Sinclair, Alan J; Gadsby, Roger; Penfold, Sue; Croxson, Simon C M; Bayer, Antony J. Diabetes Care
24. 6 (Jun 2001): 1066-8.
24. 6 (Jun 2001): 1066-8.
ABSTRAK
OBJECTIVE
- To determine the prevalence of known and undetected diabetes
diagnosed either by an elevated fasting baseline sample or by a 2-h
post-glucose load sample in a group of residents of care
homes in an urban-district setting.
RESEARCH DESIGN AND METHODS - We completed individual interviews with patients and
caregivers in 30 care homes (both residential
and nursing homes) in two metropolitan
districts of Birmingham, West Midlands, U.K. All care
homes were under the supervision of primary care
physicians (general practitioners). We carried out 75-g oral glucose tolerance
tests (OGTTs) in consenting residents without previous known diabetes. Criteria for diagnosis of diabetes Were obtained from the World Health
Organization (1998) and the American Diabetes
Association (1997) .
RESULTS
- Of 636 residents available for study, 76 residents (12.0%) were known to have
diabetes; of the 560 remaining residents, 286
either refused to participate or were deemed too ill or unavailable to undergo
testing. Complete data on 274 OGTTs were obtained (median age 83 years, range
45-101). A total of 46 subjects were diagnosed as having diabetes and 94 as having impaired glucose
tolerance. Allowing for subjects who refused or were unable to participate, the
calculated total prevalence (which includes known and newly detected diabetes) was 26.7% (95% CI 21.9-32.0). The
calculated overall prevalence of impaired glucose tolerance was 30.2%
(25.2-35.6).
CONCLUSIONS
- In a group of care home residents not known
to have diabetes and able to undergo testing,
a substantial proportion have undetected diabetes
based on a 2-h postglucose load. These residents warrant further study as they
may be at higher cardiovascular risk and require an intervention.
Diabetes Care 24:1066-1068, 2001
Abbreviations: IGT, impaired glucose
tolerance; OGTT, oral glucose tolerance test. In the U.K., current care home practices do not include screening for diabetes either at the time of admission or
subsequently thereafter. A view often expressed is that diabetes screening in older subjects is not justified, as the
benefits of therapeutic intervention and life expectancy are substantially
reduced (1). Nevertheless, a large proportion of residents newly diagnosed with
diabetes are likely to have vascular
complications that can deteriorate significantly during a 1-2 year period,
which reflects their average duration of stay (2). In addition, undiagnosed diabetes in residential care
may be a risk factor for the development of hyperosmolar nonketotic coma and
increased mortality (3,4).
Few studies have investigated the
prevalence of diabetes in residential care settings. In the U.S., the National Nursing Home Survey (5) estimated that 14.5% of nursing home residents had diabetes;
of these residents, 75% were >=74 years of age. A more recent study in a
public longterm care facility in Rochester,
NY, has suggested a prevalence of ~21% (6). In the U.K., two observational
studies of residents in residential care have
reported the prevalence of known diabetes to
be 7.2 and 9.9%, respectively (2,7), but these studies may underestimate the
true prevalence because they did not include objective testing of glucose
tolerance. The differences in prevalence rates of known diabetes between the U.K. and the U.S. also reflect the
well-recognized differences in the populations as a whole (8,9).
We therefore decided to investigate
the prevalence of known and undetected diabetes
diagnosed either by the fasting baseline sample or by the 2-h post-- glucose
load sample in a group of residents of care homes
in an urban-district setting.
RESEARCH DESIGN AND METHODS- Subjects were residents of care
homes (nursing and residential) in two multiethnic districts of
metropolitan Birmingham. Residential homes
provide personal and social care only, and
residents are usually mobile and continent. Residents in nursing homes have much higher levels of dependency and may
have physical and mental disabilities: they require 24-h nursing care. A total of 37 care
homes were potentially available for study within both districts, but 7
of them either refused or were unable to participate because of closure or
refurbishment. In the 30 participating care homes,
there was 92% occupancy, with 636 residents.
