Introduction

This section aims to give key safety messages regarding the care of frail older patients with diabetes who are inpatients including those patients in the final days of life.

The primary aim for this group of patients is to avoid hypoglycaemia (CBG <4.0mmol/l) and hyperglycaemia with potential osmotic symptoms (CBG >15mmol/l).

Elderly patients with an HbA1c <7.0% are at greater risk of in-hospital hypoglycaemia.   For all patients admitted to hospital review HbA1c and diabetes medication on admission. Consider if diabetes medication needs changing or reducing to lessen the risk of hypoglycaemia.  There may be alternative suitable agents (eg DPP IV inhibitors) which are not associated with risk of hypoglycaemia.  Pay particular attention to avoidance of hypoglycaemia at night by recommending  provision of snacks at bedtime and considering reducing teatime or evening dose of diabetes medication (insulin or sulphonylurea) by 20%.

CBG target – general inpatient target for frail older patients is 7.8-10mmol/l however this may be individualised and in moderate to severe frailty a higher range may be agreed as appropriate (eg, upto 15mmol/l).  For frail older patients undergoing  surgery the suggested range is 7-11mmol/l and for patients at the end of life the suggested range is 6-15mmol/l – again individualised where needed as 6-7mmol/l may pose and unacceptable hypo risk when patients in final days of life or with moderate to severe frailty.

KEY MESSAGE - It is clear from the above that the CBG range should be individualised – the priority being to avoid hypoglycaemia and minimise risk of symptomatic hyperglycaemia.

Discharge – when frail older patients with diabetes are discharged ensure that all concerned are aware of any medication changes, emergency contacts and / or follow-up plans. If patients are on insulin it is vital to ensure that the patient and/or carer is able to administer the medication and if not to have a robust plan in place for district  nurse support.

There is useful guidance from Diabetes UK on managing patients with diabetes who are at the end of life which can be found at DUK care recommendations. 

The following chart below summarise the management of diabetes in the final days of life

© Trend Diabetes. Chart used with kind permission. Original chart linked here: https://trenddiabetes.online/portfolio/end-of-life-guidance-for-diabetes-care/