but tried to minimise its use to ease the strain on the residents. The participants mentioned access to and familiarity with procedures, equivalent practice, explicit documentation routines, and sufficient training in DM and its symptoms as means by which to promote the appropriate use of CBGM and ensure patient safety. Currently, one or several of these factors were lacking. In conclusion, the research in this thesis shows that care home residents with DM suffer a high burden of medicines in general and use of DM medicines in particular. Patient safety may be further compromised by the lack of training and procedures in regard to CBGM and recognising deviant blood glucose concentrations. Thus, the potential to optimise medicine use and improve blood glucose-monitoring practices should be investigated further

The potential for deprescribing in care home residents with Type 2 diabetes

Background: Type 2 diabetes is a common diagnosis in care home residents that is associated with potentially inappropriate prescribing and thus risk of additional suffering. Previous studies found that diabetes medicines can be safely withdrawn in care home residents, encouraging further investigation of the potential for deprescribing amongst these patients. Objectives: Describe comorbidities and medicine use in care home residents with Type 2 diabetes; identify number of potentially inappropriate medicines prescribed for these residents using a medicines optimisation tool; assess clinical applicability of the tool. Setting Thirty care homes for older people, East Anglia, UK. Method: Data on diagnoses and medicines were extracted from medical records of 826 residents. Potentially inappropriate medicines were identified using the tool ‘Optimising Safe and Appropriate Medicines Use’. Twenty percent of results were validated by a care home physician. Main outcome measure: Number of potentially inappropriate medicines. Results: The 106 residents with Type 2 diabetes had more comorbidities and prescriptions than those without. Over 90 % of residents with Type 2 diabetes had at least one potentially inappropriate medication. The most common was absence of valid indication. The physician unreservedly endorsed 39 % of the suggested deprescribing, and would consider discontinuing all but one of the remaining medicines following access to additional information. Conclusion: UK care home residents with Type 2 diabetes had an increased burden of comorbidities and prescriptions. The majority of these patients were prescribed potentially inappropriate medicines. Validation by a care home physician supported the clinical applicability of the medicines optimisation tool

Review of Clinical Questions Submitted to Norwegian Drug Information Centres Concerning Administration and Dosage to Older Patients of Relevance to Patient-Centric Care

Patient-centric care entails optimising healthcare provision to patients based on their perspective and opinion. It involves appropriate treatment at a reasonable cost and a focus on patient characteristics in the decision-making process to make it more personally useful. The optimisation of medicines in the older population is a challenge due to physiological changes, comorbidity, and polypharmacy. Furthermore, patient-centric care is difficult to achieve due to the high proportion of patients with dementia and frailty. Decision support concerning the appropriateness of indication, formulation, dose, administration, co-prescribing, and length of treatment to older patients is frequently in demand. In the current study, we aimed to review clinical questions concerning administration and dosage to older patients of relevance to patient-centric care. We analysed questions concerning medicines to patients 65 years or older in the database of the network of Norwegian drug information centres from 2010 to 2020. The analysis included the distribution of drugs, diseases, and recurring topics among the questions. Through a Boolean search that combined the indexed categories of “older” and “administration and dosage”, we retrieved 84 question-answer pairs. Questions about psychotropic and cardiovascular drugs in relation to therapy, adverse drug reactions, and pharmacokinetics dominated, and more than 60% of the questions came from physicians. Topics relevant to patient-centric pharmacotherapy were drug withdrawal (10 questions), drug formulation (8 questions), drug initiation (8 questions), and switching drugs (5 questions). One question concerned drug withdrawal and switching, and one question drug formulation and switching. Answers provided decision support regarding appropriate formulations of drugs to patients with dementia who chew capsules or tablets, the use of parenteral administration in patients who refuse to take oral formulations, and the pharmacokinetics of transdermal or rectal drug administration. The results highlight the importance of including pharmacological factors in the assessment of the acceptability and appropriateness of oral and parenteral medicine to older patients.publishedVersio

Diabetes in care homes : Special emphasis on medicines and blood glucose measurements

