Hyperglycaemia

Hyperglycaemia is defined as blood glucose level (BGL) of greater than 15 mmol/L in the older, frail person. Hyperglycaemia has adverse effects on cognitive function, hydration, wound healing, pain and infection risk. Untreated hyperglycaemia increases the risk of hyperosmolar hyperglycaemic state and diabetic ketoacidosis, which are medical emergencies with significant associated morbidity and mortality.

All residents with diabetes should have a blood glucose monitoring plan that tailors frequency and timing to individual need. Hyperglycaemia may be detected through routine checking of BGL.

Additional checking of BGL should occur in any resident with clinical features of hyperglycaemia, including:

1. Polyuria (urinary frequency)
2. Polydipsia (increased fluid intake or thirst - this is often absent in older people)
3. Altered mental state
4. Dehydration
5. Poor wound healing
6. Oral or genital thrush

Regular blood glucose monitoring to identify hyperglycaemia or hypoglycaemia should be undertaken in a resident with diabetes and any of:

1. Recent change to insulin or diabetic medications
2. An intercurrent illness such as infection
3. Recent commencement of medications associated with hyperglycaemia (see practice point 3)
4. Change in usual oral intake or physical activity

Red flags for deterioration or an underlying life-threatening cause / complication in residents with hyperglycaemia should prompt review of Management of unstable residents pathway.

Red flags include:

• Unstable vital signs including altered level of consciousness
• Severe dehydration: review Dehydration and subcutaneous fluids pathway
• Nausea and vomiting
• Deep sighing breathing pattern
• Seizures or development of acute focal neurological change (focal weakness, vision loss or other neurological changes)
• Severe abdominal pain
• Chest pain

The goals of assessment of a resident with hyperglycaemia are to:

A. Identify underlying causes of hyperglycaemia

B. Identify complications of hyperglycaemia

A. Identify the underlying cause of hyperglycaemia:

Examples of considerations include:

B. Identify complications of hyperglycaemia

Hyperglycaemia may be associated with the following complications:

1. Dehydration - review Dehydration and subcutaneous fluids pathway
2. Diabetic ketoacidosis (DKA) - DKA is more common in residents with type I diabetes or in those taking sodium-glucose transporter (SGLT2) inhibitors (e.g. dapagliflozin, empagliflozin or ertugliflozin). It is suspected clinically where there is:
   • BGL greater than 15 mmol/L
   • Blood ketones elevated
   • Dehydration
   • Rapid and / or deep breathing may be present
   • Altered level of consciousness
3. Hyperosmolar hyperglycaemic state - this is more common in type II diabetes. It is suspected clinically where there is:
   • Persistently increasing blood glucose level
   • Dehydration
   • Altered level of consciousness or delirium or focal neurological deficits
   • Seizures (focal or generalised)
4. Electrolyte disturbance - consider blood tests to assess renal function and liver function

Escalate to HHS RaSS at GP discretion if any of:

• Presence of ketones (blood ketone monitoring is preferred as urine ketone monitoring is less accurate):
  • Serum ketones greater than 1.5
  • Urine ketones: moderate / large
• Sweet smelling "acetone" breath
• BGL persistently greater than 15 mmol/L for at least 4 hours despite treatment
• Abdominal pain
• Progressive worsening of dehydration
• Development of acute (or acute on chronic) renal impairment
• Electrolyte disturbance requiring replacement therapy
• Underlying cause that is beyond scope of GP / RACF to manage independently

With GP review / develop individualised diabetes management care plan to address and reduce incidence of hyperglycaemia. Management targets should consider the resident's functional status, life expectancy and comorbidities. The care plan should include guidance for:

• BGL monitoring frequency
  • Tailor monitoring to the individual resident's requirements and goals of care
  • Increase monitoring pre-emptively when residents have an acute illness / change in condition or when medications associated with hyperglycaemia are commenced (see practice point 3)
  • In general, monitoring should occur prior to meals and / or 2 hours after meals

Residents with stable blood glucose levels:

Residents with recent changes to medications:

Residents with unstable blood glucose levels:

• BGL target range
  • Generally 6 to 15 mmol/L is appropriate (with a HbA1C target of up to 8.5 per cent appropriate for frail older persons requiring insulin with a life expectancy predicted at less than 5 years)
• Individual residents' symptoms / signs of hyper- and hypoglycaemia and related management plans
• An individualised sick day plan including adjustment to glucose lowering medication doses. It is important to note that supplementary sliding scale or sporadic top-up insulin dosing is generally inappropriate in older and / or frail persons due to increased risk of hypoglycaemia. Instead, residents may require judicious adjustments to insulin dosing for the duration of their acute illness

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