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Management of Diabetes During Acute Stroke and Inpatient Stroke

Rehabilitation

Article  in  Archives of Physical Medicine and Rehabilitation · January 2006

DOI: 10.1016/j.apmr.2005.07.306 · Source: PubMed

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CLINICAL MANAGEMENT REVIEW
Management of Diabetes During Acute Stroke and Inpatient
Stroke Rehabilitation
Sherita Hill Golden, MD, MHS, Felicia Hill-Briggs, PhD, Kathleen Williams, MSN, APN, Karen Stolka, RD,
R. Samuel Mayer, MD
ABSTRACT. Golden SH, Hill-Briggs F, Williams K, Stolka
K, Mayer RS. Management of diabetes during acute stroke and
inpatient stroke rehabilitation. Arch Phys Med Rehabil 2005;
86:2377-84.
Objectives: To summarize evidence on the impact of hy-
perglycemia on stroke outcomes and to present therapy algo-
rithms for inpatient management in diabetic stroke patients.
Data Sources: Guidelines for inpatient management of di-
abetes were reviewed and extracted from a technical review
and recommendations from 2 national diabetes and endocrine
organizations. MEDLINE database searches were conducted
using key words: stroke, diabetes, hyperglycemia, hypoglyce-
mia, inpatient, hospitalized, treatment, outcomes, disability,
self-management, and education.
Study Selection: Studies were selected that specifically ad-
dressed the impact of the following in stroke patients: hyper-
glycemia and diabetes on rehabilitation outcomes, management
strategies for hyperglycemia and diabetes, and strategies for
facilitating diabetes self-management.
Data Extraction: Two authors independently extracted data
and management practices from selected articles and published
practice guidelines.
Data Synthesis: Diabetes is prevalent in stroke patients and
results in poorer inpatient hospital and rehabilitation outcomes.
Management of diabetes in stroke patients is further compli-
cated by impairments in mobility and vision, necessitating
accommodation strategies and tools for self-management. Op-
timal management of hyperglycemia using insulin or oral hy-
poglycemic agents results in reduced morbidity and mortality
among diabetic inpatients.
Conclusions: To achieve inpatient glycemic management
targets, use of clinical management algorithms, self-manage-
ment tools, and systems approaches such as diabetes manage-
ment teams are useful.
Key Words: Diabetes mellitus; Hyperglycemia; Rehabilita-
tion; Stroke.
© 2005 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Departments of Medicine (Golden, Hill-Briggs, Williams), Physical
Medicine and Rehabilitation (Hill-Briggs, Mayer), and Nutrition (Stolka), Johns
Hopkins University School of Medicine, Baltimore, MD; and the Department of
Epidemiology (Golden), Johns Hopkins University Bloomberg School of Public
Health Baltimore, MD.
Supported by the Robert Wood Johnson Minority Medical Faculty Development
Program Award, the National Institute of Diabetes, Digestive, and Kidney Diseases
(grant no. 3 U01 DK48485-10S1), and the National Heart, Lung, and Blood Institute
(grant no. 1 K01 HL076644-01).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Sherita Hill Golden, MD, MHS, Johns Hopkins University
School of Medicine, Division of Endocrinology and Metabolism, 2024 E Monument
St, Ste 2-600, Baltimore, MD 21205, e-mail: sahill@jhmi.edu.
0003-9993/05/8612-9849$30.00/0
doi:10.1016/j.apmr.2005.07.306
2377
IABETES, A COMMON COMORBID condition among
D patients in the acute rehabilitation setting, results in poorer
outcomes during hospitalization. Hyperglycemia among dia-
betic inpatients is associated with an increased risk of infec-
tious complications,1-3 pulmonary and vascular complications,4
and in-hospital mortality.5 In stroke patients, the problem of
poor diabetes-related outcomes deserves particular attention.
Prevalence of diabetes in acute stroke patients is reported to be
as high as 24% to 38%.6,7 An estimated 66% of stroke survi-
vors meet criteria for diabetes mellitus or impaired glucose
tolerance at 3 months poststroke.6
Diabetes management in stroke patients can be particularly
difficult. Impairments such as dysphagia, neuropathy, hemipa-
resis and ataxia, visual impairment, cognition, and mood im-
pairment have significant consequences for diabetes care and
control. The inpatient physiatrist is often challenged by these
issues, and, therefore, should be updated with the latest litera-
ture and recommendations on diabetic management in this
special population. While the literature on tight glycemic con-
trol in the inpatient setting has been recently summarized in an
extensive technical review by the American Diabetes Associ-
ation (ADA),8 our goal is to highlight and summarize the
