key: cord-0987135-bgduia7d authors: Wang, Shuang; Zhan, Junkun; Cheng, Mei; Pan, Qi; Liang, Zhen; Liu, Xiaohong; Peng, Wen; Cao, Xiaopei; Luo, Yingquan; Kang, Dongmei; Liu, Youshuo title: Clinical expert consensus on standard care of blood glucose for residents in senior care facility in China (2021 edition) date: 2021-06-11 journal: Aging Med (Milton) DOI: 10.1002/agm2.12164 sha: 040cde51712cdebc18569c247497e101bbede587 doc_id: 987135 cord_uid: bgduia7d With the demographic changes, more and more elderly people have chosen to spend their retirement life in a senior care facility. The elderly people in senior care facility are commonly suffering from various geriatric syndromes, including declined daily living activities, cognitive dysfunction, frailty, comorbidities, and polypharmacy, which make them vulnerable to adverse effects, like hypoglycemia and fall. Therefore, layered management is necessary for this population with group disparities. However, the staff in senior care facility vary greatly in concepts and skills on management of senile diabetic population, which needs urgently to be standardized and improved. For this purpose, based on literature review and panel discussion, 28 recommendations are proposed in respect of the standardized management of blood glucose, covering the comprehensive assessment, layered management and grouping, exercise, nutrition, glucose monitoring, identification and treatment of severe hyperglycemia, identification of macrovascular and microvascular complications, management of hypoglycemic drugs, falls and choking and other common problems, blood glucose screening, hypoglycemia prevention, and blood glucose management in major public health events or serious natural disasters. This guideline aims to standardize management skills of medical staff and caregivers in senior care facility for the blood glucose of elderly people and improve their quality of life. Senior care facility refer to institutions that provide full-time centralized accommodation and nursing services for the elderly, with 10 or more beds. The results showed that the common geriatric syndromes in the elderly admitted to senior care facility include declined activity of daily living (80.7%), cognitive dysfunction (80.5%), and polypharmacy (44.7%). 1 These problems affect their quality of life and make them more vulnerable to adverse effects such as hypoglycemia and falls. According to the requirements of standardized management and the combination of medical and nursing care in China's senior care facility, the ability of the senior care facility in China to manage the health conditions of the elderly who were admitted to a senior care facility has been continuously improved through the cooperation with medical institutions or the establishment of medical departments in the institutions. For this reason, we organized experts in geriatrics, endocrinology, and general family medicine to formulate the Clinical expert consensus on standard care of blood glucose for residents in senior care facility in China (abbreviated as the Consensus), following the principles of practicality, simplicity, and advancement, absorbing the management guidelines for elderly diabetes published in recent years both in China and abroad, and paying attention to the management experience in this field in China. The Consensus is designed to guide doctors, nurses, and caregivers in senior care facility to perform standardized management of blood glucose for the elderly. The health conditions of the elderly admitted into a senior care facility vary greatly from active to disabled and mentally disabled. Medical and management personnel of a senior care facility differ greatly in their concepts, abilities, and technology for the management of elderly diabetes. When there is a complicated situation, like when a comprehensive consideration of the geriatric syndrome and survival prediction is required in the management objectives of blood glucose, health managers will inevitably feel at a loss. 2-9 Therefore, it is necessary to establish an individualized program for the standardized management of blood glucose in senior care facility. Recommendation 2: Physicians in the senior care facility shall be familiar with the application of assessment tools for cognitive function, daily living ability, and frailty state of the elderly. Dividing the elderly in the senior care facility into three groups according to their daily living ability, cognitive function, weakness state, and coexisting diseases: (1) the active elderly (aged but not frail); (2) semi-disabled elderly (aged and frail with certain functions); (3) disabled elderly ( Table 1) . The elderly in different groups shall be managed with stratified methods. In setting the targets of glucose control, the diseases, functional status, and expected survival time of the elderly shall be fully considered, as shown in Table 1 . (1) For the active elderly or those with an expected survival time of 10 years or more, the targets of glucose control shall be the same as ordinary adults; (2) For the elderly with semi-disability or an expected survival time of not more than 5 years, the targets of glucose control shall be lowered to <8.0% of glycated hemoglobin (HbA1C); (3) For the elderly with disability or an expected survival time of not more than 6-12 months, the targets of glucose control should avoid the occurrence of acute complications associated with hyperglycemia; (4) For the elderly that have approached their end and no longer take food through mouth or nasal feeding pipeline, hypoglycemic