Self-care at home
Home healthcare services empower eligible patients with diabetes to manage their condition without the need for frequent hospital visits.
DEALING with diabetes can be a challenge.
From establishing a healthy lifestyle to managing blood sugar and insulin levels, the needs of diabetic patients are not limited only to adequate glycaemic control, but also with preventing complications, limiting disability and rehabilitation.
To live long and healthily with the disease, you and your healthcare team have to work together for good outcomes.
However, at the end of the day, the onus is on you to manage your condition, especially so if you’re able-bodied or fall into the younger age group.
Despite over two years of living with Covid-19, there are still those who fear visiting hospitals, which can result in their conditions deteriorating.
This is where home healthcare can come in and be of assistance.
Diabetes patients who would benefit from this service – available in some government and private hospitals – are those with frequent hospital admissions, diabetic wounds or foot ulcers, multiple new medications, or underlying disease processes that may contribute to poor diabetic control.
“If you are diabetic, you must take care of your health at home,” says endocrinologist and diabetes specialist Dr Wong Ming.
“For patients who are young, independent, knowledgeable and
have well-controlled diabetes, they do not need much monitoring.
“But for those who are elderly, are on insulin and have other problems such as liver or kidney failure, we worry when we give them hypoglycaemic agents as they are at risk of hypoglycaemia.
“These are the patients that need close monitoring, and if they don’t come in for follow-up appointments, it could worsen their condition.”
Hypoglycaemia – also called “hypo” colloquially – is a state where the level of sugar (glucose) in the blood drops too low.
People with hypoglycaemia often experience headaches, dizziness, sweating, chills, nausea, shaking, trouble speaking and anxiety.
Left untreated, this condition can lead to seizures, unconsciousness, and eventually, death.
“When people get hypo, it scares them. “Family members have told me their grandpa or grandma got hypo and died in their sleep – we don’t want that to happen,” says Dr Wong.
Self-monitoring
To reduce hospital visits, diabetic patients are asked to monitor their glucose levels up to four times a day through the finger-prick test.
They then report their results via calls, emails or texts to their assigned diabetic educator, who will then input everything systematically and show it to the doctor.
The doctor will then adjust the oral hypoglycaemic agents or insulin levels according to what is happening at home.
Dr Wong says: “Usually, I will ask patients to write their readings in a ‘homework’ book or piece of paper, snap a picture and send it to us.
“Sometimes, when they send an update, there will be a lot of other scribblings, e.g. their blood pressure readings, what they have eaten, etc.
“My nurses will write it all down properly and I’ll have a quick glance before giving feedback to the patients.
“During that time, if let’s say they have a better appetite or they eat more, we will also educate them on what carbohydrates to reduce.”
Patients are required to send their information in either two or three times a week, once a week or fortnightly, depending on how well controlled their diabetes is.
“Most patients are not too bad at following instructions.
“Of course, there are the extreme ones who will take their readings several times a day and those who will only take it once in a while.
“The sicker they are, the more they are willing to follow (instructions),” she adds.
Dr Wong notes that the doctor is the one who decides who can be monitored at home.
She shares that most of the time, it is the doctor who suggests home healthcare to the patient as most are unaware that the service is available.
Meanwhile, patients with foot ulcers and who require wound care – common complications of poorly-controlled diabetes – will be monitored by the orthopaedic team.
“The majority of these patients are elderly and if they have type 1 diabetes, we monitor them even more closely.
“I will see them once a month or so depending on how ill they are, as I cannot just prescribe a medication and leave them alone.
“But, if in between, they’ve got issues, then I’ll call them to come in a week or two earlier to titrate their medication.
“Our diabetic educators don’t go to the patient’s house – that comes under nursing respite care; when these nurses visit the patients, they will also help us monitor the glucose levels,” explains Dr Wong.
When to get help
If the patient has blood glucose levels that are really high (10 or more mmol/l) or low, they are advised to go to the hospital. How high can the level go? “We’ve seen up to 90 (mmol/l)!” exclaims Dr Wong.
“It is rare, but poorly controlled diabetes levels can range from 40 to 50 (mmol/l).
“With home monitoring, they don’t reach those high levels as we keep them in check.”
