What is the immediate management for a nursing home patient with severe hyperglycemia?

Immediate Management of Severe Hyperglycemia in Nursing Home Patients

For a nursing home patient with severe hyperglycemia (>300 mg/dL), immediately assess for diabetic ketoacidosis or hyperosmolar hyperglycemic state and arrange urgent transfer to an acute care facility if present; if the patient is stable without ketoacidosis or hyperosmolarity, initiate subcutaneous insulin therapy with increased glucose monitoring while ensuring adequate hydration. 1

Initial Assessment and Triage

Determine severity and need for transfer:

• Check blood glucose level and assess for symptoms of severe decompensation 1
• In patients with Type 1 diabetes or Type 2 diabetes on insulin with glucose >300 mg/dL (16.5 mmol/L), immediately check for ketosis using urine ketones or blood beta-hydroxybutyrate 1
• If ketosis is present, suspect diabetic ketoacidosis—call emergency services and arrange immediate transfer to intensive care unit 1
• In Type 2 diabetes patients, severe hyperglycemia should raise suspicion for hyperosmolar hyperglycemic state, which presents with variable symptoms including fatigue, confusion, and dehydration; if suspected, check serum osmolality (hyperosmolarity >320 mosmol/L confirms diagnosis) and arrange ICU transfer 1
• Assess hydration status, mental status changes, and vital signs to determine clinical stability 1

Management for Stable Patients Without Ketoacidosis/Hyperosmolarity

Insulin initiation in the nursing home setting:

• For patients without ketosis and stable vital signs, administer subcutaneous rapid-acting insulin analog (lispro, aspart, or glulisine) at 0.1-0.2 units/kg as initial correction dose 1
• Ensure adequate hydration—encourage oral fluids if patient can drink, or arrange IV hydration if available in the facility 1
• Increase glucose monitoring frequency to every 2-4 hours until glucose <250 mg/dL, then every 4-6 hours 1

Ongoing insulin management:

• Once hyperglycemia begins to improve, transition to or continue scheduled basal-bolus insulin regimen rather than relying solely on correction doses 1
• For patients with poor oral intake, use basal insulin (glargine or detemir) plus correction insulin rather than prandial insulin to avoid hypoglycemia 1
• For patients eating regularly, implement basal insulin with prandial rapid-acting insulin given immediately after meals to match actual carbohydrate intake 1

Special Considerations for Nursing Home Population

Avoid common pitfalls in long-term care:

• Never use sliding-scale insulin as the sole regimen—this approach is strongly discouraged and results in poor glycemic control with increased risk of both hyperglycemia and hypoglycemia 1
• In patients with cognitive dysfunction or irregular dietary intake, administer prandial insulin immediately after meals rather than before to match actual food consumption and prevent hypoglycemia 1
• Consider "block testing" (checking glucose at different times on different days) rather than multiple daily checks if frequent monitoring is not feasible, though during acute hyperglycemia, more frequent monitoring is essential 1

Identify and address precipitating factors:

• Investigate potential causes: infections (skin, urinary, respiratory), new medications (especially corticosteroids), acute illness, or medication non-adherence 1
• Assess for comorbidities common in nursing home residents that may complicate management: cognitive dysfunction, depression, physical disability, or poor oral intake 1

Hypoglycemia Prevention

Critical safety measures:

• Establish a hypoglycemia protocol for blood glucose <70 mg/dL (3.9 mmol/L) with immediate treatment using 15-20 grams of oral glucose if patient is conscious and able to swallow 1
• Modify insulin regimen if blood glucose falls below 100 mg/dL (5.6 mmol/L) to prevent progression to hypoglycemia 1
• In patients with renal or hepatic impairment, use lower insulin doses as requirements may be reduced 1, 2

Follow-Up and Transition Planning

Once acute hyperglycemia is controlled:

• Reassess diabetes management targets considering the patient's prognosis, comorbidities, and life expectancy—less stringent targets may be appropriate for terminally ill patients or those with severe comorbidities 1
• Perform medication reconciliation and consider checking HbA1c if not done in previous 3 months to guide long-term management 1
• Document the episode, precipitating factors, and treatment response for future reference 1
• Communicate with the patient's primary care provider regarding the acute event and any changes to the diabetes regimen 1