therapy can be discontinued as it may be appropriate. Physicians should set corresponding evaluation intervals for different groups, in order to identify the group changes of the elderly in time and adjust management strategies. screening, hypoglycemia prevention, and blood glucose management in major public health events or serious natural disasters. This guideline aims to standardize management skills of medical staff and caregivers in senior care facility for the blood glucose of elderly people and improve their quality of life. blood glucose, elderly, senior care facility Exercise is one of the three basic treatments for diabetes. Exercise can enhance the sensitivity of surrounding tissues to insulin, improve lipid metabolism, and achieve the target of a good control of blood glucose. Exercise can also improve neurological and cardiopulmonary functions, promote systemic metabolism, and enhance immunity. Appropriate exercise mode, amount, and time should be adopted by elderly patients with diabetes. The elderly patients with diabetes should choose exercise intensity according to exercise intensity classification (Table 2) . Medium intensity is defined as 5-6 points, and high intensity is defined as 7-8 points. (3) The disabled elderly should mainly engage in passive limb activity to prevent complications and maintain mobility, as shown in Table 3 . Elderly patients with diabetes are not all suitable for exercise due to various complications, so medical staff should provide timely guidance. The amount and time of exercise should be appropriate. Elderly diabetic patients with stable conditions, especially those with obesity and impaired glucose tolerance, can take exercise when their blood glucose is controlled at In the case of insulin deficiency, it is not suitable for exercise before insulin is supplemented; (2) extremely unstable blood glucose; (3) diabetic retinopathy with fundus hemorrhage; (4) diabetic nephropathy with severe renal dysfunction; (5) severe hypertension uncontrolled, and severe cardiovascular and cerebrovascular diseases uncontrolled or unstable; (6) severe situations, such as complicated acute infection, ketoacidosis, and pulmonary heart disease, etc. In order to maintain blood glucose in an ideal range, the elderly diabetic patients will control their diet alone by reducing the intake of staple foods and meat, which is the commonest practice. The long-term insufficient intake of energy and high-quality protein will increase the risk of other diseases. Since the clinical outcomes and glucose control targets of the elderly diabetic patients vary in (Table 4 ). Elderly patients with diabetes should adopt a reasonable lifestyle, including adjusting their dietary structure and habits, and take appropriate exercise to control blood glucose. There is no significant difference in the general principle of nutritious diet, the recommended amount of diet, and the distribution of three meals among different groups. It should be particularly noted that the nutritional needs of the elderly diabetic patients with enteral nutrition are consistent with those of ordinary elderly people. When fed with self-prepared food homogenate, the food should be diversified, including staple foods, meat, eggs, vegetables, oil, and salt in each meal. Besides, enteral nutrition should be timed and quantitative. As far as possible, enteral nutrition should be carried out at the same time every day and with the same amount in each meal, which is more conducive to blood glucose management. During enteral nutrition, we should try to prevent choking and reflux aspiration, reduce the pressure on the gastrointestinal tract before each meal, and pay attention to the volume and color of the fluid in the gastric tube. If tolerance is poor, consult a clinical physician or a dietician to choose a total nutrition formula. Glucose monitoring is an important part of diabetes management in senior care facility. At present, the common glucose monitoring method adopted by senior care facility is fingertip glucose monitoring with a blood glucose meter, and the results are helpful for assessing the degrees of glucose metabolism disorder of patients with diabetes and developing a reasonable treatment plan. The glucose monitoring reflects the effect of hypoglycemic therapy and guides the adjustment of therapy (Table 5) . Aerobic exercise 30-60 min, can be completed in segments ≥5 d per week 5-6 points for moderate intensity, and full score is 10 points (0 point means sitting quietly, 5-6 points means being able to talk, and 10 points means exhausted) Housework, gardening activities, climbing stairs, medium-speed walking (4.8-5.5 if permitted by conditions ( Figure 1 ). The frequency and time of blood glucose testing should be based on blood glucose control, hypoglycemia, insulin application, and concomitant diseases. The frequency of blood glucose monitoring should be increased when the blood glucose level of diabetic patients fluctuates greatly, the risk of hypoglycemia is high, during the medication adjustment period, or when the conditions of concomitant diseases have changed ( Figure 1 ). Eat foods between meals, and reduce the intake of staple foods and oil As the semi-disabled elderly may have mild dysphagia, choke prevention is required in nutrition management. For disabled elderly with enteral nutrition, the food should be prepared in the form of homogenate. The time range of blood glucose monitoring at each time point is shown in Table 6 , and the basic principles of blood glucose monitoring are shown in Table 7 . Most