management issues that affect acute stroke and poststroke
rehabilitation patients and to provide a succinct resource for
physiatrists. The purposes of this clinical management review
are: (1) to summarize literature pertaining to diabetes- and
hyperglycemia-related outcomes in acute inpatient stroke and
rehabilitation patients; (2) to describe interventions to improve
glycemic control and outcomes in hospitalized patients; (3) to
present algorithms for inpatient insulin and oral hypoglycemic
therapy, based on clinical practice guidelines; (4) to discuss
special rehabilitation considerations and specific recommenda-
tions for managing diabetes in patients with stroke and disabil-
ity (eg, dysphagia, hemiparesis and ataxia, visual and cognitive
impairment); and (5) to present areas of future research in this
patient population.
METHODS
The ADA technical review and 2005 Clinical Practice Rec-
ommendations on management of diabetes during hospitaliza-
tion and the American Association of Clinical Endocrinologists
(AACE) guidelines for inpatient management of diabetes were
reviewed and extracted. Reference lists from these documents
yielded additional studies. A series of MEDLINE database
searches were conducted using key words including stroke,
diabetes, hyperglycemia, hypoglycemia, rehabilitation, inpa-
tient, hospitalized, treatment, outcomes, disability, self-man-
agement, and education. Searches were limited to English-
language, human studies. Expert practices by a university
hospital-affiliated inpatient diabetes management service were
incorporated into the treatment algorithms presented.
Thirty studies were selected that specifically addressed the
impact of hyperglycemia and diabetes on short-term and reha-
bilitation outcomes in stroke patients, management strategies
for hyperglycemia and diabetes in stroke patients, and strate-
gies for facilitating diabetes self-management in patients with
Arch Phys Med Rehabil Vol 86, December 2005
2378 HYPERGLYCEMIA IN REHABILITATION, Golden
stroke and disability. Two authors independently extracted data
and management practices from the selected articles and the
published practice guidelines.
RESULTS
Stroke, Hyperglycemia, and Diabetes
There are several proposed mechanisms linking hyperglyce-
mia to poor clinical outcomes, including adverse effects on
immune, endothelial, and cardiovascular function; increased
thrombosis, inflammation, and oxidative stress; and adverse
effects on the brain, particularly following brain ischemia.8 As
recently reviewed by Clement et al,8 hyperglycemia has harm-
ful effects on the brain that worsen stroke outcomes, including
enhanced neuronal damage following brain ischemia, espe-
cially in the ischemic penumbra, and increased acidosis and
lactate levels, which predict clinical outcomes and infarct size
in stroke. Additional harmful effects at the cellular level in-
clude DNA fragmentation, disruption of the blood-brain bar-
rier, increased deposition of ␤-amyloid precursor protein, and
increased superoxide levels.8
Diabetes is associated with poorer prognosis following
stroke, including higher mortality rate during hospitaliza-
tion9,10; higher incidence of urinary retention and urinary tract
infection during rehabilitation11; and poorer functional out-
comes, including worse neurologic recovery,12 slowed rate of
physical recovery, and reduced rate and magnitude of cognitive
recovery.13 Several studies have shown that the degree of
hyperglycemia is directly related to outcomes in the acute
stroke setting. Capes et al14 performed a meta-analysis of 26
studies and found that for both ischemic and hemorrhagic
strokes, an admission glucose from 108 to 144mg/dL was
associated with increased in-hospital and 30-day mortality.
Hyperglycemia, defined as an admission glucose of 130mg/dL
or higher, was also found to independently predict 30-day and
1-year mortality in a study of 656 acute stroke patients, 52% of
whom had diabetes.15 Similarly, individuals with stress hyper-
glycemia, newly diagnosed diabetes, and previously diagnosed
diabetes had a higher mortality than normoglycemic patients in
another study, despite the type and site of the strokes being
similar among the groups.16
Hyperglycemia has also been associated with poorer func-
tional outcomes following stroke. Compared with individuals
with a mean admission glucose of 144mg/dL, those with an
admission glucose of 160mg/dL had less functional improve-
ment following stroke, and for every 100mg/dL increase in
admission glucose there was a 24% reduction in the odds of
neurologic improvement.17 This study did not perform sub-
group analyses in patients with and without diabetes. Similarly,
Pulsinelli et al12 found that stroke-related deficits were more
