Hospital discharging mil with diabetes levels not great.

[Burlea]

I'm posting on aibu for traffic.

I had another thread on elderly parents about mil. (91 years old) She has been in hospital for 2 weeks with a horrible water infection and uncontrollable diabetes.
On the first ward she was on there wasn't enough staff and we were concerned about her diabetes. Last week she was moved to a rehabilitation ward
where she has improved no end. The water infection has gone she can now wash, dress and take herself to the loo.
The biggest problem is her diabetic levels. On Monday we were assured that she wouldn't be discharged until they had it under control.
She is being discharged tomorrow and a district nurse will be calling every day to inject the insulin.
I don't know enough about diabetes to know what is best. Every morning since she has been in hospital her blood sugar is less than 3 and goes up
during the day sometimes as high as 27.
This morning her level was 1 and she was given lucasade, Weetabix and tea to get the levels up. When we were leaving tonight her reading was 13.
She lives on her own. We have spoken to the doctor and the discharge officer and they both said she'll be ok at home.

If anyone has any advice on helping an elderly person with diabetes we would be pleased.

She needs more than one injection a day, though perhaps she's on different insulin than I am (is she type 1 or 2?). I'm type 1 and need insulin every time I eat.
Does she test her blood sugars several times a day? If her levels were fluctuating so much in hospital what have they recommended for her to stabilise them at home? Did they suggest she get a pump? How was she managing before?
The problem with hypos is one can get very confused, and of course can go into a coma. She needs to eat regularly and test her blood alot. If she can't do this on her own I can't see how she can continue to live on her own.

I think it's v unlikely the would suggest a pump.

She's 91, it's overwhelmingly likely she is insulin treated Type 2. The aim will be keeping sugars under a reasonable control to avoid hypos and severe highs - it's not like managing a young Type 1.

Once a day insulin from the DNs is a very typical way to manage this.

Pipandmum she is type 2, until she went in hospital she was just on tablets but the water infection messed everything up and they started her on injections.
In the hospital she has insulin in the morning and tablets the rest of the day. They have told her and us she only needs to test her bloods in the morning but they
have been doing it 3 times a day. And they have also said to eat small but often and have a sandwich before bed.
The district nurse will give the injection as she has arthritis in her hands and can just about hold a fork.
No mention of a pump, if it's even possible for her. At 91 learning to test her bloods might be impossible.
We have started to broach the subject of her going in a home but she is very stubborn.
We are sure that when she is home and realises the reality of living on her own might help to change her mind.

Does she have a phone or tablet, you can get something put in your arm that reads your levels and sends it to the phone

If her level is going down to 1 mmol/L then she is not safe to be left on her own. It's very likely that at this level she'll go unconscious - I'm really surprised she was able to drink tea and eat weetabix, but it can happen. If she's on her own and it's low she's possibly not going to be able to call for help.

@Bloke23 CGMs have not been approved for Type 2 diabetes YET

Type 2 or not, if an infection has caused such a swing in blood sugars and ill-health it might be worth looking at a freestyle libre. You wear a small disc on your arm (self-adhesive disc) and instead of drawing blood onto a testing strip you simply pass a small hand-held device over it. You can tell what it is any time. My sister has learning difficulties and this really assists her independence. The problem may be getting a meaningful understanding. She should be under the care of a diabetes nurse whom she can contact if concerned (we have a team email for our local clinic) but Diabetes UK have a phone line for general info and can give specific advice on what to do in some situations. Worth doing the homework as it should become manageable. Really important that she keeps well hydrated.

At 91, strict blood sugar control to avoid complications in the next 20+ years is no longer the goal. A pump would be entirely inappropriate. It is also common to avoid the basal bolus routine of multiple injections a day used by younger people. The goal posts have moved. The most important thing is that uncomfortable symptoms are controlled and the person is able to live as independently and safely as possible.

BSLs in hospital are often different. Infection can make BSLs much higher. Low BSLs can happen when a person is on the diabetic hospital diet instead of what they usually eat at home. They resolve when back on the usual diet at home.

Is she aware of hypos and able to act quickly to treat them? If not, she shouldn’t live alone. However, she may be prepared to take that risk rather than move to residential care or have a carer in the home.

You can buy libres but they are expensive. There is sometimes funding for specific circs, such as her age, risk, hospitalisation and so in. Maybe worth buying in v short-term whilst things are settling down for everyone’s peace of mind.

I wonder if her highs a actually as a response to the hypos when they treat with additional sugar and actually her insulin regime is too tight.

If she does go home ( and I don't believe hypos down to 1 are anywhere near safe enough!) ask to be seen by the community diabetic nurse specialist ( or if she hasn't already been seen by the endocrinologists in the hospital).

I was wondering if the highs are rebound highs following on from the lows, which are down to what she has eaten.

