Created by: Zankhana Patel, RN, MSN - PowerPoint Presentation

1. Created by: Zankhana Patel, RN, MSN William Osler-Nurse Practitioner Led Outreach Team (NLOT)August 31, 2023

2. Nursing Management of Diabetes in LTC

3. Learning ObjectivesDefine and understand hypoglycemiaIdentify risk factors and signs and symptoms of hypoglycemiaReview data for blood glucose control and complicationsReview hypoglycemia consequences in the elderlyReview best treatment options for the elderly patients with type II diabetes

4. What is Diabetes?Classification of diabetesType 1 diabetes: encompasses diabetes that is primarily a result of pancreatic beta cell destruction with consequent insulin deficiency, which is prone to ketoacidosis. This form includes cases due to an autoimmune process and those for which the etiology of beta cell destruction is unknown.Type 2 diabetes: may range from predominant insulin resistance with relative insulin deficiency to a predominant secretory defect with insulin resistance. Ketosis is not as common.Gestational diabetes mellitus: refers to glucose intolerance with onset or first recognition during pregnancy.(Diabetes Canada Clinical Practice Guidelines, 2018)

5. Canadian Diabetes Association: DiabetesDefinition variesAdministrative guidelines frequently classify people >65 years of age as elderlyBy 2030, number of individual > 65 years of age with DM is expected to increase significantlyAge is associated with a decline in B-cell function(Diabetes Canada Clinical Practice Guidelines, 2018)

6. CDA: Definition of Hypoglycemia The development of autonomic or neuroglycopenic symptoms A low plasma glucose level (< 4.0mmol/L for patients treated with insulin) Symptoms responding to the administration of carbohydrates The severity of hypoglycemia is defined by clinical manifestations Certain hypoglycemia events are more prevalent in elderly patients than in younger population(Diabetes Canada Clinical Practice Guidelines, 2018)

7. Clinical Definition of Hypoglycemia MildAutonomic symptoms present (i.e. palpitations, sweating, nausea, tingling)Moderate Autonomic and neuroglycopenic symptoms (irritability, weakness, lethargy, confusion/delirium, “glassy” stare)SevereComa, seizure Episodes treated with IV dextrose or glucagon, or episodes requiring administration of oral carbohydrate Hypoglycemia unawareness Cognitive symptoms without autonomic Sx(Diabetes Canada Clinical Practice Guidelines, 2018)

8. Symptoms of HypoglycemiaNeurogenic (Autonomic)TremblingPalpitationsSweatingAnxietyHungerNauseaTingling NeuroglycopenicDifficulty concentratingConfusion/deliriumWeaknessDrowsinessVision changesDifficulty speakingHeadacheDizziness(Diabetes Canada Clinical Practice Guidelines, 2018)

9. Risk factors of hypoglycemia Risk FactorsUse of insulin for DM managementMissed or irregular mealsAdvanced ageDuration of diabetesImpaired awareness of hypoglycemia(Diabetes Canada Clinical Practice Guidelines, 2018)

10. Consequences of hypoglycemia Consequences Suboptimal glycemic control Older adults with diabetes fail to perceive hypoglycemic symptoms More likely to be diagnosed with dementia Hypoglycemic episodes in elderly  Risk for falls, delirium

11. Goals of Treatment of HypoglycemiaTo detect and treat low BS level promptly by using an intervention that provides fastest rise in BS to a safe level  Eliminates risk of injury & relieves symptoms quickly.Avoid over treatment  can result in rebound hyperglycemia and weight gain(Diabetes Canada Clinical Practice Guidelines, 2018)

12. Hypoglycemia Management: RecommendationsMild to moderate: treated with oral ingestion of 15g of carbohydrates (3 glucose tabs/gels or orange juice)Wait 15 minutes before retesting BS level and retreat with a another 15g of carbohydrate if BS level remains < 4.0 mmol/L.Severe hypoglycemia in a conscious person  treat with oral agents as noted aboveIf patient unable to swallow by mouth  glucagon injectionSevere hypoglycemia with loss of consciousness  If IV access available, give glucose 10-25g (20-50 mL of D50W) over 1-3 min(Diabetes Canada Clinical Practice Guidelines, 2018)

13. Insulin: Type 2 DM ManagementIf treatment goals have not been reached by oral agents, insulin therapy should be initiated to improve glycemic controlCombining insulin & oral antihyperglycemic agents is shown to be effectiveInsulin may be used as initial therapy in type 2 DM if A1C > 9.0%(Diabetes Canada Clinical Practice Guidelines, 2018)

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15. Types of Insulins Rapid Acting:Rapid Onset: 10-15minsShorter duration of action: 4 hoursNovorapid, Humalog, Apidra Short acting: Regular (Toronto)Rapid Onset: 30 minsShorter duration of action: 6-8 hours(Diabetes Canada Clinical Practice Guidelines, 2018)

16. Types of Insulins Basal: NPH Lantus (glargine), Levemir (detemir)Less nocturnal hypoglycemiaLonger duration of action (compare to NPH)Once daily injection Pre-mix insulin: Twice daily i.e. 30/70, 40/60, 50/50, Novo Mix 30, Humalog Mix 25, Humalog Mix 50

17. Sick days & Diabetes Management Sickness/infection  causes hyperglycemia Increase blood glucose testing Fluid hydration Carbohydrates intake if not eating regular meals May need to adjust baseline doses of insulin NO supplemental insulin (Sliding scale) recommended in LTC Monitoring ketones: Urine/blood

18. Hyperglycemia related to Illness

19. Hyperglycemia

20. Physician/NP Communication: SBARSituation: What is the concern?Background: What do you know?Action/Assessment: What did you do?AssessmentInterventionsRecommendation/Request: What help is needed?

21. ReferencesDiabetes Canada Clinical Practice Guidelines Expert Committee (2018). Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes, 42(Suppl 1): S1-S325.

22. Thank You!