severe among individuals with an admission glucose of more
than 120mg/dL, and in a subgroup of patients who were fol-
lowed prospectively, only 43% of those with admission glu-
coses of more than 120mg/dL were able to return to work
compared with 76% with glucoses below this level. Admission
glucose and/or a history of diabetes has also been shown to
independently predict hemorrhage as a complication of throm-
bolytic therapy18 and in an imaging study, doubling of the
admission glucose from 90 to 180mg/dL reduced the penum-
bral salvage, increased the final infarct size, and resulted in
greater lactate production in the area of the infarct.19 These
changes were independent of baseline stroke severity, lesion
size, and diabetes status.
In addition to being associated with poor clinical outcomes,
hyperglycemia is associated with increased length of stay
(LOS).5 In a study of acute stroke patients, those with hyper-
Arch Phys Med Rehabil Vol 86, December 2005
glycemia, defined as a blood sugar of 130mg/dL or higher, had
a longer LOS and greater inpatient charges than those who
were normoglycemic.15
To our knowledge, the Copenhagen Stroke Study10 is the
only study that has evaluated the effects of diabetes on reha-
bilitation outcomes. In this study, while clinical outcomes were
comparable in patients with and without diabetes, those with
diabetes recovered more slowly, despite having similar Scan-
dinavian Stroke Scale scores as the nondiabetic patients at
baseline and at the end of rehabilitation. This study did not
specifically examine the relation of glucose control on admis-
sion or during rehabilitation to clinical outcomes or length of
rehabilitation.
Interventions to Improve Glycemic Control and
Outcomes in Hospitalized Patients
Three clinical trials have shown that intensive glycemic control
in the acute hospital setting improves clinical outcomes in indi-
viduals with diabetes. In the Diabetes Mellitus, Insulin Glucose
Infusion in Acute Myocardial Infarction study,20 patients with
diabetes and acute myocardial infarction randomized to intensive
insulin therapy followed by a multishot regimen for 3 months
experienced a 29% reduction in 1-year mortality compared with
individuals receiving conventional therapy. Van den Berghe et
al21 demonstrated that patients admitted to the surgical intensive
care unit who received intensive insulin therapy via insulin infu-
sion to maintain a blood glucose of 80 to 110mg/dL had a
significant reduction in morbidity and mortality compared with
patients receiving less intensive insulin therapy. Finally, a recent
study22 in diabetic patients undergoing coronary artery bypass
surgery showed reduced atrial fibrillation, a shorter postoperative
LOS, and improved long-term postsurgical follow-up in patients
treated with glucose insulin infusion perioperatively compared
with standard therapy. Despite data demonstrating association of
hyperglycemia with poorer outcomes following stroke,17,19 there
have been no clinical trials examining the impact of intensive
glycemic control in the acute stroke setting on clinical outcomes.
The Glucose Insulin in Stroke Trial (GIST)23 examined the safety
of glucose-insulin-potassium infusion to lower glucose levels to
72 to 126mg/dL and found that this is safe and feasible; however,
the GIST report did not report data on functional recovery.
Two studies24,25 evaluating interventions by a diabetes team
have shown significant reductions in LOS. In 1 retrospective
study,25 the patients who were seen by the diabetes team had a
significantly shorter LOS than patients managed by their inter-
nist alone or by an individual endocrine consultant. In the
second study,24 which was a clinical trial, patients randomized
to the diabetes team had a significantly shorter LOS and a
lower 1-month readmission rate.
Guidelines for Inpatient Clinical Management of
Hyperglycemia
The ADA has recently published guidelines for the manage-
ment of hyperglycemia in the hospital in a thorough technical
review,8 which was recently summarized in the 2005 Clinical
Practice Recommendations.26 The guidelines of the ADA and
the AACE are summarized in appendix 1. These are the rec-
ommended glycemic targets for all inpatients and are not
specific to stroke or rehabilitation patients.
Insulin therapy in the hospital setting. To adequately con-
trol blood sugars, patients require both basal and nutritional
insulin. Basal insulin is the amount of exogenous insulin nec-
essary to prevent unchecked gluconeogenesis and ketosis and
nutritional insulin is the amount of insulin necessary to cover
discrete meals or other forms of nutrition (ie, intravenous
 HYPERGLYCEMIA IN REHABILITATION, Golden 2379