Just to add; you can buy the libres from local chemists but I’ve found best place is from Asda. They do vary in price but the cheapest I have managed to get them for was £44, which included a vat exemption. I fill in a form at the chemist for the reduction. I have a funny feeling that type 2s don’t get the same discount as a type 1 but I could be wrong.

Anyhow, I think the libres are really good but only if you scan at regular intervals otherwise they are pointless.

When I’m high, I feel absolutely exhausted and belligerent. People often talk about signs and symptoms of lows, but when I’m high, my eye sight goes blurry, I feel achey, often sick and could sleep standing up. There are lots of physical symptoms that your mum is likely to be experiencing, combined with crashing lows, which can be exhausting.

I hope you get the support you need. There are some excellent resources out there.

I’m a doctor. She is not safe to be discharged. Refuse to take her home and call Pals

There are 2 main types of insulin long acting and short acting, most people are on a mixture of both.
If her early morning levels are that low it sounds if her eve long acting needs reducing possibility by 2 units then review.

That all sounds quite normal actually. She's type 2 and will be seeing a nurse daily. Multiple blood tests a day are going to unnecessarily affect her quality of life, as will staying in hospital. Go with the guidance from the team of specialists whom are managing your mum, don't try to supplement it with additional testing over what is required! If she feels comfortable and well/ normal self it doesn't matter what her sugar levels are

Nope not safe, if she is hypoing at 1 in the morning and then not getting seen by nurse until later at home she may not be in a position to treat herself and could end up in a coma.
I would be talking to the discharge coordinator for the ward and the ward doctors as she doesn't sound medically fit for discharge.

Surely the insulin just needs to be stopped?

If her sugars were controlled on tablets before she became unwell. Only went off because she had an infection (and assuming liver/kidney function are back to her baseline) then put her back on her normal regimen that she was familiar with.

Insulin is great when temporarily unwell. But now her insulin requirements are lower because her uti is better. Which means she will have hyped and then reactive highs. Ask the drs to consider if they should stop it and put her back on her tablets. She needs to be safe. A hypo of 1 is immediately not safe (whereas highs in teens after a meal is much less worrisome in her age. Tight control is not the aim here)

Been here with MIL. Constantly in and out of hospital, caters 4 time a day and DN going in at least 2 a day.
Trying to ensure the caters and DN worked with eating times etc was impossible she was constantly either hypo or hyper!

No advice really just sympathy.

Olympic ....
regardless whether you are a doctor you are not qualified to make the assessment over the internet that this lady should not be discharged and advise family not to take her home. The lady has been clinically assessed and the family have been told by the doctor and discharge officer it's ok for her to go home.
Refusing to take her home and prolong her time in the hospital may expose het to further risk of infection. Also this lady may retain the capacity to make her own decisions so it's not just as simple as family refusing to take her home.
Just be mindful of the very very concrete statements and advice you throw out please. They can have serious repercussions.

OP I would ask to meet with the doctor or hospital Social Worker and put your concerns and questions to them and find the best way forward for your MIL

Hamsterholder.. very sensible advice

I'm more worried about the lows than the highs.

She is 91. What nobody is going to do is put her on a CGM or pump. You need to know about how it works and how to insert it and solve problems if it doesn't work. You can't expect that from someone with arthritis who is also 91!

People try to avoid highs because they can cause blindness and kidney damage 20 years later. She is 91 and win't be alive in 20 years so no need to try to get a very good control.

The lows can make her unconscious and can be dangerous. These are caused by too much insulin versus not eating renough carbs on time. The fact that they are only injecting once a day (presumably a long lasting insulin) means that they are trying to not let her go low. The advise to eat little and often does the same thing. Once her infection clears up her levels moght also stabilize.

Can you try to let her eat something carb high before she goes to sleep to avoid the morning low? Could be a glass of juice?

When we were leaving tonight her reading was 13.

I'd be happy with 13 in an old bird like her. It's not so high that it's uncomfortable for her and won't send her into DKA as long as she keeps hydrated. It's not worryingly high.

Doctor here, no way on earth would I discharge a patient with levels of 1. Levels that high should also being checked for HHS (and DKA!)

Every morning since she has been in hospital her blood sugar is less than 3 and goes up

That sounds potentially dangerous. She might need less insulin and/or her injection at a different time. Ensure she’s being seen by a diabetes specialist nurse rather than a general nurse. They have much better understanding.

I wouldn’t want my relative at home if her levels were dropping so much overnight.

As a PP said, if she was ok on tablets before, she might be able to stop the insulin altogether.

This is the Diabetes UK website (watch out for sites with similar names that are nothing to do with this charity - misleading):

www.diabetes.org.uk/

They have a Careline and also information you can read online.

1 - I thought most people at that level would be unconscious?

Will she have carers coming in??