It’s well-recognised that “diabetic diets” are a thing of the past. This is because dietary restrictions (such as low sugar, low salt, or reduced-fat diets) limit intake and food enjoyment, increase the incidence of malnutrition and ultimately cause harm (Volkert, 2018). Nursing staff now face the conflict of trying to improve a resident’s blood sugars, while residents are encouraged to enjoy a more liberalised diet allowing biscuits, cakes, and other high sugar foods of their preference.
The NZ Society for the Study of Diabetes recommends a relaxed HbAlc target of 54-70mmol/mol where the risks of hypoglycaemia are greater than the benefits of tight control (NZSSD, 2021) for those with reduced life expectancy due to non-diabetic comorbidities, old age and frailty or cognitive impairment, and functional dependency. Consequently, blood glucose targets are also relaxed. An example target range in aged care could be 6 -14mmol/L, avoiding the risk of hypoglycaemia, <4mmol/L.
To improve dietary management for residents with diabetes whilst protecting quality of life and reducing the risk of malnutrition, the following is recommended:
- Menus should offer similar amounts of carbohydrates across the breakfast, midday, and evening meal, to help stabilise carbohydrate intake and improve blood glucose management.
- A carbohydrate & protein-containing snack should be offered prior to bedtime to assist with stabilising blood sugars over the night and into the morning e.g cheese and crackers, yoghurt, wheatmeal sandwiches with protein.
- High fibre options (e.g wheatmeal bread and bran baking as opposed to white bread and white flour products) should be offered throughout the day in place of highly refined carbohydrates. This would be beneficial to all residents.
- Encourage good hydration to manage the increased risk of dehydration experienced by elderly residents with diabetes.
Blood Glucose Monitoring
Blood glucose testing may be needed for residents with fluctuating blood glucose levels. Testing is weighed up against the benefit for diabetes management versus the distress it may cause the resident. It’s acknowledged that nursing staff also have limited time and regular testing can be difficult.
- Whilst it is established that someone has good control, blood sugars should be tested 4 times daily, prior to meals and bedtime. If this is unrealistic, then test fasting and pre-dinner blood sugars at a minimum.
- Request GPs set target blood glucose ranges for individual residents, and give clear instructions on what to do when blood sugars are above or below target.
- Residents on insulin or sulfonylureas who are losing weight should have their blood sugars tested more frequently as weight loss often leads to reduced medication requirements.
Medications and Hypoglycaemia
Residents in aged care can be at an increased risk of hypoglycaemia, particularly those on sulfonylureas and insulin and/or with behaviour- and mood-fluctuations that impact their food intake. This can be managed by:
- Ensuring bolus insulin, mixed insulin or sulfonylureas are given with the first bite or slightly after the meal, but not any earlier. Ensure the resident gets adequate support to finish their meal in a timely manner.
- If a resident frequently does not finish a meal or takes a long time to finish a meal, give the sulfonylureas or bolus insulin at meal completion.
- Ask GP’s for an insulin range to provide to residents at mealtimes, so staff have some guidance.
- Bolus insulin should ideally be titrated according to carbohydrate intake. Consider requesting pictorials from a dietitian to demonstrate the carbohydrate content of meals, and adjust the number of insulin units provided based on the meal and the insulin range provided by the GP or diabetes nurse.
- If a resident does not eat a meal, they do not need bolus insulin.
- For those on mixed insulin, aim to provide the same amount of carbohydrates with each meal. If a resident’s food intake changes, consult the GP immediately.
- Ensure that any instructions to manage hypoglycemia are easily accessible to all staff, and that staff are regularly trained in the management of hypoglycaemia.
- If a resident is alert, always treat a hypo (<4mmol/L) with at least 15g of rapidly absorbed insulin orally (150ml fruit drink, 5 teaspoons of jam, or 8 jelly beans). Take care that hypo treatment provided is appropriate for the resident to chew and swallow easily, considering dentition/dentures.
- Once blood glucose levels are above 4mmol/L, provide a meal containing carbohydrates. Do not provide insulin for this and ensure that they reach their minimum blood glucose target.
- Do not use glucagon to treat hypoglycaemia unless the resident is unable to consume carbohydrates orally.
- Review Sick day management guidelines at nzssd.org.nz
Please note that this advice is generalised and should not replace individualised advice from a doctor, diabetes Nurse Specialist, or registered dietitian.