This area outlines the diabetes guidelines for elderly residents in long-term care facilities. This is an abridged version developed by the Diabetes Care Program of Nova Scotia¹ in conjunction with the Palliative Care and Therapeutics Harmonization (PATH) Program.

Recommendations

The guidelines advocate for more lenient blood glucose (BG) targets with frailty and make recommendations to avoid excessive blood glucose testing; and to identify, appropriately manage and prevent hypoglycemia.

Blood Glucose (BG) Targets

•  Acceptable BG may be between 10 and 20 mmol/L
• For BG <7.0 mmol/L stop or reduce treatment
• For BG between 7.0 and 9.0 mmol/L consider reduced treatment

A1C Targets

Recommended A1C target is ≥8% and <12%, as long as the resident does not have symptoms of hyperglycemia.

Blood Glucose (Bedside Capillary) Testing

On admission (with a diagnosis of diabetes) – twice daily at alternate times for one to two weeks to establish baseline and determine need to adjust treatment as per recommended glycemic targets

Routine/ongoing (if BG is stable and within liberalized glycemic target range):

• On oral agents or stable doses of basal insulin without regular/rapid insulin – routine testing is usually not necessary.
• On regular/rapid insulin (meal time insulin) – test once daily alternate times (See Clinical Pearl below)

A1C Testing

On admission (with a diagnosis of diabetes) – measure once to establish baseline

Routine/ongoing

• Lifestyle modification only – not more than once/year, but may not be needed at all
• Oral agents/insulin – once or twice/year

Clinical Pearls

• These guidelines do not apply to younger less frail residents of LTC.
• Consider that most oral medications decrease A1C by ≈ 1% when deciding whether and which medications can be stopped.
• More frequent testing may be needed with acute changes in health status, change in oral intake, when adjusting diabetes medications, when starting prednisone and based on clinical judgment.
• Use NPH as basal insulin instead of long-acting insulin analogues such as Lantus® or Levemir® (less expensive with similar outcomes).
• Basal insulin alone (without regular or rapid insulin) may be preferable due to variations in oral intake that can lead to hypoglycemia.
• A1C targets ≥8% and <12% reflects BG of 10-16 mmol/L. Consistent BG measures between 16-20 mmol/L would yield an A1C of 12-14% and an increase in treatment may be indicated.

Click here for a pdf of the information above.

For a full version of this guideline (Phase 1 and 2), go to:

http://diabetescare.nshealth.ca/guidelines-resources/professionals/guidelines/special-populations