esposla Asked October 2017
What important questions should I ask the Endocrinologist?
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My mom is 84, lives in an independent facility with type II diabetes. She injects herself daily with insulin daily, eats 3 times a day. It seems a little dementia has creeped up. I am taking her to her 4th endocrinologist appt in a couple of weeks. Are there any important questions I should ask? My brothers and I take turns.
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You do mention that you mom has some dementia. Is she aware of that? I would discuss it with the doctor, as to not embarrass your mom. But, it's important he knows, because taking insulin injections is risky, if your memory is poor. You could take too much by forgetting and taking it again. Taking pills is risky too, because you could either overtake them or not take enough, door to poor memory. So, you can have too high highs and too low lows. Both not good, but, the lows are the most concerning, since they can cause you to pass out. Her doctor can probably share his thoughts and suggestions. No doubt, they treat people who have this issue all the time.
You might inquire about a medication aid that could administer her insulin and other medications, daily. Could she afford that? But, with dementia progressing, living alone is not a permanent solution. I'd explore plans, because it can progress slowly or quickly. My LO went from running her own household to being completely reliant on others for her daily care and incontinent in a few months. She also had to take insulin and pills for Type II diabetes, but, she wasn't able to remember how to do it. Her doctor prescribed AL. She asked that my LO go voluntarily. (She did. It took a short while to get her own board, but, the fear of her situation caused her to want AL.) I'd explore plans before there is a crisis.
Also, as the family considers the options, I'd consider how they would feel finding her unconscious from low blood sugar, due to taking too much insulin, because she forgot she had already taken it. It's a serious and life threatening risk. I'd discuss it with her doctor.
Another challenge is her remembering to eat. You can't just take insulin and not eat. Your blood sugar can plummet. But, people with memory issues do forget to eat and even reminders escape them. So, even if she had a med aid, she might not eat enough food to handle the insulin and still get drops in blood sugar.
I've thought about this for myself, should I ever need help with my diabetes treatment when I become a senior. It's scary, because it's a lot of work. It's not easy. IMO, professionals are needed to help. I hope you can find some options for your mom.
And for the person or persons who are making decisions regarding mom's living situation and health care decisions. I would get a legal consult with an Elder Law attorney to inquire about your responsibilities and liabilities. I'd be concerned about that and want to make sure that I was on good legal ground.
Who is LO? We have someone come in 2x/day to help with insulin shot and be sure they take their meds; meds are set up by separate person once a week (dad's not happy about it, but we told him mom needs it). We all have DPOA for mom and dad [I have 3 brothers, one of which live 15min from them].
Good to think about your situation as you age. Do you have anyone to care for you as you age ? Does/did your mom have diabetes ?
DISCLAIMER:
I'm just giving suggestions and information. I'm not giving medical advice. Only a physician can definitively tell you what you need to do.
Definitely have the endocrinologist check her A1C. It will tell the doctor what her blood sugar has been averaging of the last 3-4 months. I would consider arranging a home health care nurse visit to check her blood sugar and administer the Insulin shot. It doesn't have to be an RN, depending of the state it could also be a LPN or CNA. Insulin comes in different types. Some are long acting 24 hours, so a once a day injection, others have to be administered 2-3 or more times a day, depending on her blood sugar level. I believe they are developing an implantable insulin pump that is inserted in the abdomen that delivers a continuous rate of insulin and can be adjusted wirelessly with a device that can read the insulin level without having to poke your finger. Not sure if it's available in the States yet. I believe the company Medtronic is making it. There is also a pump with a needle through the skin on the abdomen taped down with an outside pump I believe one has to have excellent knowledge on how to use and calibrate the settings based on carbs that are consumed at meals. This is usually utilized by very brittle Type 1 Diabetics.
Out of range blood sugars can cause altered level of consciousness and confusion. But have the Endocrinologist check for other issues as well, beside her diabetes.
No implantable pump is on the market yet. The pump will release small amounts of basal or background insulin throughput the day. Bolusing insulin will only be done when eating, based on her personal carb to insulin ratio. This makes eating whenever/whatever very flexible. There are many online pump communities for help and advice. Many type 2's use pumps. You may even find her dementia improves.
