What is the best approach to manage severe hyperglycemia in a nursing home patient?

Management of Severe Hyperglycemia in Nursing Home Patients

For nursing home patients with severe hyperglycemia, a basal insulin or basal plus bolus correction insulin regimen is the preferred treatment approach, with individualized dosing based on the patient's clinical status, nutritional intake, and prior insulin requirements. 1

Initial Assessment and Treatment Algorithm

Step 1: Determine Severity and Clinical Status

• If patient is critically ill or has diabetic ketoacidosis (DKA)/hyperosmolar hyperglycemic state (HHS):
  • Consider transfer to acute care facility
  • For DKA/HHS: Begin IV insulin infusion using validated protocols 2

Step 2: For Non-Critical Hyperglycemia in Nursing Home Setting

• Based on nutritional status:
  • Poor oral intake or NPO: Basal insulin with correction insulin 1
  • Adequate oral intake: Basal-bolus insulin regimen (basal + prandial + correction) 1

Step 3: Insulin Dosing Strategy

• Initial dosing:
  • Calculate total daily dose (TDD): 0.3 units/kg body weight 1
  • For basal-bolus: 50% as basal insulin, 50% as prandial insulin 1
  • Adjust based on renal function (lower doses for renal insufficiency) 1
  • Consider prior home insulin regimen and A1C when available 1

Monitoring and Adjustment

• For patients eating meals: Check blood glucose before meals
• For patients not eating: Check blood glucose every 4-6 hours 1
• Target glucose range: 140-180 mg/dL for most nursing home patients 1, 2
• Adjust insulin doses daily based on glucose patterns 1

Important Considerations

Avoid Common Pitfalls

1. Never rely solely on sliding scale insulin (correction insulin without basal insulin) as this leads to poor glycemic control and increased complications 1
2. Prevent hypoglycemia by:
   • Adding dextrose to IV fluids when glucose reaches 250 mg/dL 2
   • Having readily available treatment (glucose tablets, glucagon) 3
   • Monitoring more frequently in patients with renal insufficiency 1

Special Considerations for Nursing Home Patients

• Type 1 diabetes: Always maintain basal insulin; never hold completely 1
• Older adults: Consider higher glucose targets (up to 180 mg/dL) to avoid hypoglycemia 1, 2
• Insulin pen use: Safe in nursing homes but must follow "single patient use only" guidelines 1

Role of Specialized Teams

• Consult with specialized diabetes or glucose management team when available 1
• Consider nurse-led insulin protocols which have shown improved glycemic control and reduced complications 4

Transition Planning

• When transitioning from IV to subcutaneous insulin:
  • Give first subcutaneous dose 2 hours before discontinuing IV insulin 1
  • Calculate subcutaneous dose based on insulin infusion requirements during previous 6-8 hours 1

Medication Considerations

• In select cases, continuing oral medications like DPP-4 inhibitors may be appropriate 1
• Be aware of drug interactions that may affect insulin requirements:
  • Increased requirements: corticosteroids, thyroid replacement therapy 3
  • Decreased requirements: salicylates, certain antibiotics, antidepressants 3

The evidence strongly supports using structured insulin regimens rather than reactive approaches for managing hyperglycemia in nursing home patients. This approach has been shown to improve outcomes and reduce complications related to both hyperglycemia and hypoglycemia.