Unmanaged Diabetes Equals Complications

Barry called yesterday and said he had an acquaintance with a problem. He said Allen was on the way and asked for my help also. When I arrived, Barry said that a blood glucose meter reading he had given the person said “High.” I suggested that he be taken to the hospital and the person said “No Way.”

I asked what type of diabetes he had and he said type 1. I asked when he had last taken insulin and he said he was out and had not taken a shot since the morning before. At that point I said he needed to go to the hospital as he could develop diabetic ketoacidosis and without emergency treatment he could die. What he said next shocked all three of us. He said that is the plan.

We looked at each other and I said he was going to the hospital whether he wanted to or not. When he refused, Allen called 911 and the ambulance and police were there very fast. Thank goodness for the police as he was very combative. Allen explained what was happening and when they had him restrained, he started convulsing. He was loaded into the ambulance and Allen was asked to go with the ambulance.

Barry and I followed shortly after we made sure that the police has secured his home. When we arrived at the hospital, Allen said that they had treated him and he was stable, but they were monitoring him and put him under a suicide watch. Allen said he would be transferred to another hospital that could give him the counseling necessary and make sure he had the medications needed. Then the Doctor came to talk with us. We confirmed that he had refused to come to the hospital and had not taken insulin for over 24 hours. The doctor asked us several more questions and Barry gave him what family information he knew and the doctor thanked us for calling 911.

When one sister arrived, she asked which one of us had called 911 and Allen received a big hug. She briefly said that he was having vision and kidney problems and may need a kidney transplant, but until he was evaluated, she would not know for sure. She did think that could be the reason he was avoiding taking his insulin and beyond that the family was aware that he was not taking care of himself. She stated that they had been working with him, but he was rejecting help and would not tell them what his blood glucose readings were or where his medications were located.

She asked Barry and Allen to stay until after she had talked further with the doctor and then accompany her to his house and do a search for anything that might be found. She thanked me and I left. Later that afternoon, Barry called and said they had found his medications, but it looked like he had not taken them since filling the prescriptions. They found one vial of unused insulin still within the expiration date, but no others. They had even looked through the waste baskets. They found several unpaid bills and other information that the family will need to take care of and a few other problems they will need to investigate.

Barry concluded that she had contacted the rest of the family and they were at the hospital or would be during visiting hours until he was transferred, probably the next morning.

This is scary what can happen when a person is not wanting to take care of him/her self. This is an extreme example of a patient caused complication.

What Is Unmanaged Diabetes?

When reading this blog, some very definite thoughts came to mind. I do like the topic,

but I become nervous with the wording. I would like to be a little more definitive and clear a couple of points.

The American Diabetes Association (ADA) does use the HbA1c measurement of 7.0% for their guidelines. At least the American Association of Clinical Endocrinologists (AACE) uses the guideline of 6.5%. For those that are very capable of managing type 2 diabetes, many like to keep their A1c's in the 5% range. Others feel great if they can maintain A1c's in the 6% range.

Because doctors and endocrinologists are so fearful of patients having episodes of hypoglycemia, or low blood glucose they become very cautious of anything below the guidelines. Then, when we consider people aging, again they become even more cautious about peoples' A1c. At age 65, they start encouraging A1c's of 7.0 to 7.5%. Then at the age of 70, they want the range to increase to 8.0%.

This is where I disagree with their one-size-fits-all philosophy. I could agree if they were properly assessing us and individualizing our treatment. Some people are able to manage diabetes and maintain lower A1c's. Some lose diabetes management abilities as they age and this must be properly assessed and adjusted to maintain quality of life. Hopefully as they become less capable of managing their own diabetes, there will family or other caregivers available. They will lose quality of life when incarcerated in nursing homes or care facilities.

So what is unmanaged diabetes? Following the above discussion, there are many variables depending age and patient capability. My suggestions would be that for people on oral medications and below the age of 65, then unless they are on medications or a combination of medications that can cause hypoglycemia, the daily blood glucose readings should be used to see how often they get below 70 mg/dl. If they consistently show readings below 60 mg/dl then they need to be assessed to see if they are capable of managing their own diabetes.

This assessment needs to be continued as patients continue to age. Even more careful assessments will be needed if the patient is on insulin. Warning: Insulin should never be the medication of last resort. This is the habit of too many doctors and can lead to complications setting in before insulin is used.