DIABETES MELLITUS IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE 

 

DISEASE RECOGNITION

·         FBG >150 mg/dL after 8 hours fasting or random BG > 250 mg/dL*

·         With symptoms (polyuria, polydipsia, unexplained weight loss)

·         Weakness, fatigue, blurred vision, periperal neuropathy

·         Disturbed autonomic function (gastroparesis, diarrhea, constipation, urinary incontinence)

·         Vaginal pruritis, candidial infection, skin infection or poorly healing wounds

 

CONTEXT/COMMUNICATION

If the resident is moribund, blood glucose should be loosely controlled with infrequent accuchecks and rainbow coverage only. If the resident is not moribund but has a limited life expectancy, tighter control is the goal with as few accuchecks,FBGs and dietary restrictions as possible.There should be communication by the MD or NP or facility nurse with the health care agent if it would be appropriate to meet the treatment option goal but the resident is noncompliant.

 

ASSOCIATED RISKS

·         History of impaired glucose tolerance

·         Obesity (>120 % desirable body weight)

·         Drugs (Thiazide diuretics, Phenytoin, Glucocorticoids, Estrogens, phenothiazines, other antipsychotics)

 

PHYSICAL EXAMINATION

·         As directed by resident symptoms (see above) to rule out other causes

·         Evaluate for abdominal  or femoral artery bruits

·         Lower extremities: hair loss, pulses, ulcers, capillary refill

·         Absent or decreased vibration and proprioception in feet

·         Absent ankle jerks

 

DIAGNOSTIC WORK-UP

·         CBC with diff.; FBG, BUN, creatinine, electrolytes, albumin (CMP); U/A & UCS; LFTs; HbA1c

 

TYPES OF DIABETES

Type I: Disease involving destruction of pancreatic islet ß-cells resulting in absolute deficiency in Insulin secretion. Produces ketones with hyperglycemia

Type II: Disease involving hyperplastic ß-cells resulting in Insulin resistance and inadequate compensatory Insulin secretory response - rarely  produces ketones with hyperglycemia

IFG: Impaired fasting glucose when FBG is between 110 mg/dL and 125 mg/dL*

 

ADA Diagnostic Criteria for Diabetes Mellitus *

·         FBG > 126 mg/dL

·         RBG > 200 mg/dL + signs and symptoms

·         2 hour postprandial BG > 200 mg/dL

 

TREATMENT OPTIONS

 

TYPE II:

·         Start No Concentrated Sweet diet

·         Weekly FBG, accuchecks ACB & ACS  & postprandial with reporting parameters

TYPE I or II

·         When goal of FBG <150 mg/dL not met with combination oral and/or Insulin in 6-8 months or when liver and/or kidney impairment increase risks from oral medications

 

If inadequate control after four weeks start drug therapy as follows:

·         FBG > 150 and postprandial elevations start Acarbose 25 mg TID with 1st bite of each  meal (avoid in liver disease or if creatinine >2 ) or Prandin 0.5 mg before each meal

·         FBG > 150 alone start Glyburide 1.25 mg QD

·         FBG > 175 start Glyburide 1.875 mg QD 

·         FBG > 250 start Glyburide 2.5 mg QD 

·         Avandia 4mg QD can also be used unless severe HF is present (monitor LFTs and lipid levels)

 

Avoid using thiazolidinediones in patients with significant HF.

Review accuchecks and FBGs weekly and increase meds as needed. If glycemic control is not achieved with monotherapy consider two oral agents from different classes. Increase doses as needed.

If two oral agents ineffective discontinue one and start:

·         Humulin N Insulin 5 units ACB with accuchecks ACB & ACS; continue Glyburide

·         Review accuchecks and FBG every 3-5 days, increase Insulin as needed and/or start sliding scale coverage with Humulin R Insulin

·         Continue until glycemic control is achieved

·         Decrease Insulin if glycemic control achieved

 

We have chosen not to use Glucophage [Metformin] due to the likelihood of impaired creatinine clearance in our frail elderly population.

