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INSULIN IN THE ELDERLY

Chronological age is not a contraindication to insulin therapy. However "biological age" should be a factor in setting appropriate glycaemic targets and in choosing a suitable insulin regimen.

• Targets for glycaemic control in the elderly need not be as stringent as in the younger patient
• The aims of treatment are to control hyperglycaemia with particular avoidance of hypoglycaemia.
• It may be best to avoid soluble insulin in the very elderly because of the risk of hypoglycaemia. Regimens using twice daily isophane are often best in this age group.
• Consider using a once daily regimen with Glargine if elderly patients require supervised injections from a Community Nurse or carer

STARTING INSULIN

All patients starting insulin should have the following:

• Review of dietary intake, with emphasis on regular and consistent carbohydrate intake.
• An individualised regime, which must take account of lifestyle factors such as shift work, holidays, exercise etc.
• Appropriate education on self-management of insulin administration
• Education on avoidance of hypoglycaemia
• Education on "sick day rules", including avoidance of diabetic ketoacidosis for people with Type 1 diabetes.
• See Education Checklist for more information

Timing of Injections in Relation to Meals

• Standard insulin preparations should be injected subcutaneously, usually 15-30 minutes before meals
• Analogue insulins have a rapid onset of action and an early peak response. In view of this, they should be injected immediately (usually within 5-10minutes) before eating or just after. Delays between injection and eating with these preparations will predispose a patient to hypoglycaemia.
• Examples of short-acting analogues include Insulin Lispro (Humalog) or Insulin Aspart (NovoRAPID).
• Insulin analogue mixtures are also available (e.g. Humalog Mix 25 or NovoMix 30). These should also be injected immediately before eating.

Principles of Injection

Insulin administration is best taught by a nurse with specialist skills in diabetes

• Patients should be instructed to use a variety of injection sites (see below).
• Repeated injection of insulin into the same area can predispose to the development of lipohypertrophy, an accumulation of subcutaneous fat, which is a local trophic effect of insulin.
• Insulin will not be absorbed reliably if it is injected into an area of lipohypertrophy. This may result in poor or erratic blood glucose control.
• A similar problem can also occur if needles are reused.
• Lipoatrophy is another local reaction to insulin, which is due to hollowing of subcutaneous fat. This may be seen in patients with longstanding diabetes who have used animal insulins in the past. However it is rarely seen nowadays as most insulins are highly purified.

Injection Technique

• Remember to check the insulin dose and type before injecting, especially if the patient uses more than one type of insulin
• Remember also to re-suspend "cloudy" insulin prior to injection
• If recommending needle size above 6mm, insert at 90 degree angle and use a "pinch up" technique. Avoid using arms.
• If recommending needle size 6mm or below, insert at 90 degree angle but without "pinch up". Smaller needle sizes can be used at all injection sites.
• Avoid any "lumpy" or atrophic areas
• There is no need to swab the skin before or after injection
• Inject subcutaneously and maintain the needle in place for 10 seconds
• Do not advise patients to inject through clothes
• Remember that needles should be removed and disposed of carefully after each injection - see Disposal of Sharps.

TO REDUCE THE RISK OF LIPOHYPERTROPHY, Avoid injecting into fatty swellings Rotate between sites Rotate within injection sites Use a new needle for each injection.

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