Diabetes mellitus (DM) is prevalent among older adults and leads to disability, frailty, and dependency. In care homes, multimorbidity and polypharmacy may further complicate the management of DM and increase the risk of adverse events. This thesis aims to investigate the prevalence and management of DM in care homes, with special emphasis on medicines and blood glucose measurements. Paper I was a cross-sectional study of 742 residents from 19 Norwegian nursing homes (NHs). We found a DM prevalence of 16 % (n=116), and that 74 % of residents with DM used blood glucose-lowering medicines. CBGM the last four weeks was registered for 73 % of the residents, frequency varied from daily to monthly. Six out of ten residents had at least one blood glucose reading <6.0 mmol/L. An HbA1c value the last twelve months was recorded for 77 % of residents, with a mean of 57 mmol/mol (7.3 %) and a range of 28-112 mmol/mol (4.7-12.4 %). Paper II was a retrospective study of 826 residents from 30 English care homes, using baseline data from the CAREMED study. For residents with type 2 DM (T2DM), we described comorbidities and prescriptions, and identified potentially inappropriate medicines (PIMs). Of the 106 residents with T2DM, 76 % used blood glucoselowering medicines. The number of comorbidities, prescriptions, and residents using ≥5 medicines was higher among residents with T2DM compared to residents without DM. We identified 346 PIMs, and nine out of ten residents with T2DM had at least one PIM. Of the 67 PIMs in the 20 % resident sample for validation, a care home physician agreed that 26 and 40 of them could be directly discontinued or considered discontinued, respectively. Paper III was a qualitative study exploring the perspectives of NH staff on the use and usefulness, procedures, and potential challenges of CBGM in Norwegian NHs. We conducted three profession-specific focus groups, including five physicians, four registered nurses, and three auxiliary nurses, using a semi-structured interview guide. All professional groups found CBGM necessary when caring for residents with DM,but tried to minimise its use to ease the strain on the residents. The participants mentioned access to and familiarity with procedures, equivalent practice, explicit documentation routines, and sufficient training in DM and its symptoms as means by which to promote the appropriate use of CBGM and ensure patient safety. Currently, one or several of these factors were lacking. In conclusion, the research in this thesis shows that care home residents with DM suffer a high burden of medicines in general and use of DM medicines in particular. Patient safety may be further compromised by the lack of training and procedures in regard to CBGM and recognising deviant blood glucose concentrations. Thus, the potential to optimise medicine use and improve blood glucose-monitoring practices should be investigated further

Helsepersonells erfaringar, tankar og haldningar til behovsmedisinering i sjukeheimar

Behovslegemiddel er meint å bli gitt som respons på eit symptom eller medisinsk behov som oppstår hjå pasienten. Behovslegemiddel blir anten ført opp på den enkelte pasient sitt legemiddelkort, eller så kan ein nytte seg av legemiddel på generelle skriftlege direktiv som gjeld for heile sjukeheimen. Det er blitt observert forskjellar i praksisen for behovsmedisinering frå sjukeheim til sjukeheim, og avgjersleprosessen for om ein skal gi behovslegemiddel eller ei, er uklar. Det er eit behov for meir kunnskap om korleis systemet for behovsmedisinering fungerer, for å kunne utvikle best mogleg prosedyrar og rutinar for dette området. Hjelpepleiarar, sjukepleiarar og sjukeheimslegar blei invitert til å delta i tre yrkesspesifikke fokusgrupper, der dei skulle diskutere korleis erfaringar, tankar og haldningar dei hadde i høve til behovsmedisineringa i sjukeheimar. Det blei utvikla ein semistrukturert intervjuguide med fem hovudtema: Erfaringar, tankar, haldningar, forslag til betre praksis, og medisinering generelt i sjukeheimar. Gruppeintervjua blei transkribert ordrett og analysert tematisk. I tillegg blei alle dei 33 sjukeheimane i Bergen kommune bedt om å sende kopi av sine generelle skriftlege direktiv. Desse blei undersøkt ved dokumentanalyse. Gruppeintervjua avdekka eit misforhold mellom oppgåvefordeling og ansvarsmedvit i høve til behovsmedisineringa. Det blei etterlyst betre rutinar for dokumentasjon av behovslegemidlets effekt, samt organisering og gjennomføring av undervisning på området. Fleire uttrykte bekymring for at fokuset på å behandle med legemiddel i sjukeheimar er så stort. Tjuefire direktiv blei innhenta til dokumentanalysen, desse blei analysert ved hjelp av eit kodeskjema. Dei generelle skriftlege direktiva viste stor variasjon i både utforming og innhald. Talet på indikasjonar gjekk frå 3 til 17, og til saman fanst det 51 legemiddelsubstansar å velje blant. Doseringsinformasjonen mangla eller var uklar i ein fjerdedel av tilfella. Helsepersonell opplev at behovsmedisineringa ikkje fungerer på fleire område, og at ei kvalitetsbetring må til. Det same viser den varierande kvaliteten på dei generelle skriftlege direktiva

