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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Unfortunately many of your ideas are not covered by Medicare for patients with type 2 DM. (Pumps - not appropriate for someone with cognitive decline) A consistent once daily basal insulin like Tresiba has been shown to cause less hypoglycemia and has a more forgiving dosing in that if you miss a dose, you can take it when you remember as long as there is at least 8 hours between doses. If someone has to give your mom her shot, this leeway is a great thing. If she goes to a facility, be sure they can administer insulin and test blood glucose. Not all of them do
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Esposla
The geriatrics Dr. Kernisan and Tattoochick provided you very good advices.
On 1/31/2017, University of Temple published a very important research article confirming that deprive of glucose is the root cause of Alzheimer’s / dementia. Hypoglycemia is obviously the main cause of so many type II diabetics becoming Alzheimer’s. On one hand, post dinner high sugar level makes us hard to fell sleep and causes long term illness of bad circulation on legs and damages kidneys. On the other hand, long and medium acting insulin products can low blood sugar level after midnight, and kill brain cells. The best solution was seen on the ENDO EXPO San Diego a product called 4amglucose, which claimed delivery of glucose around 2-4 am and available online. I have tried it on a few patients, and the response was quite good. At least they feel their sleep improved since they do not need eat food at bedtime and pee at midnight. Besides, I think it’s also a super idea to get a CGM at night if you afford.
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For older adults with diabetes, insulin, and memory issues, it's very important to simplify, and to avoid hypoglycemia. Hypoglycemia is associated with accelerated cognitive decline.

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!
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Esposla,
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.
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Hi,

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.
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Mom's progressive dementia and insulin dependence caused a stepwise progression of care. She stayed in independent living progressing to visiting nurse to supervise injections. She stayed there until she could not consciously maintain a diabetic diet, seeking snacks until her A1C elevated. She then went to Assisted Living for staff to monitor her diet. She has severe dementia with a 1 minute attention span but she can still self inject with supervision. Once that stops, then she will need a nursing home. Having a husband who can help should delay the Assisted Living. Keep monitoring the situation. I would recommend that you get diabetic training on sugars and injections in case something suddenly becomes an emergency situation with her husband and you have to temporarily fill that gap. Do bring in either recorded sugar levels (Mom has them written on a monthly calender)  or bring the meter with you to the doctor as there is a memory in them.
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I would ask about using a continuous glucose monitor if she's not already using one. Also look into a Medtronic 670G insulin pump. If the endocrinologist isn't educated in CGM's and insulin pumps, look for another endocrinologist or certified diabetes educator who is up to date on the technology.

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. 
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Thank you Blue. I will ask Endo Dr about that. She is currently visited 2x/day to help by nurse. I need to find out the law in Florida whether LPN, RN or CNA is required. I would hope the health care agency we use is following correct guidelines. It's a process....that's what my family has been quoting lately.
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Esposla

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.
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Thank you Sunnygirl. My mom lives with dad , but they starting and ending the day togeher would help her. It just may not work out that way. Dad had some alcohol issues that are fixed, so thankful for that. He's helping more than ever, but some hours of the day they aren't on the same page. An alternative treatment has been talked about with Endo, but this seems the best so far. [one insulin shot instead of 2]
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 ?
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