A quarter of newly admitted nursing home residents who receive insulin for type 2 diabetes are treated using a contested regimen, a new study of Veterans Affairs facilities finds.

Up to 33% of patients in long-term care facilities are estimated to have diabetes. Despite guidelines discouraging its use in the elderly, sliding-scale insulin (SSI) therapy is the most commonly used therapy to manage insulin dosing in residents. The therapy involves administering short-acting injections from four to six times per day, varying the dose based on finger-stick glucose levels taken immediately prior to the injections and mealtimes.

The idea is that SSI is more precise than using a fixed dose, but it has been linked to a high risk of hypoglycemia without improvement in hyperglycemia management in older adults. In 2012, it was highly discouraged for the elderly in the American Geriatrics Society (AGS) Updated Beers Criteria. 

Tracking SSI use in facilities

In the current study, investigators tracked post-admission treatment data for residents of Veterans Affairs nursing homes from 2013 through 2017. They compared the weekly prevalence of SSI versus two other short-acting insulin regimens from week 2 to week 12 after admission. 

In week 2, fully 21% of the residents were on an SSI regimen. What’s more, it was most common among the frail subgroups, such as those with moderate-to-severe cognitive impairment. In comparison, the alternative fixed dose insulin regimen accounted for 8% of therapies and the correction dose regimen (defined as variable SSI given alongside fixed doses of insulin) accounted for 7% of therapies.

SSI use fell steadily as the weeks passed, falling to 16% by week 12. But the researchers expressed concern about its continued use. Some experts encourage clinicians to transition to other methods as soon as possible. 

Short-term use

When patients are temporarily managed with SSI, “a decision should be made within a couple of days about a more physiologic glucose control strategy,” according to recent guidance from the clinician resource UpToDate.

“More research needs to be done to explore why sliding scale use persists weeks after nursing home admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens,” the authors of the current study concluded.

Full findings was published Thursday in JAMDA.