by Flora Brahmbhatt, Pharm.D., CGP

The recent Beers criteria include sliding scale insulin as inappropriate in the elderly due to the increased risk of hypoglycemia. There are various strategies to avoiding hypoglycemia. One strategy is to better manage the dose of long-acting (basal) insulin and administer rapid-acting (bolus) insulin post meal based on amount consumed. This better manages the glycemic index and reduces the risk of hypoglycemia.

However, managing low blood sugar is a challenge in nursing homes. A common mistake is the overuse and misuse of glucagon. Historically, glucagon is almost impossible to get and when you can, it costs a fortune. For conscious patients who can take oral food or fluids, this is the preferred route.

The American Diabetic Association recommends using the rule of 15 to manage hypoglycemia. Or, more specifically, for a blood sugar less than 70 mg/dl. The rule of 15 says take 15 grams of carbohydrates and recheck blood sugar in 15 minutes; If blood sugar is still less than 70 mg/dl, repeat with 15 grams of carbohydrates and recheck. The process is repeated until the blood sugar comes up.

So how much is 15 grams of carbohydrates? It ‘s three 5-gram glucose tablets, or four 4-gram glucose tablets. It’s 1 tube of glucose gel or 4 ounces of fruit juice. All of these should be part of house stock and readily available. Make sure the fruit juice you have is sweetened and not sugar free.*   And make sure your blood sugar machine is properly calibrated on a regular basis.   Physicians can help the process by in-servicing staff and writing orders to reflect the rule of 15.

* Please note that the common practice of 8 oz of orange juice with 2 packets of sugar is no longer recommended since this is an excessive dose of carbohydrate that commonly results in unacceptable hyperglycemia.