Hypoglycaemia

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Hypoglycaemia is associated with increased morbidity and mortality in residents of aged care facilities. Early diagnosis and establishing a management plan concordant with the residents goals of care may avoid preventable suffering.

Flowchart

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Practice points

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  • Hypoglycaemia is defined as blood glucose level (BGL) of less than a resident's target range, or low enough to cause symptoms. The target range for BGL in the older person with diabetes should be individualised, however, 6 to 15 mmol/L is generally acceptable. Hypoglycaemia is associated with increased morbidity and mortality. It may be associated with major cardiovascular events or falls and adversely affects temperature regulation, cognitive function and quality of life.

    For the purpose of this pathway, hypoglycaemia is defined as:

    1. BGL less than 4.0 mmol/L in any resident or
    2. BGL of 4.0 to 5.9 mmol/L where the resident has symptoms or signs of hypoglycaemia.

    Symptoms of hypoglycaemia may include:

    1. Dizziness
    2. Weakness
    3. Headache
    4. Palpitations
    5. Anxiety
    6. Vision changes
    7. Hunger
    8. Tingling sensation around the mouth

    Signs of hypoglycaemia may include:

    1. Pale appearance
    2. Flushed face
    3. Sweating or shaking
    4. New onset confusion or behaviour change (this may include aggression or irritability)
    5. Balance disturbance and falls
    6. Seizure
    7. Altered level of consciousness or coma

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

    Red flags include:

    • Unstable vital signs including altered level of consciousness
    • Nausea and vomiting
    • Seizures or development of acute focal neurological change (focal weakness, vision loss or other neurological changes)
    • Concurrent severe abdominal pain
    • Concurrent chest pain
    • Resident with recurrent hypoglycaemia less than 4 mmol/L and resident has been administered a long-acting sulphonylurea (e.g. glibenclamide) within the last 24 hours

  • Note: low sugar or sugar-free options are NOT appropriate

    Fast-acting carbohydrates

    Resident's usual dietOptions for fast-acting carbohydrates
    Normal
    • 100 mL Lucozade
    • 1 serve Poly Joule (3 scoops)
    • 150mL lemonade or other soft drink
    • 3 teaspoons sugar dissolved in 50 mL water
    • 7 small or 4 large glucose jellybeans
    • 150 mL orange juice
    • 30 mL cordial mixed with 150 mL water
    • 250 mL Gatorade or Powerade sports drink
    Thickened fluids
    • 1 tube pre-prepared thickened cordial
    • 3 individual serves jam
    PEG tube (via tube)
    • 100 mL Lucozade
    • 1 serve Poly Joule (3 scoops)
    • 150 mL orange juice
    • 30 mL cordial mixed with 150 mL water

    Slow-acting carbohydrates

    Resident's usual dietOptions for slow-acting carbohydrates
    Normal
    • 250 mL milk
    • 1 tub (200g) yoghurt
    • 1 slice bread
    • 2 sweet plain biscuits
    • 1 piece fruit
    • Next meal (if due within 20 minutes)
    Thickened fluids
    • 1 tub pureed fruit
    • 1 serve thickened milk drink
    PEG tube (via tube)
    • 150 mL enteral feed

  • The goals of assessment of a resident with hypoglycaemia are to:

    A. Identify underlying causes of hypoglycaemia

    B. Identify complications of hypoglycaemia

    A. Identify the underlying cause of hypoglycaemia

    Hypoglycaemia may be caused by:

    1. Acute illness or infection: any illness causing a significant stress response can precipitate hypoglycaemia in an older frail diabetic. A systematic review of the resident for acute illness is indicated.
    2. Medication:
      • Diabetes medications:
        • Type of medication: insulin and many oral glucose lowering medications may precipitate hypoglycaemia. Sulphonylureas in particular are generally unsuitable for frail older persons due to significant risk of hypoglycaemia in liver or renal dysfunction. Review Diabetes management in aged care handbook for a comprehensive outline of glucose lowering medication in aged care
        • Inappropriate timing of administration of medications - glucose-lowering medications should generally be administered at mealtimes to reduce hypoglycaemia risk
      • Rarely the following medications may contribute to hypoglycaemia - consider if persistent hypoglycaemia and after common precipitants have been excluded - specialist endocrinology input is recommended. Sulphonamides, salicylates, warfarin, monoamine oxidase inhibitors, alcohol, alternative medicines such as fenugreek, bitter melon, opuntia, ginseng, aloe
      • Cessation of medications that can contribute to hyperglycaemia (e.g. steroids)
    3. Worsening renal or liver function
    4. Diet: delayed or missed meals or skipping carbohydrate portions or stopping a PEG feed
    5. Activity: increased physical activity

    B. Identify complications of hypoglycaemia

    Complications of hypoglycaemia may include:

    1. Seizures
    2. Falls
    3. Altered level of consciousness or confusion
    4. Increased risk of acute vascular events such as stroke, myocardial infarction, cardiac failure

  • A. With GP review / develop individualised diabetes management care plan to address and reduce incidence of hypoglycaemia. 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 or change in condition or when medications associated with hypoglycaemia are commenced
      • In general, monitoring should occur prior to meals and / or 2 hours after meals and occasionally overnight at 2.00 am
    • BGL target range
      • Generally 6 to 15 mmol/L is appropriate (with a HbA1C target of up 8.5 per cent appropriate for frail older persons requiring insulin with a life expectancy predicted at less than 5 years)
    • Individual resident's symptoms / signs of hyper- and hypoglycaemia and related management plans - take particular care to document if the resident is unaware of hypoglycaemia when it occurs; such residents are at risk of severe hypoglycaemia and warrant close monitoring of BGL
    • 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
    • Medication review

    For residents who require insulin:

    Cause of hypoglycaemiaResponse to hypoglycaemia

    Missed, delayed or reduced oral or enteral intake and intake returned to normal

    No indication to adjust dose of short-acting insulin unless hypoglycaemia is recurrent

    Reduced oral intake

    		GP to consider reducing mealtime short-acting insulin if on a basal bolus regimen or reduce basal insulin if on this alone

    Cause of hypoglycaemia not identified or cannot be corrected

    • Hypoglycaemia that occurs within 4 hours after mealtime insulin: reduce dose of that mealtime insulin by 20 per cent the following day
    • Hypoglycaemia that occurs outside of
      4 hours after mealtime insulin: reduce basal insulin dose by 20 per cent
    • Ensure standing order for glucagon and indication are documented on the resident's medication chart

    B. Risk management strategies:

    • Regular RACF staff education on identification and treatment of hypoglycaemia
    • Regular BGL monitoring for all residents with diabetes
    • Diet:
      • Ensure access to regular nutritious meals and snacks and provide additional carbohydrate when residents are more active
      • Standard diets that include desserts and snacks are generally appropriate in residents with diabetes. Specific "diabetic diets" are not required
      • Record nutrition, hydration and intake each care shift
    • Ensure prescribed medications are administered in correct doses at correct time
    • Every resident with diabetes should have an individualised diabetes sick day management plan

References

Last updated: 14 June 2023