Table 1: Pharmacokinetics of Various Insulins

Insulins Onset of Action Peak of Action Duration of Action

Rapid acting
Lispro/aspart 5⫺15min 1⫺2h 3⫺5h
Regular 30⫺60min 2⫺4h 6⫺8h
Intermediate acting
Neutral protamine Hagedorn 1⫺3h 5⫺7h 13⫺18h
Long acting
Ultralente 2⫺4h 8⫺14h 18⫺30h
Glargine Within 4h Peakless ⬎24h

dextrose, total parenteral nutrition [TPN], enteral feedings,
nutritional supplements).8 Table 1 summarizes the various
types of insulins as well as their pharmacokinetics, which is
important to understand in selecting insulins for basal and
nutritional coverage. In determining the appropriate dose of
insulin, the total daily dosage of insulin should be calculated
based on the patient’s body weight. Forty to 50% of this total
daily dose should be administered as basal insulin and the
remaining daily dosage should be divided to cover meals/
nutritional intake.8 A suggested algorithm is outlined in appen-
dix 2.
Patients with insulin deficiency require some form of basal
insulin administration at all times, even when they are nothing
by mouth (NPO), to prevent the development of diabetic ke-
toacidosis. Sliding scale insulin coverage is often inadequate in
these patients (see below) and failure to provide stable, basal
insulin can result in significant morbidity and potential mor-
tality. These patients include those with known type 1 diabetes
mellitus (T1D) and those with a history of a pancreatectomy or
pancreatic dysfunction, wide fluctuations in blood sugar levels,
diabetic ketoacidosis, insulin use for greater than 5 years,
and/or a history of diabetes for greater than 10 years.
Correction dose or supplemental insulin, also frequently
referred to as sliding scale insulin, is used to treat hyperglyce-
mia before or between meals and to correct hyperglycemia in
NPO patients or in those receiving basal insulin but not eating
scheduled meals.8 The following correction doses are recom-
mended based on the preprandial blood sugars: 1U per
50mg/dL increment over 180mg/dL in T1D and 1U per
30mg/dL increment over 180mg/dL in type 2 diabetes mellitus
(T2D). While supplemental insulin is useful in tightening gly-
cemic control in the inpatient setting, traditional sliding scales
are dangerous when not used with basal insulin and when they
are not modified during hospitalization to meet a patient’s
changing insulin requirements. Queale et al27 found that the
risk of hyperglycemia among medical patients was 3-fold
higher when sliding scale insulin regimens were used alone,27
highlighting the importance of their use in conjunction with
basal insulin.
Finally, there are conditions in which glucose is optimally
managed with a continuous insulin infusion in the form of a
regular insulin drip. These conditions include the following:
diabetic ketoacidosis and nonketotic hyperosmolar state, peri-
operative care, organ transplantation, myocardial infarction and
cardiogenic shock, stroke, high-dose glucocorticoid use, NPO
status in T1D, critical care illness, and during dose-finding
strategy prior to initiation, or reinitiation of subcutaneous
insulin.
Oral hypoglycemic therapy in the hospital setting. The
classes of oral agents and their mechanisms and onset of action
are summarized in table 2. The use of oral agents in the
inpatient setting has not been well studied. Each class of oral
hypoglycemic agent has restrictions that may limit its use in
hospitalized patients.8 Sulfonylureas are long-acting, which
increases the risk of hypoglycemia, they do not allow rapid
dose adjustment, and they have varied durations of action in
different individuals. Metformin is contraindicated in patients
with congestive heart failure, hypoperfusion, renal insuffi-
ciency (creatinine ⬎1.4mg/dL in women, ⬎1.5mg/dL in men),
old age (⬎80y), and conditions of hypoxia (ie, chronic obstruc-
tive pulmonary disease). In addition, metformin should not be
used in renal transplant recipients due to the increased risk of
renal insufficiency in this setting. Patients with macroalbumin-
uria (spot urine microalbumin ⱖ300mg/g of creatinine) should
have a creatinine clearance checked, regardless of age, to
ensure that it is greater than 60mL·min⫺1·1.73m⫺2. The thia-

