Original ResearchTrends in Prevalence, Incidence and Pharmacologic Management of Diabetes Mellitus Among Seniors Newly Admitted to Long-Term Care Facilities in Saskatchewan between 2003 and 2011
Introduction
The prevalence of diabetes mellitus has increased substantially over the past 2 decades, and elderly patients are most commonly affected. Nearly 1 in every 3 Canadians (23% to 29%) aged 75 to 79 years has been diagnosed with diabetes, and many more may have impaired glucose tolerance or undiagnosed disease (1). The 2013 Canadian Diabetes Association (CDA) guidelines advocate for an individualized approach to diabetes management among elderly patients (2). Diabetes medications can cause hypoglycemia, especially among frail elderly patients residing in long-term care facilities (LTCF); thus, management of many elderly patients requires lower treatment intensity to ensure patient safety. Also, medications such as glyburide 3, 4, 5 and insulin have been associated with a substantially increased risk for hypoglycemia 6, 7. Both of these medications should be used cautiously for elderly patients residing in LTCF because the level of frailty observed in these institutions is typically high.
Despite the rising prevalence and high risks for adverse events among frail elderly, the literature describing diabetes epidemiology and management among residents of Canadian LTCFs is limited. In the province of Saskatchewan, diabetes prevalence was found to range from 21% to 25%, depending on the data source (8). A lower prevalence of 17% was reported in a survey of 5 LTCFs in the province of British Columbia (9). Although it is expected that the prevalence of diabetes among LTCF patients is increasing corresponding to community-based estimates, time trends of diabetes in Canadian LTCFs have not been examined previously.
A systematic review of 20 studies with a total sample of 779 707 LTCF residents outside of Canada reported a mean prevalence of diabetes of 18.5% (10). In this systematic review, only 16% of residents with diabetes were managed with oral medications alone (i.e. without insulin), whereas 39% received insulin (alone or in combination with oral antihyperglycemic agents), and nearly half received no antihyperglycemic therapy at all (10). These findings may have been confounded by the use of survey methods rather than electronic databases in the majority of studies examined; certainly, the low rate of oral antihyperglycemic agent use would not be expected in a Canadian LTCF. In contrast, a small Canadian survey of a LTCF reported the use of oral agents without insulin in 30% of residents, whereas insulin use was estimated as 45% (9). However, the data were not confirmed by electronic prescription records, and no information was available to characterize the intensity of insulin therapy used in this small sample.
The aim of our study was to describe trends in the prevalence and incidence of diabetes among patients newly admitted to LTCFs in the province of Saskatchewan between 2003 and 2011, and also to describe the overall use of diabetes medications after LTCF admission.
Section snippets
Data source
This study was based on information derived from health administrative databases from the province of Saskatchewan, Canada. Provincial government health care benefits cover approximately 99% of all residents in Saskatchewan. Excluded persons are those covered by the federal government, such as the Royal Canadian Mounted Police, Canadian Armed Forces and inmates in federal penitentiaries (11). Data from the Institutional Care Home (ISCH) database and prescription drug database as well as person
Results
In all, 44 846 patients were admitted to a LTCF between January 1, 2003, and December 31, 2011. Among these, 14 624 (32.6%) were at least 60 years of age on admission, remained in a LTCF for at least 6 months and were covered under the provincial health plan for at least 2 years before admission without any LTCF admissions during this period (Figure 1). The mean age of patients on their index admission date was 84.1 years (median 85.0 years, SD 7.9) and 64.4% were female.
Discussion
We conducted a descriptive analysis of diabetes prevalence and incidence along with diabetic medication use among a cohort of residents newly admitted to LTCFs in Saskatchewan between 2003 and 2011. Using the CCDSS definition of diabetes, the total number of cases (i.e. incident and prevalent cases) equalled 16.9% of all new admissions to LTCF. However, using a more sensitive definition (i.e. accepting a single diagnostic claim or an antihyperglycemic dispensation), the estimated diabetes
Conclusions
The prevalence of diabetes in Saskatchewan LTCFs is consistent with previous estimates among elderly populations. Overall, medication use appears favourable in the majority of cases as evidenced by substantial use of metformin and declining use of glyburide. Continued observation of LTCFs should be employed to ensure that this growing population receives safe and effective diabetes care. Future research should examine associations between changes in diabetes medication use and clinical outcomes
Author Disclosures
This study is based in part on deidentified data provided by the Saskatchewan Ministry of Health. The interpretation and conclusions contained herein do not necessarily represent those of the government of Saskatchewan or the Saskatchewan Ministry of Health.
Author Contributions
MWA wrote the manuscript; KM contributed to the writing of the manuscript. MWA and XL researched data. KM, LML, GT, YS, AC and DFB contributed to the discussion and reviewed and edited the manuscript.
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