Newly-diagnosed diabetics who come in with foot ulcers are given high doses of medication to quickly
get their blood glucose levels under control.
However, there is a possibility that they might get hypoglycaemic after a week or two.
She says: “This is because they start controlling their diet and the medication has started to kick in.
“That’s when the diabetic educators will call them and tell them to reduce their medications.
“The challenge for home healthcare is how motivated the patients are to take care of their health.
“Some feel it’s too troublesome to prick their fingers four times a day.
“We listen to their problems and negotiate – maybe they can do it twice a day.”
The compliance, according to her, is around 80%.
As diabetes is a chronic disease, the patient’s motivation may go up and down over time.
And the continual testing is not cheap.
In addition, some become anxious and depressed, especially when they see the high glucose numbers.
Dr Wong says: “We have to handle every patient differently,
“When we talk about seeing a
psychiatrist or psychologist, then they decide they can deal with the mental part themselves, or they don’t consult me any more!”
As with most other non-communicable diseases (NCDS), following a healthy lifestyle helps slow down the progression of disease, i.e. eating a balanced diet, being physically active, self-monitoring, being compliant with medications and reducing risky behaviour.
No longer allowed to lie
Miracles do happen and deputy nurse manager Sister Janet Tan has witnessed this herself during her career in home healthcare.
An elderly woman was admitted for diabetic ketoacidosis – a lifethreatening diabetic complication where insulin levels are so low that the body starts to break down fat, resulting in high levels of acids known as ketones in the blood.
She became comatose, was ventilated and remained in the intensive care unit (ICU) for a month.
At 88, her chances of survival looked bleak and the doctors recommended comfort care and private home nursing.
With a heavy heart, the family
accepted this after they were informed the patient would only live for another month or two.
Tan recalls: “Prior to this, her son told us that his mother would not follow insulin instructions and would tell the caregiver to adjust the dosage.
“She would lie to the doctor about her readings.
“The son knew this was happening, but couldn’t do anything as the mother was a matriarch.
“After she went home, the family engaged 24-hour nursing care, and believe it or not, her blood sugar stabilised, she regained consciousness and was transferred to a wheelchair!
“She was a stubborn old woman, very set in her ways, but because we were monitoring her 24/7, she couldn’t do anything outside the doctor’s advice!”
The patient lived for another seven months, and towards the end, she started having delusions and became emotionally unwell.
“The seven months gave extra time for the family to prepare for her ‘departure’.
“She passed away in her sleep on the same day of the death anniversary of her husband,” shares Tan.
Timely intervention
Nurse Siti Nur Hidayah Abdul Samad shares an incident where she helped prevent a patient from going into hypoglycaemic shock while she was doing nursing respite care.
“The apartment was locked and I knocked many times, but no one opened the door.
“The patient stays with her 95-year-old mother who cannot hear properly.
“So I went to the window and saw that the patient was restless.
“She eventually fell off the bed and I ran to the neighbour to contact the patient’s sister for the key,” she remembers.
While waiting for the sister, Hidayah and the neighbour saw the key lying on a table, grabbed a broom and successfully manoeuvred the key out through the grill gate.
She continues: “We opened the door and I quickly did a random blood sugar test and found the patient’s sugar level was dangerously low.
“She was sweating on the floor and I made her a cup of Milo.
“When I checked her sugar level again, it was 3.9 (mmol/l).
“I calmed her down and only then did her mother come out from the next room to ask what had happened!”
Hidayah stabilised the 60-plusyear-old patient, who had previously suffered a mild stroke and was referred to nursing respite care after being discharged from a government hospital.
“If I was not there, the patient would have been unconscious – that was how she was initially admitted.
“She works for a kindergarten and her kind employer sponsored her private nursing care.
“Today, the patient is able to walk using a walking frame and we tell her not to skip breakfast,” says Hidayah.
The demand for home healthcare, especially nursing respite care, has steadily increased during the Covid-19 pandemic.
More families, if their wallets allow, are opting for this service because they cannot get a foreign maid or are wary of hiring one due to fear of exposure to Covid-19.
Most home healthcare teams comprise trained, qualified and experienced healthcare personnel from a hospital, so patients feel safe putting their trust in them.
Plus, such teams also have direct access to a doctor for consultation, which is a good advantage for any medical situation.