Table 2: Mechanism of Action of Oral Agents

Class of Oral Agents Agents Mechanism of Action

Sulfonylureas Glipizide Insulin secretagogues

Glyburide
Glimepiride
Metglitinides Nateglinide
Postprandial insulin secretagogues
Repaglinide
Biguanides Metformin Insulin sensitizer (liver)
Thiazolidinediones Pioglitazone Insulin sensitizer (skeletal muscle)
Rosiglitazone
␣-glucosidase inhibitors Acarbose Delay glucose absorption by antagonizing enzymes that
hydrolyze starches to oligosaccharides (pancreatic
␣-amylase) and oligo-, tri-, and disaccharides to
glucose (intestinal ␣-glucosidases)
Miglitol

Arch Phys Med Rehabil Vol 86, December 2005

2380 HYPERGLYCEMIA IN REHABILITATION, Golden
Fig 1. Algorithm for initiation of oral hypoglycemic therapy. Abbreviations: ALT, alanine transaminase; AST, aspartate transaminase; bid,
twice daily; BMI, body mass index.© 2004 by the Endocrine Society. Adapted with permission.50
zolidinediones may precipitate congestive heart failure due to
increased intravascular volume, are contraindicated in patients
with liver disease, and have a slow onset of action (ie, several
weeks).
In patients who are newly diagnosed with T2D during their
hospitalization, it may be necessary to initiate therapy with oral
agents in preparation for hospital discharge. A suggested algo-
rithm, used by our inpatient diabetes management service, is
outlined in figure 1. Finally, patients well controlled with oral
hypoglycemic agents in the outpatient setting may require
supplemental insulin while hospitalized. Current guidelines
recommend short-acting supplemental insulin as needed prior
to meals (1U per 30mg/dL increment over 180mg/dL).8 If there
is significant fasting hyperglycemia with an elevated glycosy-
lated hemoglobin (Hb A1c) level, consideration can be given to
adding a shot of 10 to 20U of bedtime insulin, in the form of
neutral protamine Hagedorn (NPH) insulin or glargine, to the
oral agents. Initiating insulin therapy in the hospital allows
time for diabetic teaching so that the patient is comfortable
with insulin administration prior to discharge.
Prevention and management of hypoglycemia. Hypogly-
cemia is a side effect of insulin therapy in the hospital and is
usually avoidable. Most studies28-30 showing that hypoglyce-
mia leads to brain injury independent of ischemia have been
conducted in animals; however, a recent study31 in humans
demonstrated axonal injury postmortem in 13 patients with
Arch Phys Med Rehabil Vol 86, December 2005
hypoglycemic coma. Moreover, during acute hypoglycemia,
patients demonstrate impairments in cognition, mood, and be-
havior, and function that may not fully recover until 90 min-
utes32 to as much as 1 day33 after restoration of blood glucose
to normal. Thus, hypoglycemia should be avoided in poststroke
patients. Although the overall frequency of hypoglycemia in
this population is unknown, treatment of hyperglycemia in
acute stroke with glucose-potassium-insulin infusions resulted
in hypoglycemia in 16% of patients in an initial study23 and in
9% of patients in a larger, follow-up study.34
Risk factors for development of hypoglycemia include sudden
NPO status or reduction in oral intake; discontinuation of enteral
feedings, TPN, or intravenous dextrose; administration of premeal
insulin without ingestion of the meal; unexpected transport from
the nursing unit after rapid-acting insulin is given; and reduction in
the dose of corticosteroids.8 Prevention of hypoglycemia in these
settings requires open communication between nursing and phy-
sician staff and recognition of when to administer intravenous
dextrose in certain situations (eg, prior to transport of patient from
the unit after rapid-acting insulin is given).
Impact of Stroke-Related Impairments on Diabetic
Management: Special Considerations—Dysphagia
Dysphagia leads to dietary restrictions; however, it is possi-
ble to provide a pureed or soft diet that also limits fat and
carbohydrate load. Often, institutions will serve mashed pota-
 HYPERGLYCEMIA IN REHABILITATION, Golden
toes and gravy for a pureed diet. This is high in both fats and
carbohydrates. Healthier alternatives may include low fat pro-
teins like tuna salad, ground turkey, or scrambled eggs. Most
vegetables can be pureed as well. Low-sugar puddings and
yogurts are widely available.
Fluid restrictions require particularly close monitoring in
patients with diabetes, who are more prone to dehydration and
renal insufficiency. Patients who require thickened liquids may
require intravenous or percutaneous endoscopic gastrostomy
