WITH World Diabetes Day falling on Nov 14, 2015, what better time to focus on the disease. According to the International Diabetes Federation, there were 3.2 million cases of diabetes in Malaysia in 2014.
Dr Alexander Tan, consultant endocrinologist and senior lecturer at the University Malaya Medical Centre, says that those caring for elderly diabetics should watch out not just for symptoms of high blood sugar but also low blood sugar.
Some signs of high blood sugar are:
- Increased thirst;
- Increased urination;
- Urinary incontinence;
- Decreased mental function;
- Infections that take a long time to heal; and
- Blurry vision.
Why and when to monitor
According to Dr Tan, blood sugar monitoring is important but it should be done with a purpose as it provides direct immediate information about what is happening to your glucose.
“The problem with glucose in the body is that it’s not like a disease like asthma where you know that asthma is bad because you can’t breathe.
“But, if your glucose is very high, your sugar level is very high, most of the time you don’t have any symptoms until it’s really very, very high … in the 20s and 30s that you start to get lots of urine and other signs. So, blood glucose monitoring is an immediate piece of information for the patient so that you know if his or her sugar is high or not,” says Dr Tan.
He informs that blood sugar monitoring can be used to:
Check which foods cause the elderly’s blood sugar to go up. For instance, if the elderly wants to eat pasta and you want to know if it will badly affect their blood sugar level. Or if someone claims a particular bread doesn’t cause the sugar to become high, then you can test to see if it really does as it claims.
Help the doctor adjust the treatment. The doctor may ask you to monitor the sugar level so that at the next checkup the doctor will know if the treatment is just right or if it needs to be adjusted further.
How often should you monitor the blood sugar level?
Dr Tan says that this depends on the individual. The best thing to do is to follow the doctor’s instructions. Sometimes if the doctor is very active in trying to adjust the treatment, he may ask you to monitor up to six times a day. That is in very extreme cases. Sometimes the doctor may ask you to do the test just once or twice a day.
According to Dr Tan, for most patients, if their treatment is quite stable, then they don’t need to be tested daily, especially if the readings are pretty much the same every day.
“If you want to find out whether eating a certain thing makes the sugar high, then I think monitoring the glucose is actually very useful in that instance, especially before food and after food.
“Monitoring of the blood glucose is a tool. There’s no point to just do it for the sake of doing it. What’s the point of monitoring it daily, writing down the readings but you don’t take any action and the doctor doesn’t even look at it. Then, there’s no point.
“When you monitor the sugar, you must have a purpose – whether you want to find out about a certain type of food, or whether you want to find out if the treatment is working,” he says.
For those who want to monitor the effect of certain meals, then Dr Tan recommends testing the elderly before they eat and two hours after the meal.
“The testing is expensive – sometimes up to RM2 per test. So, there must be a purpose to doing it. The action from doing the monitoring could be no more curry laksa because it’s not so good, it makes the sugar go up.
“Or perhaps you notice that your elderly dad has less appetite and you wonder if his sugar is going high or if it is low. You do it so you get the information, so that you can find out what’s going on,” says Dr Tan.
He cautions carers to watch out for side effects from the medications, especially since the elderly tend to have other illnesses and health problems and are likely to be taking a lot of different medicines.
Low blood sugar
According to him, the elderly who are taking insulin or sulfonylureas can develop low blood sugar, which is also known as hypoglycaemia.
If the elderly takes too much insulin, it can cause very low readings, and sulfonylureas can also cause the blood sugar readings to go very low.
“We like to be extra cautious when we use these drugs. Then we would recommend blood glucose monitoring.
“Low blood sugar can cause an old person to lose balance and knock his head, and that could be the last thing ever to happen to him,” says Dr Tan.
The classic signs of hypoglycaemia are:
- Patient will start to feel a bit weak;
- They may start to feel strange;
- They’ll start to sweat;
- They may start to feel hungry;
- Their hands may start to shake;
- As the sugar gets lower, they may start to get confused; and
- They may start to mix up their words and maybe even start to make unintelligible sounds.