I am not a doctor and you should discuss with your mom's doctor what would be best for her.
Two years ago I was not seeing the signs in dementia in my mom. They where there but I just did not accept what was happening. 18 months ago mom was found unconscious from her Diebates. She never fully recovered and this past July she passed.
What I have learned. Dementia is a sad silent condition in the beginning. Add in a second medical condition and things get out of control fast.
My mom was on a insulin pump, however having dementia she needed to be taken off. The pump is not an independent thing. You have to test your gluecouse levels, some read them wirelessly and some you have to enter the info in. Then you most enter in the carbs you are about to eat. Then it calculates the amount of insulin to give. It does not just give you a set amount, at give times, that is to dangerous.
The patient has to be able to do these things, plus refill the insulin when needed, change the batteries, check the lines and changes the place of insertion. As dementia sets in there is the free of the patient just removing it as well.
As most know here eating and dementia become a problem. It is difficult in many cases to get the patient to eat at all. They just eat less. Add debiates and this because life threatening.
My mom in the last month's of her life was in a Memory care faculty, just because she needed that extra care for her diabetes. It took me a lot of research to find one that could give her the multi insulin injections she needed a day. As her eating became less and less her sugar levels where just out of control. Each time it jump from a low to a high it greatly damaged her brain (oxygen lot the brain decreases during these events). Her dementia advances rapidly.
I was not ready for her to die so quickly.
This is not to scare or say your mom will have an experience even close to this.
Getting involved her medical care now is the best decision you can make. Let the doctor know what is going on and your concern. If he will not listen, find some one that will.
Thanks for the extra info. LO stands for Loved One. Sorry, I may use it too much. The LO I refer to is my cousin and I am her DPOA and HCPOA. She is a Type II diabetic. My parents are okay right now.
Is there some reason that your dad isn't welcoming with the help coming in? Are you sure the alcohol issue is under control?
Hopefully, I have awhile before I need help with my care, barring something unforeseen. I do have family members, but, managing Type I diabetes is quite a chore and takes years of practice. I can't imagine a novice doing it. lol You have to adjust your insulin intake to cover your carbs and it's a continuous struggle.
I really watch my health, get good nutrition and treat my conditions with the best medical care in the country. My mother does not have diabetes, but, I had two great aunts who were Type I, like me. It's odd. Type I doesn't happen due to lifestyle, weight, diet, but, some unknown reason your pancreas just shuts down. Type I is most prevalent with teens or young adults, but, can happen at any age.
If I may comment on the Continuous Glucose Monitor. It can be very helpful, but, it also can be very challenging. I have one and I will say that it is A LOT of work. There's not enough space here to go into why it's so challenging, but, I would research it a lot before getting one for a senior. You can go online to see testimonials about them. If you want more info, PM me and I'll tell you more. The same goes for an insulin Pump. They are a lot of work and without constant supervision, I'd be wary of one for a senior who is Type II diabetic.
Please post when you get more information. Hopefully, her doctor will have some ideas.
I would recommend you ask the endocrinologist what her A1C is, and also discuss what should be a suitable goal. For older adults, it's often appropriate to aim for an A1C of 7.5% or so. Err a little higher if there has been any concern about hypoglycemia. We even sometimes accept a goal of 8-9% if the person is frail and has limited life expectancy.
I would also encourage you to make sure the endocrinologist is aware of your concerns regarding possible dementia. They may not notice and think to simplify and emphasize safety otherwise. If you aren't comfortable bringing this up in front of your mom, send the info in a letter before the appointment.
(Also, make sure your mom's memory and thinking are being evaluated by her usual doctors.)
In geriatrics, we almost never have people using insulin pumps or continuous monitoring. Usually, the risks and burdens of such approaches vastly outweigh the potential benefits.
There may be some ways to simplify her insulin regimen, it depends on what's she taking right now and how often she ends up too high or too low. Remember that too low is usually a bigger problem for the elderly than too high (provided she doesn't get above 250 or so, which is when many people start peeing too much due to sugar spilling into the urine).
good luck!