Nursing home patients with diabetes: Prevalence, drug treatment and glycemic control

Aims: Determine prevalence of diabetes, and describe use of blood glucose lowering (BGL) drugs and glycemic control in Norwegian nursing homes. Methods: In this cross-sectional study we collected details of BGL drugs, capillary blood glucose measurements (CBGM) in the last four weeks and HbA1c measurements in the last 12 months from the medical records of patients with diabetes, within a population of 742 long-term care patients from 19 randomly selected nursing homes in Western Norway. Descriptive statistics were applied, and Pearson’s chi-squared (P 0.05) or non-overlapping 95% confidence intervals were interpreted as significant effects. Results: 116 patients (16%) had diabetes, 100 of these gave informed consent and medical data were available. BGL treatment was as follows: (1) insulin only (32%), (2) insulin and oral antidiabetics (OADs) (15%), (3) OADs only (27%) and (4) no drugs (26%). Patients with cognitive impairment were less likely to receive medical treatment (P = 0.04). CBGM and HbA1c measurements were performed for 73% and 77% of patients, respectively. Mean HbA1c was 7.3% (57 mmol/mol), 46% of patients had an HbA1c <7.0% (53 mmol/mol), and CBGM consistent with risk of hypoglycemia was found for 60% of these patients. Conclusions: Prevalence of diabetes and BGL treatment in Norwegian nursing homes is comparable to other European countries. Although special care seems to be taken when choosing treatment for patients with cognitive impairment, there are signs of overtreatment in the population as a whole. The strict glycemic control unveiled may negatively affect these frail patients’ quality of life and increase the risk of early death

Nurses as adverse drug reaction reporting advocates

Adverse drug reactions (ADRs) is a challenge in modern healthcare, particularly given the increasing complexity of drug therapy, an ageing population, rising multimorbidity, and a high patient turnover. The core activity of detecting potential ADRs over the last half century has been spontaneous reporting systems. A recent Norwegian regulation commits healthcare professionals other than physicians and dentists to report serious ADRs. In this discussion paper, we share our preliminary experience with a training programme using nurses as ADR advocates to stimulate ADR reporting among the clinical staff in a hospital department.publishedVersio

‘I try not to bother the residents too much’ – the use of capillary blood glucose measurements in nursing homes

Background Capillary blood glucose measurements are regularly used for nursing home residents with diabetes. The usefulness of these measurements relies on clear indications for use, correct measurement techniques, proper documentation and clinical use of the resulting blood glucose values. The use of a regular, invasive procedure may also entail additional challenges in a population of older, multimorbid patients who often suffer from cognitive impairment or dementia. The aim of this study was to explore the perspectives of physicians, registered nurses and auxiliary nurses on the use, usefulness and potential challenges of using capillary blood glucose measurements in nursing homes, and the procedures for doing so. Methods This was a qualitative study that used three profession-specific focus group interviews. Interviews were transcribed in modified verbatim form and analysed in accordance with Malterud’s principles of systematic text condensation. Five physicians, four registered nurses and three auxiliary nurses participated in the focus groups. Results All professional groups regarded capillary blood glucose measurements as a necessity in the management of diabetes, the physicians to ensure that the treatment is appropriate, and the nurses to be certain and assured about their caring decisions. Strict glycaemic control and excessive measurements were avoided in order to promote the well-being and safety of the residents. Sufficient knowledge of diabetes symptoms, equivalent practices for glucose measurement, and unambiguous documentation and communication of results were determined to be most helpful. However, all professional groups seldom involved the residents in managing their own measurements and stated that guidelines and training had been inconsistent or lacking. Conclusion Inadequate procedures and training in diabetes care may compromise the rationale for capillary blood glucose measurements in nursing homes, and hence the residents’ safety. These concerns should be addressed together with the possibility of involving and empowering residents by exploring their ability and wish to manage their own disease