The worst case scenario is that they lose consciousness and ultimately they may go into a coma and die.
“One of the difficult things sometimes is that older people are unable to show these signs. They can’t tell you that they feel weak and hungry. Sometimes the carer just needs to be aware that if they detect that grandpa or grandma is behaving a bit unusual today, maybe they should check their sugar level. That’s one time that blood sugar checking becomes useful. If the sugar is low, maybe you should give the elderly diabetic something sweet. Or if the sugar is okay, then maybe he’s just tired.
“That’s something to be aware of. They may not even sweat because elderly people don’t sweat as much and they don’t even develop any tremors.
“Doing the test takes you about 30 seconds or less. If you have a tester at home, just test and if the sugar is low give him something sweet. But if you don’t have a tester or if he’s already unconscious, then of course you need to get an ambulance to take him to the hospital,” he adds.
Because of the risk of hypoglycaemia, doctors tend to allow the sugar to run slightly higher in the elderly than would be permitted in a younger person.
“We don’t want to be too strict with it mainly because we want to avoid that side effect. It’s bad to cause damage because someone’s sugar is high, but it’s even worse if you as the person looking after them cause it to be too low and then he falls over, knocks his head and has internal bleeding or fractures a limb.
“I think that is the one thing I would look for if I were looking after somebody who is elderly with diabetes,” says Dr Tan.
Diet and exercise
He advises the carer to take the elderly to see a dietitian, who can draw up a personalised diet plan. Each person is different in terms of diet preferences and health issues, so it is best to see a dietitian who can advise on what to avoid and what to eat.
Generally, a healthy diet, and eating everything in moderation is advised. If the elderly has other health problems, then they may need to avoid certain foods.
“You can have cheat days, but don’t cheat every day. We are all human and elderly people also have weddings and birthdays to attend. Just don’t have the cheat meals or cheat days too often. Again, make it meaningful. Don’t cheat just because you’re sitting in front of the TV. There’s no point to it. If you cheat because you are celebrating when your one and only grandson graduates, then that’s okay, we are all human,” says Dr Tan.
He advises carers to prepare the elderly diabetic’s medication for them as the elderly might forget to take their medication.
If the elderly are reluctant to exercise, the carer should try to find out why. Is it because they are tired or in pain? You need to put yourself in their shoes and see why they don’t want to have physical activity.
“Physical activity is something I would highly encourage and if possible do to the best of their ability. Motivating somebody is a different thing. What motivates a person to wake up early to exercise could be a lot of different things, and I guess it’s different for each individual,” he adds.
Eyesight, hearing and infections
Carers should also monitor the elderly’s eyesight and hearing and watch out for infections.
In general, people with diabetes, should get their eyes checked once a year by an eye specialist, not the optician who makes glasses. This is because people with diabetes have a higher risk of developing cataract and internal eye disease or diabetic retinopathy. These eye problems can lead to a reduction in the ability to see and also lead to blindness. The elderly who have diabetes also have a high risk of developing glaucoma. So, a checkup by an eye specialist should be done at least once a year.
The other thing that they should get done at least once a year is an examination of their feet by their doctor. The doctor would make sure that the pulses, the blood flow to the feet, is good. He needs to check for the sensation of the feet to make sure that the nerves are still intact.
Another thing that should be done on a yearly basis by every person with diabetes is to have their urine checked to see if there is any urine leakage. This is a sign that the kidneys may be starting to fail.
Of course they should have, at a bare minimum, blood tests done every year. If something abnormal is detected, the doctor then can advise for more frequent checkups.
Dr Tan says that carers should look out for anything abnormal and if they detect anything unusual, they should bring the elderly to see their doctor.
“I think carers need to realise that in elderly people with diabetes we don’t need to be too aggressive in terms of the treatment. In the elderly we can have a higher glucose level, so don’t be too alarmed if it is just slightly high. If it’s 10, don’t be too alarmed. Sometimes that’s okay as long as it is not very, very high or not too very, very low,” says Dr Tan.