Detailed examination of medical
records and treatment charts confirmed the presence of diabetes
in 76 residents, giving a 12% prevalence of known diabetes.
Subjects without a history of diabetes were
considered for an oral glucose tolerance test (OGTT) that consisted of a 75-g
anhydrous glucose load (115 ml Hycal), given after a confirmed overnight fast.
Fasting and 2-h postchallenge capillary plasma glucose samples were taken and
analyzed using a glucose-oxidase method. Confirmatory testing was not
performed.
Data from the OGTTs were analyzed
using World Health Organization (1998) (10) and American Diabetes Association (1997) (11) diagnostic criteria
for fasting and 2-h capillary plasma samples. For capillary glucose levels,
these are as follows: diabetes, fasting
glucose >=7.0 mmol/l or 2-h value >=12.2 mmol/l; impaired glucose
tolerance (IGT), fasting glucose <7.0 mmol and 2-h value 8.9-- 12.1 mmol/l;
and impaired fasting glucose, fasting glucose 6.1-6.9 mmol/l and 2-h value
<8.9 mmol (if measured) (Table 1) . The method used to calculate overall
prevalence was based on our previous study (9). Assuming that subjects not
tested had a prevalence of diabetes similar to
those who were tested, it is possible to calculate the prevalence and 95% CIs
for various categories of glucose intolerance for the entire population (9). A
proportion of the known diabetic subjects equivalent to the ratio of
"subjects tested to all samples eligible for testing" was added to
the total tested sample, and this set of data was used for the denominator in
the prevalence calculations in a standard fashion. The prevalence would be the
same without this data manipulation, but this is necessary to give realistic
95% CIs. The alternative approach is to assume that all subjects not tested
either had or did not have each of the diagnostic labels, which gives very wide
(not 95%) CIs that encompass the true population prevalence but are too wide to
be meaningful. The results are given in Table 2. These values were calculated
using standard methods (Arcus Pro-Stats 3.25; Medical Computing, Aughton, U.K.).
In view of the small numbers, subgroup analyses are not reported.
RESULTS
- A total of 58 residents refused to consent to OGTT without providing a
reason, and in another 227 cases, permission to participate was denied by the care home manager, the matron, or the next of kin on
the basis of extreme frailty or acute illness. One resident died before the
OGTT was undertaken. The demographic characteristics of consenting subjects
were similar to those of the general care home
population in the U.K. (12), and the authors were not aware of any obvious
differences between subjects who consented and subjects who did not. Complete
data on 274 OGTTs (median age 83 years, range 45-101) were available. There
were 50 male white subjects (median age 79 years), 179 female white subjects
(median age 86 years), 17 male nonwhite subjects (median age 72 years), and 28
female nonwhite subjects (median age 74 years).
The results of the 274 OGTTs are
presented in Tables 1 and 2. The raw data presented in Table 1 shows that the
majority of positive diagnoses for diabetes
are derived from elevated 2-h glucose values (n = 43), and only three residents
had a purely elevated fasting capillary value >7.0 mmol/l. The calculated
total prevalence is reported in Table 2. The actual prevalence of known diabetes was 12.0%, whereas the calculated total
prevalence (based on the method reported in reference 9) was 26.7%. The
calculated overall prevalence of IGT was 30.2%. Only one subject had impaired
fasting glucose according to the criteria previously stated. No significant
differences were found between residential and nursing homes
in prevalence rates of diabetes.
CONCLUSIONS
- In this study of care homes, we found a 12%
prevalence of known diabetes. This value is
similar to figures reported in two previous studies of institutional settings
in South Wales and North West England (2,7) and compares with a 6.0% prevalence
rate in community-dwelling older subjects in the U.K. (9). By following OGTTs
of approximately half of the remaining residents without known diabetes, it was calculated that at least one in
four residents of residential and nursing homes
meet diagnostic criteria for diabetes, and
overall about one in two residents appear to have an abnormality of glucose
tolerance. The particular problems of recruitment and consent for conducting
research in long-term care settings have been
widely acknowledged (13,14), and in our study, a large number of residents were
unable to participate. However, the prevalence of diabetes
among these subjects is unlikely (because of medical illness and/or frailty) to
be lower than that of subjects tested. Indeed, we believe that we are more
likely to have underestimated rather than overestimated the true prevalence of diabetes.
Based on fasting glucose level, the
majority of residents tested would be classed as nondiabetic, but postchallenge
hyperglycemia may have significance in defining a group of individuals at high
cardiovascular risk, who may also have an elevated mortality rate, as recently
demonstrated in the DECODE study (15), which may be especially important in
older subjects (16). The clinical significance of detecting IGT in this
population of institutionalized subjects is uncertain, as is the relationship
between these findings and the likely risk of microangiopathy. However, it is
possible that residents with newly detected diabetes
will benefit from early treatment of raised glucose levels by experiencing
reduction of osmotic symptoms, improvement in cognition (17), and assessment of
any vascular complications. Whereas these actions are unlikely to lead to an
increase in life expectancy of diabetic residents, they may add some value to
their quality of life.
Screening for diabetes in
the absence of specific intervention data involving diabetic residents in care homes is currently unjustified in the absence
of proven benefits. However, we do suggest that further studies be warranted,
especially in view of the likelihood that a high prevalence of undetected diabetes is present.
Acknowledgments- We thank Mary
Holden for her meticulous efforts in coordinating the study in the care homes.
REFERENCES
1. Patterson KR: Population
screening for diabetes mellitus: report of the
British Diabetic Association. Diabet Med 10:777-- 781, 1993
2. Sinclair AJ, Allard I, Bayer A:
Observations of diabetes care in long-term
institutional settings with measures of cognitive function and dependency. Diabetes Care 20:778-784, 1997
3. Grobin W: A longitudinal study of
impaired glucose tolerance and diabetes
mellitus in the aged. J Am Geriatr Soc 37: 1127-1134, 1989
4. Wachtel TJ, Tetu-Mouradjian LM,
Goldman DL, Ellis SE, O'Sullivan PS: Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode
Island. J Gen Intern Med 6:495-502, 1991
5. National Center for Health
Statistics: The National Nursing Home Survey
1977. In Summary for the United States Hyattsville, MD. Washington, DC, U.S.
Govt. Printing Office, 1979 (DHEWH publ. No. PHS-- 79-1794; Vital and Health
Statistics, Set. 3, no.143)
6. Tariot PN, Ogden MA, Cox C,
Williams TF: Diabetes and dementia in
long-term care. JAm Geriatr Soc 47:423-429,
1999
7. Benbow SJ, Walsh A, Gill GV: Diabetes in institutionalised elderly people: a
forgotten population? BMJ 314:1868-1869, 1997
8. Harris MI, Flegal KM, Cowie CC,
Eberhardt MS, Goldstein DE, Little RR, Wiedmeyer H-M, Byrd-Holt DD: Prevalence
of diabetes, impaired fasting glucose, and
impaired glucose tolerance in U.S. adults: the Third National Health and
Nutrition Examination Survey, 1988-1994. Diabetes
Care 21:518-524, 1998
9. Croxson SCM, Burden AC, Bodington
M, Botha JL: The prevalence of diabetes in
elderly people. Diabet Med 8:28-31, 1991
10. Alberti KG, Zimmet PZ:
Definition, diagnosis and classification of diabetes
melitus and its complications. Part 1: Diagnosis and classification of diabetes mellitus provisional report of a WHO
consultation. Diabet Med 15:539-553, 1998
11. The Expert Committee on the
Diagnosis and Classification of Diabetes
Mellitus: Report of the Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus. Diabetes
Care 20:1183-1197, 1997
12. Crawford VLS, Beringer TRO,
Stout RW: Comparison of residential and nursing home
care before and after the 1993 community care
policy. BMJ 318:366, 1999
13. Hoffman P, Marron KR, Fillit H,
Lobow LS: Obtaining informed consent in a teaching nursing home. J Am Geriatr Soc 31:565-569, 1983
14. Ouslander JG, Schelle JF:
Research in nursing homes: practical aspects.