(PEG) tube supplementation of fluids if they cannot maintain
adequate oral hydration. Chemistry panels should be monitored
frequently, and daily intake and output should also be tracked.
In patients with underlying renal insufficiency who are on
long-term management with thickened enteral supplementa-
tion, scheduled hydration via PEG tube should be considered.
In an algorithm suggested by Kerr et al,35 they recommend
administering 100 to 200mL of water over 2 hours via the PEG
tube after each bolus feeding to maintain adequate hydration.
In addition to adjusting hydration requirements, insulin ther-
apy may need to be adjusted during trials of thickened liquids.
The total carbohydrate content of the meal determines the
amount of insulin coverage; therefore, the carbohydrate content
of a thickening agent is considered along with the carbohydrate
content of the liquid.
Patients who are unable to swallow at all and require enteral
feedings pose a particular challenge. However, in some ways,
these patients may be easier to manage, as their intake is highly
regulated and the exact caloric intake is stable from day to day.
When tube feedings are cycled or bolused, the timing of
nutritional insulin will need to be adjusted to cover these
enteral cycles. Bolus feedings more approximate natural eating
patterns and can be covered with an injection of short-acting
insulin prior to each bolus. Night-time cycled feedings will
require higher dose basal insulin coverage overnight but lower
morning doses. We found 1 study35 that has attempted to create
an algorithm for determining the insulin dosage necessary to
cover PEG feedings. In a study by Kerr,35 after patients are
transferred to their dedicated stroke unit and PEG feedings are
commenced, patients are started on day 1 on a 22-hour con-
tinuous feed and their glycemic control is managed with intra-
venous insulin, with blood glucose readings being checked
every 2 hours. This is maintained for 24 to 48 hours to deter-
mine the patient’s total daily insulin requirement. Patients are
then changed to three 6-hourly feeds and are treated with basal
insulin in the form of NPH at 2200 and prandial insulin prior
to each feed.35 The insulin dose is based on the requirements
in the preceding 24 to 48 hours. Finally, patients are transi-
tioned to three 4-hourly feeds with similar insulin coverage.
Using this method in 332 consecutive patients, they achieved a
mean fasting blood glucose of 158mg/dL with stable insulin
requirements on day 1 (22-h feed; 43⫾5.4U/h) and on day 7
(bolus feeds; 47⫾4.4U/h).35 While they did not perform this
method for patients maintained only on overnight tube feed-
ings, presumably determining the insulin requirement on over-
night tube feedings by maintaining an insulin drip during the
initial feeding period might provide a means for determining
insulin requirements in this setting as well.
Finally, for patients who are not consuming full meals by
mouth and are instead “grazing” on frequent, small meals, we
would recommend a regimen of carbohydrate counting to de-
termine the amount of nutritional insulin required. In this
manner, patients will receive enough coverage to prevent hy-
perglycemia. In this setting, the rapid-acting analogs, such as
lispro or aspart, are preferred, as their half-lives are short and
they are associated with less risk of hypoglycemia. Because of
their rapid onset of action, they can also be administered after
2381
the meal, once it is clear how much actual carbohydrate the
patient consumed.
Impact of Stroke-Related Impairments on Diabetic
Management: Special Considerations—Hemiparesis and
Ataxia and Visual Impairment Impact on
Self-Management
Diabetes self-management education is an essential compo-
nent of the care of patients with diabetes prior to discharge.8 In
its position statement on diabetes education for people with
disabilities, The American Association of Diabetes Educators36
emphasizes that disability does not necessarily preclude pa-
tients from managing diabetes effectively; therefore, persons
with disabilities should be provided with reasonable accommo-
dations, including appropriate, adaptive diabetes self-manage-
ment education and methods.
Hemiparesis and ataxia. Hand function may be impaired
either from hemiparesis or ataxia. This makes self-administra-
tion of insulin difficult. For these patients devices are available
that secure the insulin vial to allow syringe loading with 1
hand. This type of device has also been described as feasible to
construct and assemble during inpatient rehabilitation, gener-
