Insulin Aspart Sliding Scale for an 83-Year-Old Complex Female Patient
For an elderly complex patient with hyperglycemia, a simplified sliding scale for insulin aspart should use premeal glucose >250 mg/dL (>13.9 mmol/L): give 2 units, and for premeal glucose >350 mg/dL (>19.4 mmol/L): give 4 units of insulin aspart. 1
Recommended Insulin Aspart Sliding Scale in mmol/L
| Blood Glucose (mmol/L) | Insulin Aspart Dose |
|---|---|
| <5.0 | No insulin, consider reducing basal insulin |
| 5.0-13.9 | No correction dose needed |
| >13.9 (>250 mg/dL) | 2 units |
| >19.4 (>350 mg/dL) | 4 units |
Rationale and Considerations
Target Blood Glucose Range
- The target blood glucose range for older adults is 5.0-8.3 mmol/L (90-150 mg/dL) 2, 1
- This target is higher than for younger adults to minimize hypoglycemia risk
- Goals may be adjusted based on overall health status and care objectives
Monitoring and Adjustment
- Monitor effectiveness of sliding scale every 24-48 hours 1
- If >2 glucose readings/week are <4.4 mmol/L (<80 mg/dL), decrease basal insulin by 2 units 2
- If 50% of glucose readings are above target, increase basal insulin by 2 units 2
Important Considerations for Elderly Patients
- Hypoglycemia Risk: Elderly patients are at higher risk for hypoglycemia, which can lead to falls, cognitive impairment, and cardiovascular events
- Simplified Regimens: Simplified insulin regimens are preferred for elderly patients, especially those with cognitive impairment 1
- Avoid Bedtime Rapid-Acting Insulin: Do not use rapid-acting insulin (like aspart) at bedtime to avoid nocturnal hypoglycemia 2
Basal Insulin Considerations
- If the patient is also on basal insulin, consider using 70% of total daily dose as basal insulin in the morning 2
- For patients with poor oral intake, use a lower total daily dose (0.1-0.15 units/kg/day) 1
- If initiating basal insulin, start with 0.1-0.2 units/kg/day for elderly patients 1
Common Pitfalls to Avoid
- Using Sliding Scale Alone: Sliding scale insulin alone without basal insulin has been associated with poor glycemic control and increased hyperglycemic events 3, 4
- Aggressive Glycemic Control: Tight glycemic control in elderly patients increases hypoglycemia risk without improving outcomes 5
- Complex Regimens: Overly complex insulin regimens can lead to administration errors and poor adherence in elderly patients 1
- Failure to Adjust: Not adjusting insulin doses based on patterns of glucose readings can lead to recurrent hypo- or hyperglycemia 1
By following this simplified sliding scale approach for insulin aspart while maintaining appropriate basal insulin coverage, you can achieve reasonable glycemic control while minimizing hypoglycemia risk in this elderly complex patient.