J Am Geriatr Soc 41:182-187, 1993
15. The DECODE Study Group on Behalf
of the European Diabetes Epidemiology Group:
Consequences of the new diagnostic criteria for diabetes
in older men and women: the DECODE Study (Diabetes
Epidemiology: Collaborative Analysis of Diagnostic Criteria in Europe). Diabetes Care 22:1667-1671, 1999
16. Shaw JE, Hodge AM, de Courten M,
Chitson P, Zimmet PZ: Isolated post-challenge hyperglycaemia confirmed as a
risk factor for mortality. Diabetologia 42:1050-1054, 1999
17. Gradman TJ, Laws A, Thompson LW,
Reaven GM: Verbal learning and/or memory improves with glycaemic control in
older subjects with non-insulin-dependent diabetes
mellitus. J Am Geriatr Soc 41:1305-1312, 1993
AUTHORAFFILIATION
ALAN J. SINCLAIR, MD, FRCP1
ROGER GADSBY, MB2
SUE PENFOLD, MB5
SIMON C.M. CROXSON, MD, FRCP3
ANTONY J. BAYER, MB4
From the 1Diabetes Research Unit,
Selly Oak Hospital, University of Birmingham, Bimingham; 2Red Roofs Surgery,
Nuneaton; the 3Department of Medicine for the Elderly, Bristol General
Hospital, Bristol; the 4Department of Geriatric Medicine, University of Wales
College of Medicine, Llandough Hospital, Penarth; and 5the Department of
Primary Care Medicine, the Ladywood Project,
U.K.
Address correspondence and reprint
requests to Prof. AJ. Sinclair, Professor of Medicine and Consultant
Diabetologist, Diabetes Research Unit, Centre
for Health Services Studies (CHESS), University of Warwick, Coventry CV4 7AL,
U.K. E-mail: a.j.sinclair@bham.ac.uk.
Received for publication 22 August
2000 and accepted in revised form 23 February 2001.
A table elsewhere in this issue
shows conventional and Systeme International (SI) units and conversion factors
for many substances.
MeSH Aged, Aged, 80 & over, Blood Glucose --
metabolism,
Diabetes Mellitus
-- diagnosis,
England --
epidemiology,
Family Practice, Glucose Intolerance
-- diagnosis,
Glucose Tolerance
Test, Humans, Middle Aged, Nursing Homes --
statistics & numerical data, Patient
Participation,
Prevalence, Treatment Refusal, Urban Population, Diabetes Mellitus
-- epidemiology
(major), Glucose Intolerance
-- epidemiology
(major), Residential
Facilities -- statistics & numerical data (major)
Title Prevalence of diabetes in care home
residents
Pages 1066-8
Number of pages 3
Publication year 2001
Publication date Jun 2001
Year 2001
Place of publication Alexandria
Country of publication United States
ISSN 01495992
CODEN DICAD2
Source type Scholarly Journals
Language of publication English
Document type PERIODICAL
Accession number 11375372
ProQuest document ID 223041925
accountid=62690
Copyright Copyright American Diabetes
Association Jun 2001
Last updated 2011-04-06
Database ProQuest Agriculture Journals
ANALISA 5W + 1H
2.
WHERE : di dua
kabupaten metropolitan Birmingham, West Midlands, U.K
3. WHEN : (6 Juni 2001)
4.
WHY :
Untuk menentukan prevalensi diabetes dikenal dan tidak terdeteksi
didiagnosis
baik oleh sampel awal puasa atau ditinggikan oleh sampel 2h pasca-glukosa beban
dalam kelompok
5.
WHAT :
prevalensi dari diabetes warga perawatan rumah ( prevalence
of diabetes in
care home residents )
6. How :Kami menyelesaikan wawancara individu
dengan pasien dan perawat di 30 rumah perawatan (rumah baik perumahan dan
menyusui) di dua kabupaten metropolitan Birmingham, West Midlands, Inggris
Semua rumah perawatan berada di bawah pengawasan dokter perawatan primer
(dokter umum) . Kami melakukan 75-g tes toleransi glukosa oral (OGTTs) dalam
menyetujui warga tanpa diabetes yang dikenal sebelumnya