ally by occupational therapists, and taught by occupational
therapists and nursing staff.37-39 Using these devices, hemiple-
gic patients have been reported to become independent in
accurate insulin self-administration within a few days of in-
struction39,40 and to maintain accurate use over succeeding
months, with significant improvement in Hb A1c.40
Limb stabilization devices are available to hold the hand in
place during testing of blood glucose. Large-button meters,
self-activated meters, meters that utilize auto disks rather than
individual test strips, and meters that do not require a test strip
can accommodate for impaired manual dexterity.
Visual impairment. Visual problems may arise from dip-
lopia, hemianopsia, or diabetic retinopathy.41 Adaptive blood
glucose monitoring and insulin injection equipment are readily
available. Rehabilitation providers need to be aware of these
adaptations. Recommended insulin self-administration accom-
modations for visual impairment include: devices that guide the
needle accurately into the insulin vial, syringe-loading magni-
fier devices for reading the calibrations on the needle; devices
with an auditory signal for each increment of insulin being
drawn into the needle; and premixed and predrawn insulin
devices and pens.
Adaptations to blood glucose monitoring systems for pa-
tients with visual impairment include tactually identifiable con-
trol buttons, large print displays, and talking monitors for
step-by-step instruction and reading of results. Methods for
guiding placement of blood on the test strip include curved test
strips to guide the finger to the target and auditory signals that
indicate that a sufficient amount of blood has been placed on
the test strip. A review and product evaluation of accessibility
of 17 blood glucose monitoring systems, with product evalua-
tion of available features for visual impairment, has been
published by Uslan et al.42
Cognitive and mood impairment. Cognitive and commu-
nication deficits can have a significant impact on diabetes
self-management in stroke patients. Speech therapists and re-
habilitation psychologists must assess the degree of deficits and
the potential for new learning. In some cases, the stroke patient
may no longer be capable of self-management, and family
training will be needed.
Clinically significant depressive disorder is present in an
estimated 15% of persons with diabetes and is associated with
poorer glycemic control and nonadherence to diabetes self-
Arch Phys Med Rehabil Vol 86, December 2005
2382 HYPERGLYCEMIA IN REHABILITATION, Golden
care.43,44 Poststroke depression occurs in up to two thirds of
patients and is also associated with poorer stroke recovery.45,46
The resulting high risk of depression in patients with diabetes
following stroke necessitates evaluation and appropriate man-
agement. Choice of effective treatments, including cognitive-
behavioral psychotherapy, antidepressant medications, psycho-
therapy, or a combination may be determined based on
depression severity and symptom profile. When antidepres-
sants are used, selection of agent is based on factors including
coexisting medical conditions, drug interactions, and side ef-
fects. It is important to consider side effects of tricyclics prior
to prescribing them for the patient with diabetes, including
potential for weight gain, potential for hyperglycemia unrelated
to weight gain (nortiptyline), anticholinergic side effects, and
orthostatic hypotension.44 Selective serotonin reuptake inhibi-
tors have not been associated with weight gain or hyperglyce-
mia, and fluoxetine has been reported to improve glycemic
control47; however side effects of gastrointestinal distress, and
sexual dysfunction, which may complicate diabetes-related
gastric and sexual complications, must be considered.44
DISCUSSION
The current literature supports an association between hy-
perglycemia and poor clinical outcomes in the acute stroke
setting. The literature is less clear about the role of tight
glycemic control in the poststroke rehabilitation setting in
improving long-term clinical outcomes. The inpatient rehabil-
itation setting, however, represents a window of opportunity to
tighten glycemic control and to initiate diabetes self-manage-
ment education prior to discharge so that patients can maintain
tighter control after discharge. While there are not specific
inpatient rehabilitation data to support stringent glycemic tar-
gets following discharge from rehabilitation in poststroke pa-
tients, we know that poor glycemic control is associated with
