(P07) A Sticky Situation: Type 1 Diabetes in Long-Term Care

Introduction: The prevalence of type 1 diabetes mellitus (DMT1) in long-term care (LTC) settings is low compared to type 2 diabetes (~18-30% of all LTC residents). Though people with DMT1 live longer now, many staff are not aware DMT1 requires a different approach than DMT2. Little guidance exists on how to best to manage DMT1 and navigate the challenges imposed by the LTC environment.

Case Description: A 78 year old woman with DMT1, coronary artery disease, peripheral vascular disease status post a recent complicated revascularization, and cognitive impairment was readmitted to skilled rehabilitation after a hospitalization for diabetic ketoacidosis complicated by hypovolemic shock and metabolic encephalopathy. At admission, she was prescribed insulin detemir 30 units at bedtime, 10 units of insulin lispro at breakfast and lunch, 5 units at dinner, along with a sliding scale 4 times a day. This resulted in low fasting glucose levels in the 50s and lunchtime glucose levels in the 500s. Some glucose checks were obtained postprandially, though it was difficult to tell which ones. There was not a recent A1C. The facility does not offer a concentrated carbohydrate diet, and residents may choose from a variety of foods on daily menus. A snack cart containing sweets and chips is brought to rooms in the evening. Candy wrappers were observed in our patient's trash bin. After discussion with her endocrinologist, reviewing her glucose trends and the unique considerations of the LTC setting, her daily basal insulin requirement was divided in half and insulin detemir was administered at 7 am and 9 pm. Preprandial insulin lispro was discontinued. Sliding scale short-acting insulin lispro was to be dosed and given before meals, with the sliding scale at breakfast dosed 3 units higher at each interval than the lunchtime, dinnertime, and bedtime sliding scales which were the same. The need for pre-prandial glucose levels and insulin administration was emphasized. Lunchtime glucose levels came down to 200-300s while the dinnertime glucose level was in the 200s. Fasting glucose levels remained normal or slightly elevated.

Discussion: Multiple guidelines on diabetes management in LTC were reviewed. None contained specific guidance about how to dose insulin or what types of insulin to use in DMT1. The LTC system imposes challenges on DMT1 control: compressed meal schedule, carb content, and acceptable window time for glucose checking (1 hour before to 1 hour after meal). Patient’s nutrition status, dysphagia, dementia, and inconsistent oral intake thwart dosing of rapid insulin. At this time, continuous glucose monitoring is not permitted in LTC, and LTC nurses are not trained to use these devices. Review of her Glucose trend and the unique LTC setting led to these lessons: 1) insulin regimen must be individualized, 2) split the dose of long-acting insulin to allow for adjustment, 3) short acting insulin must be given right before or right after the meal. 4) target glucose level should be relaxed to prevent hypoglycemia in this age group.