Safer and Smarter Insulin Use in Long-Term Care Settings

Caring for older adults with diabetes in long-term care and assisted living communities requires more than just routine insulin administration—it demands vigilance, adaptation, and a deep understanding of the unique challenges faced in these settings. With nearly one in three long-term care (LTC) residents living with diabetes, ensuring safe insulin use is critical to resident well-being.

Understanding the Risks: Why Insulin Requires Caution

Insulin is one of the most effective tools for managing blood glucose—but also one of the most dangerous when used incorrectly, especially in frail older adults. Hypoglycemia can lead to confusion, falls, hospitalization, and even death. Recurrent low blood sugar episodes are often under-recognized in this population due to non-specific symptoms like fatigue, dizziness, or behavioral changes that may be mistaken for dementia. These events aren’t just acute concerns—they’re tied to long-term physical decline, impaired cognition, increased fracture risk, and progression to frailty.

Multiple factors increase the risk: erratic meal intake, renal impairment, polypharmacy, cognitive impairment, and recent hospitalization. In fact, insulin is one of the top medications associated with emergency department visits in adults over 65. In LTC settings, the goal is not perfect glucose numbers—but stable, symptom-free days. A conservative, individualized approach that avoids both highs and lows is the safest and most sustainable strategy for preserving function and quality of life.

Safe Use of Insulin: What You Need to Know

Safe insulin use requires a clear understanding of each product’s onset, peak action, and duration—key factors that affect meal timing and the risk for hypoglycemia. Rapid-acting insulins are typically administered just before meals to manage post-meal glucose spikes, while long-acting basal insulins help maintain stable glucose levels throughout the day and night.

An insulin reference guide, used alongside the manufacturer’s instructions, is recommended to support safe administration. These resources provide critical details on:

• Timing of administration in relation to meals
• Onset and duration, to help anticipate and monitor for blood sugar changes
• Storage requirements, including how long pens remain stable at room temperature

Nursing and other medication administration staff should always confirm insulin type, timing, and dosage against current guidance and reach out to the pharmacist or prescriber with any questions or concerns.

Priming Insulin Pens: A Simple Step with Big Impact

Before each use, insulin pens must be primed to ensure the device is functioning correctly and to remove air bubbles. Skipping this step can result in underdosing—a critical error, especially for residents with tightly managed glucose levels.

Priming instructions vary slightly by pen type, but general best practices include:

• Dialing 2 units for the test dose
• Repeating the test up to 6 times if no insulin appears
• Holding the injection button for at least 6 seconds to ensure full delivery

Staff should always follow the manufacturer’s instructions for priming and administration. This small but essential step helps ensure accurate dosing and safer care.

Simplify, Streamline, and Individualize

In LTC settings, simplified insulin regimens aren’t just helpful—they’re essential. Frequent staff turnover, inconsistent meal intake, and limited on-site practitioner presence make complex regimens harder to manage and more prone to errors.

Safe insulin use involves:

• Individualized care plans based on each resident’s comorbidities, nutritional intake, and functional status
• Basal-only or basal-plus regimens that reduce injection frequency while maintaining stability
• Avoiding unnecessary complexity, such as skipping mealtime insulin in residents with cognitive decline or poor appetite unless clinically necessary

The routine use of sliding scale insulin (SSI)—a reactive approach that chases high blood sugars with corrective doses—is not recommended. SSI has been associated with wide glucose fluctuations and higher risks for hypoglycemia. Instead, scheduled insulin regimens—particularly basal insulin with or without oral agents—offer a more consistent, safer, and less burdensome option for both residents and staff.

What to Watch For: When to Notify the Practitioner

Prompt communication with the prescriber is critical for avoiding complications. Consider contacting the provider if:

• Two or more blood glucose readings are <70 mg/dL in 24 hours
• Readings are >300 mg/dL for two consecutive days
• A resident is vomiting or refusing food
• There are signs of confusion, dizziness, or change in behavior—possible signs of hypoglycemia

Standing orders and protocols for glucose monitoring can empower care staff to act quickly and appropriately.

Continuous Glucose Monitoring: A New Standard in Diabetes Care

The 2025 Standards of Care from the American Diabetes Association recommend offering continuous glucose monitoring (CGM) to all individuals with diabetes—including those with type 2 diabetes not on insulin. These updated guidelines reflect growing evidence that CGM supports better glycemic control, improved time-in-range, and greater patient engagement across a wide range of treatment regimens. For residents in senior living, CGM offers an opportunity to simplify care, reduce the need for finger sticks, and provide caregivers with real-time insights that support more timely interventions. Individualized device selection and proper training are essential, as is ensuring staff competency in reviewing and using CGM data to guide therapy adjustments.

Nutrition Matters, Too

Gone are the days of rigid “no sugar” diets. Today, a liberalized, consistent-carbohydrate approach is recommended. Restrictive diets may lead to poor intake, unintentional weight loss, and dehydration. For residents on mealtime insulin, consistent carbs help stabilize blood glucose while still honoring food preferences and quality of life.

Staff Education: A Cornerstone of Safety

Insulin safety starts with informed caregivers. All staff responsible for administering insulin should understand:

• The differences between insulin types
• How to prime and administer insulin pens correctly
• The importance of timing insulin with meals
• Symptoms of hypo- and hyperglycemia (which may be atypical in older adults)
• When to escalate concerns to the prescriber

Ongoing staff education and clearly written protocols can reduce errors and improve outcomes.

Transitions and Communication: Don’t Drop the Baton

Transitions between care settings—such as hospital to skilled nursing—are risky periods for residents on insulin. Medication regimens are often changed in the hospital but not properly communicated upon discharge. Nursing staff should verify insulin orders, understand the prior regimen, and ensure all equipment (e.g., pens, needles, glucose meters) is available on arrival.

Whenever possible, obtain:

• Recent A1C and lab results
• History of recent hypoglycemia or hyperglycemia
• Dietary preferences and support needs
• Instructions for monitoring frequency and timing

Final Thoughts: A Team Approach to Safer Care

Insulin safety in LTC requires collaboration among nursing staff, prescribers, dietitians, pharmacists, and caregivers. As front-line providers, nurses play a pivotal role in ensuring proper insulin use—from recognizing early signs of trouble to advocating for simpler, safer regimens.

With smart protocols, the right insulin choices, and continued staff training, we can reduce risks, improve quality of life, and deliver the kind of care every resident deserves.

References:

Abdelhafiz AH, Rodríguez-Mañas L, Morley JE, Sinclair AJ. Hypoglycemia in Older People – A Less Well Recognized Risk Factor for Frailty. Aging and Disease. 2015;6(2):156–167. doi:10.14336/AD.2014.0330.

American Diabetes Association Professional Practice Committee. Standards of Care in Diabetes—2025. Diabetes Care 1 January 2025; 48 (Supplement_1): S14–S26. https://doi.org/10.2337/dc25-S001

Candace Dufour, PharmD
Director of Consulting Services
Southern Pharmacy Services