Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.
Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
J Am Geriatr Soc. 2022 Nov;70(11):3176-3184. doi: 10.1111/jgs.17962. Epub 2022 Aug 4.
Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels.
We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/- metformin but no insulin), (4) long-acting insulin (+/- oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission.
Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation = 1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status. Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact).
NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration in monitoring decisions. Future studies should determine whether decreasing fingersticks in NH residents with moderate/severe cognitive impairment can reduce burdens without compromising safety.
指南建议认知障碍的养老院（NH）居民接受较低强度的血糖治疗和较少的指尖血糖监测。我们的目的是通过检查 VA NH 中患有糖尿病的认知障碍程度不同的居民的指尖血糖监测频率，来确定当前的实践是否符合指南建议。
我们确定了 2016 年至 2019 年间在 VA NH 中居住超过 30 天且年龄≥65 岁的患有糖尿病的 VA NH 居民。根据认知功能量表，居民被分为认知功能正常、轻度认知障碍、中度认知障碍和重度认知障碍。我们还将居民分为相互排斥的降糖药物（GLM）类别：（1）无 GLM，（2）仅使用二甲双胍，（3）磺脲类/其他 GLM（+/- 二甲双胍但无胰岛素），（4）长效胰岛素（+/- 口服/其他 GLM 但无速效胰岛素），和（5）任何速效胰岛素。我们的结局是 NH 入住第 31 天的平均每日指尖血糖监测次数。
在 13637 名 NH 居民中，平均年龄为 75 岁，平均血红蛋白 A1c 为 7.0%。在认知状态方面，使用速效胰岛素的 NH 居民比例从重度认知障碍患者的 22.7%到认知正常的患者的 33.9%不等。整体而言，第 31 天的平均每日指尖血糖监测次数为 1.50（标准差 1.73）。与认知状态相比，GLM 类别之间的平均指尖血糖监测次数差异更大。指尖血糖监测次数在 GLM 类别之间差异很大，从每天 0.39 次（无 GLM）到 3.08 次（速效胰岛素），而在认知障碍程度方面略有差异，从 1.11 次（重度认知障碍）到 1.59 次（认知正常）。
NH 居民接受频繁的指尖血糖监测，无论认知障碍程度如何，这表明认知状态在监测决策中只是一个次要因素。未来的研究应该确定在中度/重度认知障碍的 NH 居民中减少指尖血糖监测次数是否可以在不影响安全性的情况下减轻负担。