importantly, physicians and nursing staff in the senior care facility to control hyperglycemia should identify DKA and HHS in time. Specific identification and treatment process is shown in Figure 2 . Pre-meal blood glucose Fasting blood glucose is high or there is a risk of hypoglycemia (the elderly, people with blood glucose well controlled) The fasting blood glucose is well controlled, but HbA1c still fails to reach the standard level and patients who need to know the effects of diet and exercise on blood glucose Blood glucose before sleeping Patients treated with injection of insulin, especially those who are injected with insulin before dinner Blood glucose at night Those whose blood glucose reach the standard level after treatment, but the fasting blood glucose is still high, or those who are suspected to have hypoglycemia at night Others Blood glucose should be monitored in time when symptoms of hypoglycemia appear and should be monitored before and after strenuous exercise TA B L E 7 Basic principles of blood glucose monitoring To understand the effects of diet control and exercise on blood glucose and adjust diet and exercise according to the blood glucose monitoring results Monitor fasting or post-meal blood glucose 2-4 times per week, or continuously monitor the blood glucose for 3 d in the week before seeing a doctor, and 7 times per day (before and after breakfast, lunch, dinner, and at bedtime) Fasting blood glucose should be monitored for those using basal insulin; fasting and pre-dinner blood glucose should be monitored for those using pre-mixed insulin; pre-meal and post-meal blood glucose should be monitored for those using insulin before meals (3) Question: Are there palpitation and perspiration, loss of appetite, nausea and vomiting, thirst, polydipsia, or abdominal pain? (4) Examination: Diabetic ketoacidosis should be highly suspected if the fasting blood glucose is ≧16.7 mmol/L or random blood glucose is ≧20 mmol/L. If permitted by the conditions of the senior care facility, the urinary ketone or bedside blood ketone should be detected. Both DKA and HHS treatments should observe the following principles. Recommendation 15: Fluid infusion should be carried out as soon as possible to restore blood volume, reduce blood glucose level, and solve electrolyte and acid-base imbalance. Besides, we should identify and remove the causes, prevent and treat for the complications, and reduce the mortality rate. Elderly diabetic patients with suspected DKA and HHS should be transferred immediately after urgent treatment. The treatment process is shown in Figure 2 . Macrovascular diseases (including coronary atherosclerotic heart disease, cerebrovascular disease, and lower extremity vascular disease) and microvascular diseases ( The specific process is shown in Figure 3 . F I G U R E 3 Identification and treatment of diabetic macrovascular and microvascular complications by medical staff in senior care facility Patients with diabetes usually need to receive hypoglycemic drugs, and attention should be paid to the risk of hypoglycemia in the elderly patients with diabetes during medication. [10] [11] [12] Recommendation 17: Emphasis should be placed on hypoglycemia warning education, especially for the elderly patients who need to take sulfonylurea, glinides, and insulin. Blood glucose should be monitored during medication. Besides, in order to ensure hypoglycemic effect and reduce the risks of medication, patients should adopt an appropriate method of medication. Injectable drugs should be injected subcutaneously into the abdomen, thighs, or upper arms, and the injection points should be changed in rotation. The specific usages and common adverse reactions of various hypoglycemic drugs are shown in Table 8 . Elderly diabetic patients are prone to falls due to a variety of reasons, which may result in fractures, craniocerebral injury, and other Oral Choking is closely related to adverse clinical events such as hypoglycemia and malnutrition in the elderly with diabetes. the elderly in the senior care facility. Among the elderly with a risk of choking, most of the choking incidents can be avoided by interventions such as improving feeding patterns and food properties ( Figure 5 ). Nasal feeding tubes are required to supply some elderly patients with nutrition, but they cannot effectively avoid choking and aspiration. The screening process of non-diabetic elderly in senior care facility is shown in Figure 6 . Recommendation 20: Diabetes usually has a long asymptomatic period, and interventions in prediabetes can prevent or delay the F I G U R E 5 Swallowing function assessment and lifestyle prevention of choking for the elderly in senior care facility Colour figure can be viewed at wileyonlinelibrary.com] Screening process for nondiabetic elderly in senior care facility Note: 2h-OGTT refers to blood glucose at 2 hours after glucose load. Colour figure can be viewed at wileyonlinelibrary.com] onset of diabetes. The elderly are at high risk of diabetes, so it is recommended that the senior care facility conduct diabetes screening at least once a year. Recommendation 21: Fasting blood glucose detection is simple and easy to perform and is suitable for routine screening in senior care facility. However, the specificity and sensitivity of fasting blood glucose detection in the elderly population are decreased, and there is a possibility of missed diagnosis. The Diabetes Risk Score in China (Table 9 ) can be used for auxiliary screening. For those with a total score of ≥25, OGTT (fasting blood glucose