Diabetes Management in the Nursing Home Setting: Clinical Tips

Recently, Joanne Schultz, who is an MDH surveyor and a Registered Dietician sent me the following message:

Twice in the last two weeks I have been on a survey where residents who were insulin dependent diabetics were also receiving thickened liquids because they had swallowing difficulties. The products used to thicken liquids and some foods are made from modified food-starch and are metabolized into glucose by the body and may cause a rise in blood sugar for the resident.

In the first instance the resident ran consistently high blood sugars from about 240-290 mg/dl. The facility was monitoring blood sugars every other day and administered a prescribed dose of insulin. When I interviewed the dietitian she stated she did not know about the carbohydrate content of the thickened liquids even though it was clearly labeled on the package. We issued a deficiency at F325.

In the second instance, the resident was running blood sugars in the 400 mg/dl range and was receiving both prescribed insulin and sliding scale insulin as directed. He was originally on pudding thick liquids and graduated to nectar thick liquids. Someone (not the dietitian) noticed the high blood sugars and consistently used the sliding scale insulin. In this case, there was not a deficient practice. I did talk with the dietitian about the extra carbohydrate provided by the thickened liquids.

The amount of extra carbohydrate provided by the thickener will vary depending on how much the liquids and foods need to be thickened and how much liquid is consumed by the resident. It is helpful for the dietitian to know approximately how much carbohydrate the resident is consuming so that she can inform the doctor or nurse practitioner.

The incidents described above highlight the importance of an integrated approach in caring for nursing home residents with diabetes. While there may be other important issues related to the use of dietary supplements and handling nutritional problems, they are used in this context to highlight the importance of communication of changes in blood glucose levels or other related factors among members of the health care team. This is not written for the sole purpose of focusing attention on dietary considerations. Individuals with diabetes will have variable regimens for managing the illness. Basic to the care of diabetes is integration of information about the treatment choice (insulin, oral hypoglycemic agents, diet alone), blood glucose monitoring, physical activities, nutrition and concurrent medical problems.

This “Clinical Web Window” will review each of the variables in diabetes management and will offer some suggestions for providing care to residents with diabetes in long term care. The intent is to review basic clinical principles and the broad spectrum of clinical approaches that may be used for individual residents, not to suggest that there are specific regulatory requirements. Stated differently, the regulations generally require care that meets current standards, no more, no less. This will be dictated by caregivers’ assessment of each individual’s needs as it relates to diabetes and other co-existent factors. This is not intended to be a primer on diabetes care, but rather a refresher to guide long term care practitioners as they review their facility’s approach to care of residents with diabetes. It will also serve to guide MDH staff as they attempt to evaluate situations such as those described above.

Goals for Treatment

In general, the goal is to keep the blood glucose as close to normal as possible as much of the time as possible without excessive risk of hypoglycemia or hyperglycemia. However, the degree to which this treatment goal can be achieved for different individuals varies widely depending on the type of diabetes, type of treatment chosen, other medical conditions, the patient’s understanding of diabetes care and motivation to achieve tight glucose control. In the long-term care setting, it is very helpful to facility staff to have explicit and realistic glucose goals (target ranges), ideally for the individual or, minimally, broad facility guidelines. In the first example sited above, guidelines for glucose levels may have helped nursing staff respond to persistently high glucose levels leading to an assessment of the added carbohydrate intake associated with the supplements or other factors that may have caused unexpected glucose elevations. Importantly, when there are dietary changes or glucose levels repeatedly out of target ranges, there may be a need to adjust medication dosages. The facility attending physicians or nurse practitioners are essential in establishing these parameters for their patients and analyzing other factors that may lead to out of range glucose levels (medications, acute illness and other conditions). Medical Directors can help establish broad glucose guidelines for the overall facility.

