Management of the Hospitalized Diabetic Patient

Elderly diabetic individuals are hospitalized about twice as often as elderly people without diabetes. In the NHANES II study, only 16.5% of individuals 65 to 74 years old without diabetes reported having been hospitalized once or more within the previous year, whereas 29.8% of those with known diabetes reported having been hospitalized.

In the hospital, the goal for glycemic management is to minimize the likelihood of insulin deficiency, which can contribute to a catabolic state. Tight control is not necessary to achieve this goal.

Reasonable goals would be a mean plasma glucose level of less than 250 mg/dL (14 mM) and minimal glycosuria. Stressful illnesses such as myocardial infarction, pneumonia, influenza, and stroke can exacerbate hyperglycemia and may even precipitate hyperosmolar hyperglycemic nonketotic coma in a patient who is already hospitalized. Fifty percent of all severe episodes of dehydration develop in the hospital. This setting is thus a high-risk environment that could lead to hyperglycemia.

Thus, elderly patients usually treated with oral agents may need to be treated temporarily with insulin. Appropriate intravenous fluid therapy to prevent dehydration and worsening of hyperglycemia should be given. Frequent glucose monitoring is recommended to prevent wide variations in glycemia. Sliding scales of regular insulin can be useful for the acutely ill patient or postoperative patient who is unable to eat. However, once oral intake is adequate, split dosing of insulin with adjustments made as needed on the basis of results of frequent glucose monitoring is possible.

Hypoglycemia is a significant problem for all hospitalized patients with diabetes. In general, hypoglycemia in the hospital results from decreased caloric intake or inappropriate changes in insulin dosage. Hypoglycemia may be prevented by frequent glucose monitoring, with adjustments being made in the insulin dose as the patient's medical condition changes.