an increased risk of stroke. In our recent meta-analysis of 3
community-based cohort studies,48 there was a 17% increased
risk of stroke for every 1-percentage point increase in glycosy-
lated hemoglobin (a measure on long-term glycemic control).
There are circumstances, however, where glycemic targets
may need to be relaxed at the time of discharge to prevent
complications from intensive therapy, namely, hypoglycemia.
These include patients with a poor prognosis and shortened
APPENDIX 1: INPATIENT DIABETES MANAGEMENT CLINICAL PRACTICE GUIDELINES
ADA8
Target plasma glucose levels:
⬍110mg/dL preprandial
⬍180mg/dL peak postprandial
Intensive insulin therapy:
Maintain blood glucose 80⫺110mg/dL to reduce
morbidity and mortality in surgical intensive care unit
Intravenous insulin infusion:
Post myocardial infarction (followed by multidose
injection)
Major surgery, hemodynamic instability, nothing by
mouth status, poorly controlled patients with
fluctuating sugars, severe insulin deficiency or
resistance
Arch Phys Med Rehabil Vol 86, December 2005
lifespan who are at low risk of developing long-term hyper-
glycemia-related complications of diabetes, and patients who
lack adequate out-of-hospital support to assist with in-home
diabetes monitoring and management, if needed. In these set-
tings, discharging patients with prefilled insulin syringes and/or
insulin pens of premixed insulin (70/30) may be preferable.
While this type of regimen limits the ability to individually
adjust the nutritional and basal insulin, it may provide a safer
alternative.
Areas of Future Research
Our literature review has identified several areas of limita-
tion that need to be addressed in the future by well-conducted
cohort studies and clinical trials of diabetes management in the
acute and rehabilitation phases of stroke recovery. Clinical
trials are needed to study the use of intensive insulin therapy in
the acute stroke setting and inpatient rehabilitation setting to
determine more systematically the extent to which better gly-
cemic control in patients with diabetes may be associated with
improvement in clinical outcomes (eg, medical morbidity and
mortality during hospitalization, stroke recurrence, develop-
ment of further diabetes complications postdischarge), rate of
functional recovery, and of rehabilitation LOS. Development
of additional methods are required for determining the amount
and type of insulin therapy needed to cover tube feedings in
poststroke patients. Finally, well-done observational studies of
stroke and rehabilitation patients with diabetes are required to
determine the frequency of and risk factors for hypoglycemia
in this population.
CONCLUSIONS
Intensive inpatient control is important in improving post-
stroke outcomes and preventing complications in the inpatient
rehabilitation setting. Adaptive devices enable patients to
achieve this, even those with physical limitations. Glucose
management can be challenging in these complex patients;
therefore, the physiatrist should enlist the help of an endocri-
nologist and/or diabetes management team. In the future, op-
timal inpatient management of diabetes will likely require more
systems approaches, including diabetes management teams and
development of clinical management algorithms.8
AACE49
Intensive care unit:
110mg/dL
Noncritical care units:
110mg/dL preprandial
180mg/dL maximal glucose
Values ⬎180mg/dL are an indication to monitor glucose
levels more frequently to determine the direction
of glucose trend and determine the need for more
intensive intervention
 HYPERGLYCEMIA IN REHABILITATION, Golden 2383

APPENDIX 2: ALGORITHM FOR DETERMINING A PATIENT’S INSULIN REQUIREMENT8

Calculate the total daily dose (TDD) of insulin—multiply body weight in kilograms by:
● 0.5 to 0.7U if patient has type 1 diabetes mellitus
● 0.4 to 1.0U (or more) if patient has type 2 diabetes mellitus
Determine the basal insulin requirement:
● 40% to 50% of TDD
● Administer once daily in the morning or at bedtime using a long-acting insulin analog (glargine) or administer using
an intermediate-acting insulin (neutral protamine Hagedorn) twice daily or at bedtime
Determine nutritional insulin requirement:
● TDD minus basal insulin dose
● Split the dose to cover meals
If using lispro or aspart, divide dose into 3 injections (prior to breakfast, lunch, and dinner)
If using regular insulin divide into 2 injections prior to breakfast and dinner

15. Williams LS, Rotich J, Qi R, et al. Effects of admission hyper-

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