Medications

Pharmacologic treatment of diabetes includes a spectrum of different insulin preparations and oral agents. Insulin therapy usually involves a combination of short acting and intermediate or long-acting preparations. When the blood glucose level is not stabilized, a sliding scale may be used to cover glucose levels that are out of established goals for glucose control. Oral agents may be used alone or may be combined with other oral agents or combined with insulin. The specifics of insulin or oral agent dosing are beyond the scope of this “Web Window.” Specific and detailed guidelines are available from AMDA Diabetes Clinical Practice Guideline1. Key parameters for facility staff with respect to diabetes medication, insulin or oral agents are 1) timing of medication administration with food intake and activities, 2) interpretation of blood glucose levels and 3) guidelines for identifying and managing very high (hyperglycemia) or very low (hypoglycemia) glucose levels.

Nutrition

Nutritional guidelines for diabetes care have become liberalized in recent years. Ideally, the diet is tailored to be healthy and to reflect personal preferences. The specific diabetes treatment is then adjusted accordingly. The old “diabetic diet” is no longer a recommended approach in the care of individuals with diabetes, although it may be used when it meets the individual’s needs effectively. There are several guiding principles behind nutritional choices for individuals with diabetes including: 1) maintenance of an ideal body weight, 2) limitation of fat and cholesterol, 3) establishment of goals for glucose levels and on-going monitoring especially if food intake is variable or changing and 4) medication adjustment when glucose levels are outside of target ranges for the individual or if diet changes for any reason (choice, acute illness, treatment of other conditions.) Individuals also are free to exercise personal choice with respect to food selection. Some people with diabetes will make choices based on personal preference that are not necessarily consistent with medical recommendations. It is advisable to provide education and nutritional counseling, but ultimately, the individual may make choices as they wish. In this situation glucose target levels may be higher than optimal.

Exercise

Exercise continues to be an important component of diabetes care. As with medications and nutrition, it must be tailored to the individual’s preferences, abilities and overall medical condition. When an exercise program is initiated, monitoring for the exercise effect on the blood glucose level may reassure the resident and caregivers that the activity can be undertaken safely. Continued monitoring of the glucose level with exercise will usually not be necessary unless the individual experiences marked variations in glucose levels or the amount of exertion changes. It is also important for staff to monitor for signs of hypoglycemia keeping in mind that some individuals who have longstanding diabetes may develop hypoglycemic unawareness. Staff supervising the activity should be aware of residents who have diabetes and the signs of hypoglycemia and should have ready access to a source of glucose to administer if hypoglycemia occurs. If hypoglycemia occurs with exercise or activities, the physician or nurse practitioner should be notified for recommendations (adjusting medications, testing glucose before exercise, pre-treating with a snack, timing of exercise) to minimize problems related to glucose control during exercise. It is usually not necessary to discontinue an exercise program simply because of an episode of hypoglycemia.

Blood Glucose Monitoring

Monitoring regimens for diabetes vary depending on the type of diabetes, the type of treatment and the goals for glucose control. Individuals with diet-controlled diabetes may have the blood glucose tested infrequently (weekly or monthly) with periodic addition of a hemoglobin A1c measurement. Individuals with Type 2 diabetes treated with oral agents may have testing several times/week at varying times with periodic addition of a hemoglobin A1c measurement. Individuals treated with insulin, whether Type 1 or Type 2, will have testing based on goals for treatment and stability of disease. Testing may range from 2 to 4 times/day typically with additional testing when acute illness or when other factors affect the level of glucose control and with periodic addition of a hemoglobin A1c measurement. Attending physicians and nurse practitioners will set the glucose-monitoring schedule according to the specific needs of the individual. In general, the testing frequency increases with attempts at tighter glucose control or when control becomes out of target ranges. People with terminal illness and diabetes may choose to minimize glucose and other types of testing.

Minimally, guidelines for treatment of low and high blood glucose levels occurring acutely and repeatedly are very helpful to staff managing individuals on a day-to-day basis. “Guideline for Diabetes in Long-Term Care Facilities2,” revised in 2000, and the AMDA Guideline1 offer helpful suggestions for handling extremes in blood glucose levels and for developing facility protocols. The former can be obtained from: http://www.health.state.mn.us/diabetes/resources/ltcorderform.html. These guidelines, like all care for individuals with diabetes are not intended to be prescriptive but are intended to give assistance with individualizing care.