and blood glucose 2 hours after glucose load) should be performed to determine whether they have diabetes. The application of HbA1c is not recommended in routine diabetes screening in senior care facility. Recommendation 22: The normal range: Fasting blood glucose <6.1 mmol/L and/or 2 hours post-glucose load blood glucose (2h-OGTT) <7.8 mmol/L. It is suggested to receive a screening at least once a year. Recommendation 23: Fasting blood glucose ≥6.1 mmol/L and/or 2 hours post-glucose load blood glucose ≥7.8 mmol/L are prediabetic or diabetic stage with impaired fasting blood glucose and impaired glucose tolerance (Table 10) . It is recommended to be diagnosed by a diabetes or endocrine specialist and develop a treatment scheme. Definition: Hypoglycemia is defined as a state of intravenous blood glucose below 2.8 mmol/L in non-diabetic patients and below 3.9 mmol/L in diabetic patients. Due to the lower threshold of hypoglycemia in the elderly, hypoglycemia should be dealt with in advance and as soon as possible when the blood glucose of the elderly in the senior care facility is lower than 5.0 mmol/L, and the hypoglycemia drugs should be adjusted. Symptoms: hunger, palpitations, sweating, tremor, pallor, dizziness, and weakness, etc. The elderly rarely have hypoglycemia prodrome, directly manifested as vertigo, disorientation, sudden behavioral changes, or even serious clinical events such as cardiac arrhythmia, myocardial infarction, falls, syncope, convulsion, and coma. Recommendation 24: Blood glucose monitoring in senior care facility is not as frequent as that in hospitals, the former mainly avoids the occurrence of hypoglycemia through health education and early identification of hypoglycemia. The blood glucose threshold of the prodrome of hypoglycemia in the elderly is very close to the threshold of hypoglycemia. When hypoglycemia symptoms occur, blood glucose may already be lower than 3.9 mmol/L. For the elderly in senior care facility, it is recommended to loosen the diagnostic criteria of hypoglycemia. Hypoglycemia should be treated immediately when blood glucose is lower than 3.9 mmol/L. Similarly, when blood glucose is below 5.0 mmol/L, hypoglycemia should be treated as soon as possible in advance. Recommendation 26: Whether the elderly have diabetes or not, when hypoglycemia occurs, they should be treated according to Figure 7 . If the elderly have recurrent hypoglycemia in a short period, they should be referred to a general hospital to find out the cause of hypoglycemia. Recommendation 28: When major public health events or severe natural disasters occur suddenly, the elderly patients' awareness and ability to precautions are weak, and changes in living environment and living habits may lead to unstable glycemic control of diabetes, aggravation of basic diseases, and the occurrence of new complications. So the senior care facility should provide the elderly with necessary protection measures and timely emotional counseling, psychological support, crisis intervention, and other services. The blood glucose management process in major public health events or serious natural disasters in senior care facility is shown in Figure 8 . Due to the impact of COVID-19, and the need for defense and isolation, telemedicine was developing at a high speed in 2020, and the strategy of Internet plus medicine was implemented quickly. Impaired fasting glucose and impaired glucose tolerance are collectively referred to impaired glucose regulation or prediabetes. Recommendation 30: Encourage senior care facility and general hospitals to establish remote education and consultation platforms to promote the level of diagnosis and treatment. It is recommended that if permitted by conditions, senior care facility can make full use of various devices based on medical Internet for blood glucose monitoring. Smartphone APP and related intelligent terminals can be used to connect with the remote chronic disease management centers and realize a remote, refined and systematic management of blood glucose. The authors have no conflicts of interest to disclose. https://orcid.org/0000-0001-9835-4074 Diabetes Professional Committee of Chinese Aging Well Association. 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Definition, diagnosis and classification of diabetes mellitus and its complications Clinical expert consensus on standard care of blood glucose for residents in senior care facility in China (2021 edition) Beijing Hospital Cuntai Zhang (Department of Geriatrics, Tongji Hospital Affiliated to The Tongji Medical College Huazhong University of Science and Technology) Zaijin Jian (Department of Geriatrics, the Second Xiangya Hospital The Second Xiangya Hospital, and the Institute of Aging and Geriatrics Caixia Cao Ping Chen (Department of Geriatrics, Sichuan Provincial People's Hospital), Qiong Chen Jirui He Caiping Li (Department of Geriatrics, Tongji Hospital Affiliated to The Tongji Medical The Second Xiangya Hospital, and the Institute of Aging and Geriatrics Wen Peng (Department of General Medicine, Union Hospital Affiliated to The Tongji Medical College Huazhong University of Science and Technology The Second Xiangya Hospital, and the Institute of Aging and Geriatrics Kexiang Zhao (Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University), Xinlan Zhao (Department of Geriatrics, Mawangdui District of Hunan Provincial People's Hospital) F I G U R E 8 Emergency management process of diabetes when a major public health event occurs in senior care facility Colour figure can be viewed at wileyonlinelibrary.com]