Burden of Hypoglycemia and Hyperglycemia in Insulin-Treated Veterans Affairs Nursing Home Residents

To avoid potential harms from hypoglycemia, guidelines for diabetes management in nursing home residents recommend less intensive glycemic control. However, it is unknown how often hypoglycemia and hyperglycemia co-occur in the same resident, which may present challenges for deintensification of diabetes treatment.

We conducted a cross-sectional study of insulin-treated Veterans Affairs nursing home residents with diabetes aged ≥ 65 years from 1/1/2016 to 9/30/2019 with a nursing home stay ≥ 7 days. Residents missing fingerstick glucose measurements during the first 7 days were excluded. We classified insulin use as basal insulin only, bolus insulin only, or a combination of basal and bolus insulin. We examined the prevalence of fingerstick-detected hypoglycemia (< 54 mg/dL, 54-69 mg/dL) and hyperglycemia (250-299, 300-349, 350-399, ≥ 400 mg/dL) overall and stratified by type of insulin.

Among 12,031 insulin-treated residents, the mean age was 74.4 years, 98% were male, and 22% were non-White. Most residents (n = 7176, 59.6%) were treated with a combination of basal and bolus insulin, 31.8% (n = 3829) used bolus insulin alone and 8.5% (n = 1026) used basal insulin alone. During the first 7 days of the nursing home stay, 5730 (48%) had hyperglycemia ≥ 250 mg/dL alone, 862 (7%) had hypoglycemia < 70 mg/dL alone, 1488 (12%) had both hyperglycemia and hypoglycemia, and 3951 (33%) had neither hypoglycemia nor hyperglycemia. Residents on a combination of basal and bolus insulin were more likely to have hyperglycemia ≥ 400 mg/dL (10.2% vs. 3.6% for bolus insulin alone and 1.6% for basal insulin alone, p < 0.001) and to have hypoglycemia < 54 mg/dL (8.4% vs. 2.9% for bolus alone vs. 5.9% for basal alone, p < 0.001).

Nearly two-thirds of nursing home residents with hypoglycemia also had hyperglycemia. Efforts to de-intensify diabetes treatment in nursing homes will need to address the high burden of hyperglycemia by tailoring the timing and type of insulin to minimize hypoglycemia while also not worsening hyperglycemia.