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UKCPA Viewpoint: Diabetes in care homes

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UKCPA Viewpoint: Diabetes in care homes

Pharmacists can improve the quality of life for residents with diabetes in care homes.

Doris has diabetes. She is in a care home that is expert in dealing with her dementia. Over the past few months she has been losing weight, partly because she has lost interest in food, and also because she has become increasingly aggressive and less co-operative with staff when they help her to eat her meals. When she entered the home a year ago her BMI was 26.2; now it is 19.0, showing she has lost a significant amount of weight.

Doris is on a standard regimen of metformin 1g bd and gliclazide 80mg bd, which she has taken for some years. Her GP says her diabetes is well controlled (39mmol/mol). The care home thinks Doris should transfer to a home with a higher staffing ratio to deal with her aggressive behaviour.

What could you do?

It could be that some of Doris’ symptoms are from undiagnosed hypoglycaemic events. Hypos can come on quickly and cause different symptoms for different people.

The pharmacist can highlight to staff that, for Doris, one of the symptoms which might suggest a hypo is aggression and, if this occurs, it may be necessary to offer her an appropriate snack or drink.

It would be beneficial to measure Doris’ blood glucose to exclude low glucose levels being a possible cause of her aggression and a contributing factor to her apparently worsening dementia. Testing in fact shows the level is low. Hypos can be caused by over-treatment of diabetes, and the weight loss may mean her medicine doses need adjusting.

When treating hypos, we now recommend that care homes have access to a hypo box, which includes options such as:

  • 100ml Lucozade
  • Small can of a non-diet fizzy drink
  • 200ml carton of smooth orange juice
  • Four jelly babies
  • Four to five GlucoTabs
  • Five to six dextrose tablets.

Care plan

Staff should have a heightened awareness of how to identify a hypo in Doris and should write an individualised care plan for her, which includes her common symptoms and which of the hypo box choices she prefers. They should also make sure Doris does not miss meals.

Medication

The pharmacist could also recommend reducing the dose of the diabetes medicines. Any medication adjustments should be stepwise so the effects can be evaluated. The first step should be to halve (or stop) the gliclazide and request that the GP moves forward the next blood test for HbA1c and checks U&Es at the same time to monitor renal function.

If renal function has deteriorated, then the metformin dose will need to be reduced. Metformin can reduce appetite, so a lower dose may help. Finally, discuss setting a higher target for Doris (e.g. HbA1c 53-64mmol/mol). In older people, diabetes goals can change with the primary aim being hypo prevention rather than tight control to minimise long-term complications.

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