Complications

Acute and long-term complications of diabetes are well described in multiple medical sources. Most commonly, acute complications that may occur among long-term care residents include dehydration from persistent glucose elevations, increased susceptibility to infections, falling or confusion from hypoglycemia or hyperglycemia and erratic glucose levels associated with concurrent acute illness. Long-term complications may include acute worsening of underlying chronic complications such as kidney failure, peripheral neuropathy, vascular disease and retinopathy. Because there are myriad acute problems associated with diabetes, all of which cannot be addressed adequately with protocols, it is critical that the facility care team is educated about possible acute complications and works closely with the physician and nurse practitioner as problems arise. It is often important to intervene early when an individual with diabetes develops an acute change of condition which may be manifest as a functional change, may present with clinical symptoms or may first show up as a change in the blood glucose levels. As with all acute changes of condition, the assessment should be geared toward finding the underlying cause of the acute problem.

Summary

In summary, care of the individual with diabetes requires a coordinated approach. Facilities will assist staff in managing care of individuals with diabetes by educating staff, working closely with attending physicians and nurse practitioners and by developing protocols for handling hypoglycemia, hyperglycemia and acute illness.

In the scenarios described, the key failure that occurred in the first situation was lack of planning for added carbohydrates when the nutritional supplement was started and lack of responding to glucose elevations that may have resulted from the additional carbohydrate intake. In the second scenario, although the added carbohydrate in the thickener also wasn’t recognized, the sliding scale gave staff a mechanism for responding to unexpected glucose elevations. While this is a common and often an effective short-term approach, there are other interventions that may have been used in this situation. The key is to have established glucose goals (target ranges) for individuals with diabetes and a process for intervening when the levels are outside of the these goals, short-term or on a repeated basis. The care-giving staff needs to have enough information to know how to react to blood glucose levels that fall outside of acceptable ranges. It is not enough to carry out the glucose testing. Staff should have guidance for when to react to either low or high glucose levels (when to notify the supervising nurse, when to give glucose, when to follow-up with a repeat glucose test, when to notify the physician/NP on an urgent basis or after repeated out of target glucose levels.) While complex, the care of individuals with diabetes can be handled adequately with a combination of individualized care and facility protocols as suggested above. The key is to establish a base of knowledge for staff and establish open communication with the attending physician and nurse practitioner.

Summary Points:

1) Treatment plans vary for individuals with diabetes depending on type of diabetes, concurrent disease and individual needs;
2) Blood Glucose target ranges should be defined and should be realistic for individual residents;
3) Dietary needs will vary for individuals with diabetes and dietary changes may be reflected in BG levels;
4) Nursing staff should have information about parameters for diabetes medications: timing with meals & activities, identifying BG levels that require immediate MD notification vs BG level patterns that require notification on a more routine basis;
5) Exercise for the resident with diabetes should be encouraged and can be managed safely if there is: an awareness of Dx by activity staff, a readily available source of glucose during the activity and staff know when to notify MD/NP about severe hypoglycemia or repeated hypoglycemia during exercise;
6) Facility Protocols for handling hypoglycemia, hyperglycemia and BGs that are persistently out of goal range help staff with day to day management of residents with diabetes;
7) Acute changes in clinical condition may present as blood glucose level deviations suggesting the need for further assessment of the underlying cause.

References:

1) American Medical Directors Association. Managing Diabetes in the Long-Term Care Setting, 2002.
2) http://www.health.state.mn.us/diabetes/resources/ltcorderform.html
3) Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, New York, McGraw Hill, 1999, pp 1001-1011.
4) Funnell MM. Care of the Nursing-Home Resident with Diabetes. Clinics in Geriatric Medicine, 1999; 15 (2): 413-22.
5) Morley JE. An Overview of Diabetes Mellitus in Older Persons. Clinics in Geriatric Medicine, 1999;15 (2): 211-24.
6) Morley JE. The Elderly Type 2 Diabetic Patient: Special Considerations. Diabetic Medicine, 1998; 15(Suppl. 4): S41-46.

July 21, 2004