Managing diabetes takes a lot of work for anyone, and older adults living with dementia may have extra difficulties with closely monitoring glucose levels and following prescribed treatments. Caregivers often face challenges in recognizing symptoms of poorly managed diabetes in their loved ones or nursing home residents, which can lead to hospital visits.
Not only are hospital visits expensive, but they also place patients living with dementia at high risk of delirium and new illnesses contracted in the hospital environment. Researchers at the UW and Kaiser Permanente Research Institute are interested in better understanding the factors behind potentially preventable hospital visits and suggesting effective solutions.
A new study, published in the Journal of Gerontology, reports significantly higher rates of potentially preventable hospital admissions related to diabetes symptoms among persons living with dementia, compared with those without dementia. The analysis also shows that placement in nursing homes is a strong predictor of these hospitalizations for this population.
"We found that hospitalizations due to diabetes and urinary tract infections are common in people with dementia, and these hospitalizations might be linked to poor glucose control," said study lead author Oleg Zaslavsky, PhD, MHA, RN, Associate Professor in the UW School of Nursing. "We were surprised to observe 5- and almost 6-fold increased rates of diabetes, urinary tract infections, and dehydration-related hospitalizations in people with dementia compared to their counterparts without dementia. These are high numbers that hard to ignore."
The study population came from the Adult Changes in Thought (ACT), a long-running study to understand risk factors for the development of dementia among older adults in Seattle. The ACT study enrolls participants at age 65 without a diagnosis of dementia, so researchers can get a picture of the health issues that evolve over time in a group of well-characterized individuals, some of whom develop dementia during life and some who do not.
For this study, the researchers selected 565 participants who has been enrolled in the ACT Study for 2 or more years, and who were treated for diabetes with antidiabetic medication.
The researchers collected data on any hospital visits requiring an overnight stay for the participants. They used a classification system from the Agency for Healthcare Research and Quality to determine which hospitalizations were potentially preventable visits. Overall, in the study population, 22% of hospitalizations before dementia and 31% after dementia were classified as being potentially preventable with better primary care management.
This study provides knowledge that may help primary care providers to start earlier diabetes management strategies. The team focused on a clinical measure of glucose levels called HbA1c. “The measure of HbA1c tells me whether diabetes is managed effectively or not,” says Zaslavsky. “High values mean that diabetes is not managed well.” In the study population, poor glucose control (HbA1c >8%) was associated with an increased rate of potentially preventable hospitalizations, relative to more moderate glucose control (7-8% HbA1c), as well as increased rates of visits for dehydration and urinary tract infection when compared with stricter glucose control (<7% HbA1c levels). These findings provide observational data to support the treatment goals in the American Diabetes Association’s Standard of Care recommendations for patients with cognitive impairment and co-existing chronic conditions.
The authors view their findings as an opportunity to envision models of proactive primary care for people living with dementia that focus on frequent monitoring and avoiding complications that lead to hospitalizations. They point to collaborative care models, which use multidisciplinary teams to integrate medical and psychosocial approaches in the care of persons living with dementia and their caregivers.
Real-world implementation of collaborative care models is one of the key recommendations in the recent report Meeting the Challenge of Caring for Persons Living with Dementia and Their Care Partners and Caregivers: A Way Forward. This report, the culmination of a 3- year collaboration among the National Institute on Aging (NIA), Agency for Healthcare Research and Quality, and NASEM, gave advice to federal agencies on implementing select interventions that follow the guiding principles of dementia care, such as person-centeredness, respect and dignity, justice, and accessibility.•
Oleg Zaslavsky, PhD, RN, Onchee Yu, MS, Rod L Walker, MS, Paul K Crane, MD, MPH, Shelly L Gray, PharmD, MS, Tatiana Sadak, PhD, PMHNP, Soo Borson, MD, Eric B Larson, MD, MPH, Incident Dementia, Glycated Hemoglobin (HbA1c) Levels and Potentially Preventable Hospitalizations in People Age 65 and Older with Diabetes, The Journals of Gerontology: Series A, 2021.
This study was supported by funding from a National Institute on Aging (R03AG061305). The Adults Changes in Thoughts study is funded by a National Institutes on Aging Cooperative Grant (U01 AG006781).