Resident-Focused and Evidence-Based Management of Diabetes Mellitus in the Nursing Home Setting

Affiliation:

College of Nursing and Health Sciences, Texas A&M University Corpus Christi, Corpus Christi, TX

Abstract: Diabetes mellitus (DM) represents a significant health burden in the United States in terms of increased economic costs, morbidity, and mortality. Improving patient outcomes and reducing costs of DM care in the nursing home (NH) requires an evidence-based, resident-centered, and interprofessional approach. Because of disease progression and medication contraindications in elderly persons, insulin injections are an important part of DM management in the NH setting. Sliding-scale (SS) insulin use is still prevalent in NHs, even though it has been shown to be an ineffective and risky approach when used long term, increasing hypoglycemia risk and leading to possible prolonged periods of hyperglycemia. Transitioning NH patients away from SS insulin toward safer medications, such as basal-bolus insulin, is challenging. This article reviews the safety and efficacy associated with SS insulin use and describes a process for transitioning NH residents away from SS insulin toward safer insulin regimens.

Key words: Diabetes, insulin, sliding-scale insulin, basal-bolus insulin, long-term care, nursing homes.
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Providing care to elderly NH residents with DM is multifaceted and complex, as clinicians often have to manage DM and DM complications in the setting of multiple acute and chronic problems. The complications of DM in elderly persons may include cardiovascular disease, nephropathy, neuropathies, retinopathy, and nontraditional complications of DM and DM treatments, such as falls, adverse medication effects, cognitive dysfunction, depression, urinary incontinence, and pain syndromes.⁵ Further, individuals admitted to the NH often have DM in the presence of one or more acute problems, such as stroke, congestive heart failure, pulmonary disease, end-stage renal disease, infection, and fractures.⁶

Improving the quality of care has the potential to reduce costs and improve patient outcomes in individuals with chronic disease.^7,8 A systematic review of DM management trends in the NH population suggests that DM management according to current evidence-based guidelines may reduce disease progression and complications and improve quality of life.⁷ In many cases, the management of residents’ most pressing medical conditions, rather than the management of their DM, requires medical priority.⁷ Caring for complex NH patients with DM demands a coordinated team approach, as resident outcomes have been shown to improve in this group when a multidisciplinary team approach to disease management is used.⁵ In an effort to improve DM management and resident outcomes, some NHs in the United States have employed nurse practitioners with specialized training as a part of the healthcare team to manage and coordinate DM care.⁹

Insulin therapy is often used in elderly NH residents with DM because of disease progression, diminished beta-cell function, and because of individual contraindications for use of oral antidiabetic agents. Current evidence-based guidelines for managing DM in the NH population encourage resident-centered, individualized care and discourage the long-term use of sliding-scale (SS) insulin.² SS insulin regimens are injections of short- or rapid-acting insulin with doses adjusted according to a scale based on preprandial and nighttime capillary glucose measures. SS insulin has been shown to be ineffective for glucose control, increasing the risk of developing dangerous hypoglycemia or, potentially, causing prolonged periods of hyperglycemia, and increasing the risk of medication errors in elderly individuals.^7,10-13

The frequency of hypoglycemia among the elderly population is not fully understood. Evidence suggests that hypoglycemia occurs much more often than is captured by capillary glucose testing or by the recognition of its signs and symptoms.¹⁴ NH residents are more likely to have cognitive deficits and functional problems that make it more difficult for them to recognize and communicate the symptoms of hypoglycemia to their caregivers. This lack of hypoglycemia awareness can result in unrecognized, untreated, and more severe hypoglycemia in NH residents using insulin.^15,16

This article outlines the safety and efficacy associated with SS insulin use and describes a process for transitioning NH residents away from SS insulin toward safer insulin regimens, such as basal-bolus (BB) insulin. Information regarding goal-setting and individualized care is synthesized to increase practitioner knowledge for clinical decision-making. This practical approach for transitioning away from SS insulin is aimed at helping practitioners improve the quality of DM care and the quality of life of their NH residents.

Sliding-Scale and Basal-Bolus Insulin

The use of SS insulin was first introduced in the 1930s by Elliott P. Joslin, MD. Patients would dip a reagent strip into their urine to evaluate their glucose levels, and the strip would change color according to the level of glucose in the urine. Insulin was dosed according to the color of the reagent strip and this “rainbow” sliding scale was used by patients.¹² During the 1970s, capillary blood glucose testing replaced urine strips to measure glucose levels. The rainbow scale concept was therefore converted to accommodate capillary glucose values instead of strip colors, becoming what is known as variable-dose insulin therapy or SS.^12,17

The literature lacks major studies in the NH population evaluating the safety of different insulin regimens.⁶ This lack of evidence may be due to the exclusion of elderly NH residents from controlled studies because of conditions such as renal failure, frailty, debility, cognitive impairment, and polypharmacy.¹⁸ Although population-specific evidence is limited, the current evidence supports the following facts, which we will discuss throughout the article:

•   SS insulin increases the risk of hypoglycemia in the elderly, especially when used as monotherapy for glucose control, and also increases the risk of prolonged periods of hypergylcemia.^10-13,19,20
•   SS orders do not effectively control blood glucose levels.^{3,10-13,17,19,20}
•   The BB insulin regimen is effective for blood glucose control.^3,12,19
•   An interprofessional team approach to improving DM care is ideal to achieve the best patient outcomes.^5,21

Residents admitted to the NH for rehabilitation and healing often come from noncritical, acute care settings. Because these NH admissions are an immediate step down from a higher level of care, evidence gathered in acute care settings can be relevant to the NH population. A 2007 expert review by Umpierrez and colleagues,¹⁷ for example, found that SS orders are convenient and allow for the timely treatment of hyperglycemia in the inpatient setting. Nurses are able to treat hyperglycemia when it is detected without the need to contact the practitioner for orders. Although SS insulin may be convenient and timely, the authors also found that the risks of SS insulin did not outweigh the potential benefits, concluding that the use of SS insulin is an inappropriate and costly approach to treating DM.¹⁷

SS algorithms are reflective of insulin sensitivity levels and are often categorized as mild, moderate, or aggressive control of hyperglycemia (Table). Insulin dosing starts when glucose levels reach 150 mg/dL. The scales do not treat mealtime carbohydrate consumption. Prescribing insulin to treat hyperglycemia in the absence of carbohydrate intake can lead to hypoglycemia.¹⁰ SS algorithms require repeated injections of insulin for hyperglycemia and can cause hypoglycemia because of “stacking” (ie, the overlapping duration of action of insulin).¹⁰ Additionally, when mealtime insulin treats only hyperglycemia without accounting for carbohydrate intake, the resident can experience persistent and prolonged periods of hyperglycemia.¹² For example, if the resident’s preprandial glucose level is 145 mg/dL, no insulin will be administered according to the SS. When the resident consumes 60 g to 90 g of carbohydrates at mealtime, the postprandial glucose level will rise without insulin coverage.

SS orders have received increasing attention during the past several years, with published articles urgently warning against the use of SS as monotherapy for the treatment of DM in the elderly.^3,20,22 SS has been described as a “medical myth” based on the rationale that the tradition continues to be taught to medical students even though the regimen is not evidence-based.¹⁷ In Caring for the Ages, the magazine of AMDA–Dedicated to Long Term Care Medicine (formerly the American Medical Directors Association), Karl Steinberg, MD, CMD, medical director and CEO, Stone Mountain Medical Associates, Inc, issued a challenge to NHs at the start of 2011 to “stamp out” SS from NH facilities.²³ Further, in 2012, the American Geriatrics Society updated its Beers Criteria for Potentially Inappropriate Medication Use in Older Adults to include a strong recommendation to avoid the use of SS insulin in any care setting because of the increased risk for hypoglycemia without the benefit of improved hyperglycemia management.²⁴ The list of medications included in the Beers Criteria is developed through systematic review and the evaluation of current evidence by an interprofessional panel of experts in geriatrics and pharmacotherapy.²⁴

Despite the mounting evidence showing its harms, SS regimens are still frequently used in NH facilities.²² In 2008, a large study of admissions to a chain of nursing facilities for skilled services revealed that approximately half of the 9804 patients with DM were admitted on SS orders. After admission to the NH, an additional 33% of patients were started on SS orders. In addition, researchers found that SS orders persisted over time, with 83% of patients remaining on SS regimens throughout the average 6-month stay in the facility.²²

The BB insulin approach to managing DM in the elderly NH population improves glycemic control and provides a resident-specific approach to DM management.² This approach more closely matches the natural physiology of pancreatic insulin release.¹¹ Basal insulin injections once or twice daily provide a baseline level of insulin throughout the day, which is similar to normal pancreatic action.¹⁹ The use of basal insulin also reduces the incidence of hypoglycemic events as compared with other types of insulin because basal insulin does not have a true peak action.³ In addition to the basal insulin, mealtime bolus doses of rapid-acting insulin are administered to “cover” postprandial glucose excursion from carbohydrate intake.¹² A drawback to BB insulin is that intensive DM treatments with multiple daily injections of basal and bolus insulin can be painful and may reduce the resident’s perception of his or her quality of life^25,26; however, individualized BB insulin dosing can include as few as one daily basal insulin injection and one daily bolus injection administered around the time of the resident’s largest meal of the day.²⁷

Establishing Outcome Goals for Diabetes Mellitus Management

DM is a chronic, complex disease—even more so in the elderly population, in whom there are wide-ranging individual differences in life expectancy, cognitive function, functional status, length of disease, and treatment preferences.²⁶ People with DM may have differing perceptions regarding the impact of DM treatments on their quality of life. Brown and colleagues²⁸ studied patient perceptions about the effect of DM treatments on quality of life in 332 older, community-dwelling patients. The findings demonstrated that quality of life was negatively impacted by intensive DM treatments, especially when multiple daily insulin injections were included in the treatment plan.²⁸ Because of the individual differences in patient perceptions about the benefits and risks of DM treatments and their effects on quality of life, the patient and his or her caregiver(s) should be involved in all decisions regarding treatment.²⁸

Elderly NH residents with reduced life expectancies may not live long enough to realize the long-term benefits of tight glucose control aimed at preventing micro- and macrovascular complications of DM, such as coronary artery disease, retinopathy, and nephropathy.²⁹ For residents with limited life expectancies (generally <5 years), the early recognition and treatment of glucose excursion and improving quality of life are good outcome goals.⁹ Preventing hypoglycemia and severe hyperglycemia may help to prevent short-term DM complications, such as falls, infections, dehydration, and cognitive dysfunction.¹²

Residents admitted to the NH on a short-term basis for skilled services may benefit from tight glucose control to promote healing and to prevent long-term complications. Current recommendations call for tighter glucose control for the community-dwelling population, with a glycated hemoglobin (HbA_1c) goal of less than 6.5% (average, 140 mg/dL) or less than 7% (average, 154 mg/dL) to prevent long-term vascular complications.^29,30 For the elderly NH resident with limited life expectancy, extensive comorbid conditions, and at significant risk for hypoglycemia, glucose control goals should be individualized. Higher targets for glucose control with HbA_1c levels of up to 8% (average, 183 mg/dL) are considered acceptable in this population.^29,31

HbA_1c is an important and useful tool for evaluating and measuring glucose control, but it has some limitations. Practitioners must consider that age and individual condition can impact HbA_1c levels.³² Some other factors that can influence HbA_1c levels include hemoglobinopathies, race, chronic diseases, and intake of high doses of salicylates and vitamins C and E.^32-34 Conditions that shorten erythrocyte survival, such as hemolytic anemia, will lower HbA_1c values, and conditions that increase erythrocyte age, such as splenectomy or aplastic anemia, will increase HbA_1c values.³³ It is important for practitioners to review the patient’s hemoglobin concentration when evaluating his or her HbA_1c levels, especially when HbA_1c levels are near the diagnostic threshold.³³

A patient’s HbA_1c level is an average measure of his or her glucose levels over 8 to 12 weeks; thus, extreme highs and lows of blood glucose are averaged together. Because HbA_1c is an average, an individual could have an HbA_1c level that is reflective of controlled glucose even in the presence of dangerous hypoglycemia and severe hyperglycemia. To illustrate the limitations of judging glucose control by HbA_1c levels alone, one should compare the two scenarios that follow. In the first scenario, the patient has an HbA_1c of 7.9% and routinely has mild preprandial hyperglycemia (160-180 mg/dL) without hypoglycemia. In the second scenario, the patient also has an HbA_1c of 7.9% and routinely has moderate preprandial hyperglycemia (220-260 mg/dL) with uncaptured nighttime hypoglycemia in the range of 40 to 70 mg/dL. In both scenarios, the HbA_1c levels are at the established goal, yet the second patient demonstrated more severe hyperglycemia with increasing risk for DM complications² and dangerous hypoglycemia.

Evidence-based clinical practice guidelines recommend individualized glucose goals; however, liberalizing HbA_1c goals alone has not been shown to prevent hypoglycemia in residents with overall poor glucose control.^2,14,30 The practitioner should consider preprandial and postprandial capillary blood glucose values along with HbA_1c levels when evaluating glucose control.² While HbA_1c is important, focusing on reducing the incidence of severe hyperglycemia and eliminating hypoglycemia are important outcome goals for DM management in the elderly.⁹ 

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Evidence-Based Approach to Diabetes Mellitus Management in the Nursing Home

The evidence-based American Association of Clinical Endocrinologists (AACE) and American Diabetes Association (ADA) Consensus Statement on Inpatient Glycemic Control¹⁹ single out SS insulin as an ineffective means of managing hyperglycemia in patients with type 2 DM. These two national professional organizations collaborated to review the evidence and update practitioners on diabetes management in noncritical acute care patients. The AACE/ADE consensus statement recommends BB insulin regimen as the evidence-based method for the control of hyperglycemia in inpatients.
AMDA’s population-specific DM clinical practice guidelines encourage a patient-centered approach to DM management with an individualized plan of care. AMDA recommends that SS regimens be converted to safer medications and insulin regimens; however, it states that SS can, in fact, be useful for new admissions, for newly diagnosed DM when a patient’s insulin needs are not known, when there is a change of condition, and when new therapies, such as tube feeding, are added. SS orders should be reevaluated within 1 week of initiation.²

For newly admitted residents with a diagnosis of DM, the practitioner should complete a detailed health history and physical examination. The interview should include questions about the patient’s health history, family health history, home medications, length of disease, glycemic control, frequency of glucose monitoring, hypoglycemia awareness and incidence, and support systems for managing DM at home.⁹ The hospital record and resident/family/caregiver interviews are good sources of information about previous home medications and previous DM control prior to the patient’s admission to the NH. Contacting the practitioner who provided primary care to the resident prior to his or her NH admission may also be useful to understand previous treatments, goals, and level of control.

In addition to the history and physical examination, the initial evaluation should include a record of the patient’s meal intake, current capillary glucose values, and diagnostic testing, including HbA_1c and glomerular filtration rate. When the evaluation period is complete and a clear picture of the individual’s condition, cognitive function, and insulin needs is available, clinical recommendations about the best approach for management can be formulated. Insulin therapy should be considered when oral medications are contraindicated, when incretin-based therapies are not feasible, and when random glucose levels are greater than 180 mg/dL or fasting glucose levels are greater than 140 mg/dL.² Establishing outcome goals will guide the selection of interventions used in the patient’s plan of care. Simplifying DM treatment regimens should be considered and can include transitioning the resident back to his or her previous home medications, transitioning the resident to oral medications, and transitioning the resident from an SS insulin regimen to a BB insulin regimen.³⁵

Developing the DM plan of care according to the individual’s condition, preferences, and participation is well established, supported by evidence, and included in evidence-based guidelines for NH DM management.^2,5,7,29 King’s Transaction Process provides a framework for respectful interaction and goal-setting that can involve the resident and his or her family.³⁶ During the transaction process, information is exchanged between the practitioner and the resident/family about the condition, treatment options, and patient’s preferences.³⁶ In the cognitively impaired elderly individual, the primary caregiver/family members can fully participate in the process.³⁷

As previously stated, goals for the management of DM in the long-term NH resident should be focused on controlling severe hyperglycemia and reducing the risk of hypoglycemia.⁹ Fasting and preprandial glucose values in the HbA_1c range of 7% to 8% would be in the range of approximately 154 to 183 mg/dL. The AMDA clinical practice guidelines include a table for suggested basal insulin dosing adjustments for titration to reduce fasting glucose levels to 100 to 120 mg/dL.² Administering once-daily basal insulin in the morning takes advantage of its duration of action during the daytime hours, when oral intake is present.⁹ Basal insulin will be “wearing off” by the time fasting glucose levels are checked the following morning, thus allowing basal coverage to be maximized.

The total daily dose of basal insulin should be approximately 50% of total daily insulin use.³⁷ Although some individuals can be well managed on basal insulin plus oral medications, treating moderate preprandial hyperglycemia with basal insulin alone is not recommended (>200 mg/dL).¹⁰
If the resident has significant preprandial hyperglycemia, consider initiating rapid-acting insulin at one or more meal(s). As the glucose level becomes more controlled with the addition of mealtime insulin, watch for signs that the basal insulin dose is too high (eg, if the glucose level is lower in the morning than it was the previous evening when no bolus was administered) or too low (eg, if the glucose level is higher in the morning than it was the previous evening without carbohydrate consumption).³⁸

The mealtime insulin dose can include the following two elements: (1) the dose of rapid-acting insulin to cover carbohydrates consumed during the meal; and (2) a correction dose of rapid-acting insulin added to the fixed mealtime dose to treat preprandial hyperglycemia. When converting from SS insulin to BB insulin, the rapid-acting bolus dosage can be calculated by averaging the total daily use of SS insulin and dividing the average into three divided mealtime doses. Covering mealtime carbohydrate consumption is a proactive approach to glucose management and helps to prevent hyperglycemia. When carbohydrate consumption is not covered with bolus insulin, glucose may rise after the meal, requiring larger amounts of insulin at the subsequent meal. Carbohydrate counting has been facilitated in some NHs with a system of meal preparation that delivers carbohydrates in 15-g portions.⁹ For the frail elderly NH population with varying levels of endogenous insulin production and insulin resistance, the carbohydrate-to-insulin ratio varies.^35,38

