From the Guidelines
For patients with impaired glucose regulation who cannot count carbohydrates due to living in an assisted living facility, a fixed-dose insulin regimen is the next best option. This approach is supported by the American Diabetes Association's 2016 standards of medical care in diabetes, which emphasize the importance of timely dose titration and adjustment of both basal and prandial insulins based on self-monitoring of blood glucose (SMBG) levels 1. A typical regimen might include a long-acting basal insulin (such as insulin glargine 10-20 units once daily) combined with fixed doses of rapid-acting insulin (like insulin aspart or lispro 4-8 units) before each meal. Some key points to consider when implementing a fixed-dose insulin regimen in an assisted living facility include:
- Training facility staff to recognize and treat hypoglycemia with 15-20 grams of fast-acting carbohydrates, followed by blood glucose rechecking after 15 minutes
- Regular blood glucose monitoring (before meals and at bedtime) to adjust insulin doses gradually based on patterns rather than individual readings
- Standardizing meal timing and content to simplify administration and reduce the need for individualized decision-making
- Considering the use of basal insulin analogues, such as glargine, detemir, or degludec, which have been shown to be effective in improving glycemic control 1 By implementing a fixed-dose insulin regimen, patients with impaired glucose regulation who cannot count carbohydrates due to living in an assisted living facility can achieve reasonable glucose control and reduce the risk of hypoglycemia and other complications.
From the Research
Alternatives to Carbohydrate Counting
Given the challenges in counting carbohydrates in an assisted living facility, the next best option for managing insulin therapy would be to consider alternative approaches that do not rely on precise carbohydrate counting. Some of these alternatives include:
- Using insulin analogs, which can provide a more predictable and consistent insulin effect, reducing the need for precise carbohydrate counting 2, 3
- Implementing a simplified meal announcement approach, which has been shown to be a viable alternative to carbohydrate counting, particularly for individuals who find carbohydrate counting burdensome 4
- Considering factors beyond carbohydrates, such as protein and fat content, when determining mealtime insulin doses, as these can also impact postprandial glucose levels 5
Insulin Management Strategies
In the absence of carbohydrate counting, insulin management strategies can focus on:
- Using basal insulin analogs, which can provide a longer duration of action and less variability in insulin effect 2, 3
- Adjusting insulin doses based on the protein and fat content of meals, as well as the timing of mealtime insulin doses 5
- Utilizing advanced insulin management systems, such as hybrid closed-loop systems, which can help optimize insulin delivery and glucose control 4
Clinical Considerations
When implementing alternative approaches to carbohydrate counting, it is essential to consider individual patient factors, such as: