Need some advice for my dad please

My dad is a Type 2 diabetic and his doc is trying and failing to get him regulated.

Not sure how much he takes, but he’s on long-acting only Lantus i believe. His MD only has him check his sugar twice per day, and I’ve told him to do the Dexcom Hello at least, but he refuses.

Last night, my mom said he woke up delirous in the middle of the night, tested at 57. She gave him a bunch of carbs and it went up to 140.

So I guess my questions would be:

  1. At what point do they need to call 911?
  2. Wouldn’t it be a good idea to split the dose into 2
  3. At what point would he need to consider adding short acting meatlime insulin?

This is all with MD approval of course.

He is just so stubborn! He has all kinds of other heart and health issues as well, so dibetes is really at the bottom of his list. But I hate to see it not controlled like that!

This is really a tough one, because 57 to one person is critical, while a nothing burger to another. I regularly run 57 and don’t really begin to consider myself as beginning to be low until under 55 but I normally keep my range between 55 and 95. Someone that normally has a range of lets say 150, 57 is critically low.

Pushing the CGM, where it is covered by Medicare is really a no brainer so try everything to make him think CGM is a great idea.

I don’t believe in long-acting Lantus as it consistently gave me nighttime lows but nobody can convince an endo of that experience unless backed up by CGM data. I have been totally off lantus for the past few years. Short acting Humalog is all that is needed and even very little of that if eating fairly low carb and exercising.

He also does not seem to be that bad off if he only goes from 55-140 with a bunch of carbs.

Any chance of getting him to at least consider a program like virta health by telling him they could most likely get him off of all medications. He sounds like a potentially ideal candidate for virta. It sounds like with his attitude, if he buys into virta, he would pig headedly get his BG under control and keep it there.

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Unfortunately sometimes it can be difficult for some when you are older to want to make changes or adjustments. But if he is dropping too low at night, his Lantus dose is too high and probably should be lowered. They should put a call into their doctor immediately to get direction of what he wants them to do. If something happened and it’s a fluke or??? A lot of older patients also have a tendency to want to follow doctors orders exactly. So any changes need to be done through his doctor.

If you are not used to lower numbers, you feel them more. “Delirious” sounds bad so that’s a concern you need to ask his doctor about in case other factors are involved. If I fall under 60 I get jittery and really don’t want to focus on anything except downing juice or some gummy bears, other people are more used to it and feel nothing and are fine. But that is not your Dad , especially since other conditions are involved. I don’t believe they will want him even close to going to 57. And your Dad is also on heart meds and that might add to whatever is going on.

Lowering his Lantus might raise his overall numbers, if it does optimally you would add a fast acting insulin. That would be great but the problem becomes the engagement of the patient. If he doesn’t want to deal with changes, he might not want to take a fast acting insulin or learn how to do it. Sometimes they can give a patient a small set amount with meals, that still comes with extra risks. The doctor will have to try to judge if it should be added to your Dad’s regimen and if your Dad even wants to try. Sometimes the safer option might not always be the optimal option.

Of course a Dexcom would be the nicest one to get but the new Libra2 has alerts and is easier overall, and advertised more. You could try to see if he would be more open to that? It’s less complicated, less fuss etc. It would be a lot easier for him to get and that sounds important. Sometimes people want easy even if it doesn’t do as much.

His low is no different than yours, as long as he is able to ingest carbs on his own there is no need to call 911, If he was unable to safely swallow carbs or was too combative or refused carbs offered by you mom that would be the time to call 911.

Possibly, the idea is to time peak insulin action to when its most needed and avoid action when it is not needed. This can often be done by splitting dose.

That is the sixty four thousand dollar question for type 2s. The answer is always the same in T1s but in T2 you have a lot more factors to consider. How much insulin does he make, how bad is his insulin resistance and more must be considered. There is no set protocol for T2 and insulin. Some doctors will start with basal only and add bolus insulin if basal only will not do the job, some doctors take the opposite approach and start with bolus insulin first. Heck my brothers doctor started him on 70/30 mixed insulin at meal time.

It looks like your doctor has chosen the basal insulin first approach. It will be time to add bolus insulin when his insulin requirement requires more fine tuning than can be achieved with basal alone. Even then don’t expect his MDI regime to look like yours, especially if he is being treated by a GP

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Thanks guys for the replies. Not sure if it’s hi GP or an endo he’s consulting with.

My mom said when he awoke in the middle of the night he was talking nonsense and couldn’t cary on a conversation. she didn’t take his number at first but assumed he was low and gave him some carbs and then took it later, so unsure how low it actually got.

57 for him would be really low because he is typically in the 100-120 or so range when the insulin is working. My mom cooks for him and cooks very healthy. I think they just panic when he goes even the slightest bit low (80s) and he binges and then goes too high.

He’s been go the standard diabetic classes and has seen the dietician, but as we all know, they don’t always give the best advisce.

I really wish he’d give in and get a dexcom or yes even a libre. He just doesn’t want another thing attached to him and doesn’t have a smart phone, so he’d have to do the handheld that Dexcom provides. Neither he nor my mom want a smart phone. They only have a tracphone flip phone for emergencies. They are old and set in their ways.

My dad already has a pacemaker/defribulator implanted, is on constant Oxygen and CPAP at night. He can barely walk 10 feet without being tired/winded. Definitely one foot in the grave if you know what I mean. I want him to have the best quality of life he can for as long as he can. He knows he is not in good health. He also won’t go into a nursing home which really is where he belongs. He’s wearing my mom out.

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I agree with everything that everyone else wrote.

Here’s my strategy for dealing with other people’s medical problems. I identify (sometimes its as easy as asking and sometimes you don’t even need to ask) what is more likely to motivate them taking care of themselves. Your gonna have to play to that motivation. I WARN YOU, sometimes these appeals are not as effective when they come from individuals within the family. My success rate is much higher appealing to individuals outside my family.

There are people who are primarily motivated by their own interests - They might not want to deal with the hassle of diabetes, or they might not want to get into any trouble, or pay the $ to go to the hospital, etc.

There are also people who are better motivated by appealing to them about the effect of their illness on others. For example, “Mom was really scared the other night,” or “The effects of diabetes are putting unbearable burden on the family.”

If your going to make an appeal for a change in behavior or A1c or technology or anything, know walking in what will primarily motivate him better - his own interests or the desire not to be a burden on others. Often, you end up touching on both.

Do you feel like you could have a diabetic to diabetic chat with him? You are rather experienced at talking to diabetics. I might call this a ‘specialty’ of yours and I feel like you could make some ground here. My best friend taught me that it is always better to start a conversation like this by talking about yourself. You open up and say, “I feel like I would feel more secure if I had a family emergency plan for what to do if I am hospitalized. This is a list of all my medications and dosages - I want everyone to have a copy.” Then, see where that goes. Let him think about you and your relationship with your illness. That will spark him thinking about his own.

God bless you, Brad. This is a tough one.

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