For mealtime insulin coverage, the differences between rapid-acting and short-acting insulin onset, peak, and duration of action must be considered. Mealtime insulin doses—typically administered every 4 hours—can overlap one another.³⁹ When episodes of moderate hyperglycemia occur, an insulin correction dose scale provides a means for nurses to treat hyperglycemia. Diet-related hyperglycemia, for example, may occur when the resident goes to a restaurant, when snacks are brought into the NH, or when there is a holiday activity involving higher consumption of carbohydrates. Practitioner notification parameters should be established for severe hyperglycemia. The AMDA clinical practice guidelines recommend that the practitioner be notified as soon as possible when the patient’s glucose level is greater than 250 mg/dL in the presence of a change in condition or if his or her glucose level is greater than
300 mg/dL on two consecutive finger sticks.² For mild to moderate hyperglycemia, an individualized correction scale can be provided to treat the elevated glucose without the need to call a practitioner for orders. The correction dosing scale may look familiar to NH staff, as it can look like a “mini” SS. Because the correction scale is individualized, it will look different for each person. The following is an example of what mealtime insulin coverage could look like: two units of insulin aspart subcutaneous injection three times daily before meals; for glucose 180 to 250 mg/dL, add 2 units (total 4 units); for glucose 251 to 350 mg/dL, add four units (total six units); call for glucose >350 mg/dL. The amount of insulin needed to correct hyperglycemia guides the practitioner in making adjustments to fixed mealtime insulin dosages.²

To create an individualized correction dose scale for rapid-acting insulin to be added to the fixed mealtime dose to treat preprandial hyperglycemia, one should calculate a correction factor (CF). A CF is a relative measure of individual insulin sensitivity that helps the practitioner to estimate the glucose response when one unit of insulin is administered. To calculate a CF, add the total daily dose of insulin (both basal and mealtime insulin) and then divide by a correction rule number. The correction rule number varies, depending on the type of insulin and the level of glycemic control.³⁹ The AMDA clinical practice guidelines recommend CF calculation using the Rule of 1500.² See the Figure for the formula and application of this calculation.² 

The monitoring and evaluation of the individual response to insulin will provide the practitioner with a clear picture of individual insulin needs that can be used to create safe, individualized insulin orders. The frequency of monitoring of capillary blood glucose levels in the NH should be based on the individual insulin regimen and the risk for hypoglycemia.⁸ Intensive insulin therapy increases the risk of hypoglycemia, and more frequent monitoring may be needed. Practitioner monitoring of capillary glucose values is important for evaluating the progress toward one’s goals and for deciding the frequency of testing.⁴⁰

Conclusion

Although the long-term use of SS insulin is not supported by evidence for the NH population, it is still frequently being used in many NHs in the United States. The AMDA clinical practice guidelines recommend transitioning residents away from SS insulin to reduce the risk of hypoglycemia and to improve overall glucose control. When individuals are admitted to the NH, they often have complex and pressing medical problems that take priority over the care of their DM, which may explain why SS orders persist over time. Transitioning residents from SS insulin to safer medications in the midst of more pressing problems requires a team approach. Some NHs are beginning to employ a specialized nurse practitioner to manage and coordinate DM care among residents. As part of the healthcare team, the nurse practitioner can work to improve resident outcomes through goal-setting, disease management, communication, and care coordination.

NH residents are often admitted from acute care settings with SS insulin orders and their home medications discontinued. For residents admitted to the NH for short-stay skilled services, aiming to control glucose for healing and prevention of long-term complications are the priority for DM care. Simplifying DM treatment regimens in preparation for discharge to home begins at admission and includes transitioning away from SS insulin to safer medications and insulin regimens. For those residents who live in the nursing home, reducing hyperglycemia, preventing hypoglycemia, and improving their quality of life should be the goal of DM care. The simplification of DM treatment regimens to improve individual perceptions about quality of life and reduce risks of intensive treatments is the priority. Improving the quality of care and health outcomes in the NH population reduces patient suffering and has the potential to reduce the costs of DM care.

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Disclosures: The author reports no relevant financial relationships.

Address correspondence to: Cristi Day, DNP, FNP-C, RN, ADM-BC, Assistant Professor, College of Nursing and Health Sciences, Texas A&M University Corpus Christie, 6300 Ocean Drive 344, Corpus Christi, TX 78412; cristi.day@tamucc.edu