 

·         Start Humulin N Insulin 12 units ACB and 6 units ACS

 (or 0.5 u/kg/d to 1.0 u/kg/d)

·         Discontinue oral agents if started

·         Order accuchecks ACB & ACS with reporting parameters and weekly FBG

·         Start sliding scale coverage with Humulin R if accuchecks frequently > reporting parameters

·         Review weekly with adjustments accordingly

ONGOING MONITORING

·         No Concentrated Sweets diet. Order HS snack if on BID Insulin

·         Monthly FBG – We typically do not use A1C levels to monitor our resident’s diabetic control since we are not looking for tight control in this population

·         LFTs for Avandia or Actos every 2 months for 12 months.

·         Accuchecks as needed for dosage adjustments with reporting parameters

·         Podiatry, annual eye exam (as tolerated and appropriate)

 

References for Diabetes Mellitus

1.      Butler, RN, Rubenstein, AH et al: Type 2 Diabetes: Causes, complications, and new screening recommendations in Geriatrics, March, 1998, 47-54.

2.      Codario, RA: A guide to combination therapy in type 2 diabetes in Patient Care, April 2003, 16-24.

3.      Dornhorst, A.: Insulinotropic meglitinide analogues in The Lancet, Vol. 358, Novemner 17, 2001, 1709-1712.

4.      Gavin, JR, Reasner II, CA et al: Oral antidiabetics drugs: One size does not fit all in Patient Care, February 15, 1998, 40-68.

5.      Genuth, S, Palmer, J et al: New criteria for diagnosis, screening, and classification in Patient Care, February 15, 1998, 26-39.

6.      Gonsalves, MY: Coordinating care for patients with type 2 diabetes in Patient Care For The Nurse Practitioner, September 2001, 15-36.

7.      Johndrow, PG, Chappell, L: Clinical Management of Type 2 Diabetes in Advance for Nurse Practitioners, August, 2001, 39-44.

8.      Kaplan, D (ed): New diagnostic criteria for diabetes in Patient Care for the Nurse Practitioner, February, 1999, 2-6.

9.      Kaplan, D (ed): Advances in therapy for type 2 diabetes in Patient Care, October 15, 1999, 189-200.

10.  Lardinois, CK: Type 2 diabetes; Glycemic targets and oral therapies for older patients in Geriatrics, November, 1998, 22-39.

11.  Masoudi, FA, Wang Y, et al: Metformin and Thiazolidinedione Use in Medicare Patients With Heart Failure in JAMA, July 2, 2003, Vol. 290, No. 1, 81-85.

12.  Mitzner, L: Selecting the Best Medication for Type 2 Diabetes in The Clinical Advisor, July 2003, 23-26.

13.  Orland, MJ: Diabetes Mellitus in The Washington Manual, 28th Edition, 1995, 437-463.

14.  Reuben, DB, Grossberg, GT et al: Endocrine Disorders in Geriatrics At Your Fingertips, 1998/99 Edition, 108 -111.

15.  Sanders, SL: Diabetes Mellitus Management in Advance for Nurse Practitioners, December 1997, 41-42.

16.  Sinha, B, Nattrass, M: Efficacy of New Drug Therapies for Diabetes in the Elderly in Annals of Long-Term Care, Vol. 9, No. 6, June 2001, 23-29.

17.  Strock, E. et al: Type 2 Diabetes: Gaining Optimal Control With a New Treatment Paradigm in Supplement to Consultant, Vol. 41, No. 13, November 2001.

18.  Quillen, DM, Samraj, G et al: Improving Management of Type 2 Diabetes Mellitus: 2. Biguanides in Hospital Practice, October 15, 1999, 41-44.

19.  Woolf, SH et al: Controlling Blood Glucose Levels in Patients with Type 2 Diabetes Mellitus in Journal of Family Practice, Vol. 49, No. 5, May, 2001, 453-460.

 

MS/8.99
©EMS
Revised 4.04

 

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