No apparent association between glycemic control, outcomes in diabetic nursing home residents
The study included patients 65 years of age and older with type 1 or type 2 diabetes admitted to a Veterans Affairs nursing home, and they were categorized by baseline HbA1c (6.0% to 6.9%, 7.0% to 7.9%, 8.0% to 8.9%, and 9.0% or higher).
Degree of glycemic control did not appear to be associated with persistent functional decline or death in a recent study of Veterans Affairs nursing home residents with diabetes.
Researchers evaluated patients 65 years of age and older who had type 1 or type 2 diabetes and were admitted to 1 of 114 Veterans Affairs nursing homes between Jan. 1, 2005, and Dec. 31, 2011. Patients who were not taking glucose-lowering medications were excluded. The study's primary outcomes were death and persistent functional decline. The latter was determined by the Minimum Data Set (MDS)-ADL score, which examines 7 activities of daily living, each scored from 0 to 4 (0= independence; 4=total dependence), with a total score range of 0 to 28. Persistent functional decline was defined as an increase of 2 points from the baseline MDS-ADL score on 2 consecutive assessments, and linear interpolation was used to determine HbA1c level at the time of MDS-ADL assessments. Four categories of HbA1c were used: 6.0% to 6.9%, 7.0% to 7.9%, 8.0% to 8.9%, and 9.0% or higher. The study results were published online as a research letter by JAMA Internal Medicine on Nov. 21.
The total cohort included 7,459 nursing home residents with a mean age of 76 years. Most (98.2%) were men, just below half (48.8%) had a baseline HbA1c level of 6.0% to 6.9%, and 16.9% had an MDS-ADL score of at least 17, which the study authors noted would indicate a need for extensive assistance with most activities of daily living. A total of 5,101 patients (68.4%) resided in the nursing home for less than 6 months.
The authors found that percentage of patients with functional decline or death during the study period did not differ significantly by baseline category of HbA1c. The adjusted hazard ratio for persistent functional decline with death as a competing outcome was 0.94 (95% CI, 0.80 to 1.10) for patients with an HbA1c of 6.0% to 6.9% at baseline, 0.81 (95% CI, 0.65 to 1.01) for those with an HbA1c of 8.0% to 8.9% at baseline, and 0.88 (95% CI, 0.65 to 1.18) for those with an HbA1c of at least 9.0% at baseline, with a baseline HbA1c of 7.0% to 7.9% as the reference group. Results did not appear to vary by type of glucose-lowering medication or length of nursing home stay.
The study authors concluded that in this national sample of frail Veterans Affairs nursing home residents, glycemic control and persistent functional decline or death were not associated over a 2-year study period. “Our results suggest that an HbA1c level even greater than 9.0% may not increase the risk or persistent functional decline in nursing home residents with diabetes, suggesting that stringent glycemic control is not beneficial for these patients,” the authors wrote.