Dangers of delayed or self-diagnosis

MRS Maharaj,* who her family affectionately call “Nanni,” is 75 and has been a regular patient of mine for the past five years. She is diabetic.

She was initially been seen by me because her son believed her regular dizzy spells and blackouts were linked to a medical condition, and not “tiredness,” as Nanni had described it.

For a long time she had believed her monthly “sugar” (blood glucose level) check was adequate monitoring to remain healthy.

However, there was a catch – when she first consulted me, Mrs Maharaj said she used to fast every day before her monthly clinic visit, to ensure that she had a good sugar reading.

This was done so the nurse at the day care centre would not scold her, as she done other patients with high sugar readings.

Mrs Maharaj also had other medical conditions, including high blood pressure, rheumatoid arthritis, peptic ulcers, dyslipidaemia (high cholesterol) and a history of angina (chest pains). She had been in hospital for various operations.

Before consulting me, she had not done any home care or selfmonitoring, as she had believed that her monthly clinic visits and daily medication were enough.

She also believed that although she had been prescribed her diabetic medication to be taken twice daily, that was too much.

She decided that because her sister was taking the “sugar tablets” (diabetic medication) once a day, she could do so too! It was therefore no surprise when her first random blood glucose reading was 26 mmol/L (26 on the “sugar machine”).

At that stage, she excitedly said that her sugar was always “normal” on clinic days.

During the first consultation I recommended to the clinic that she be issued a glucometer (known by most older patients as a “sugar machine”) and the required test strips for testing twice daily.

I also recommended that her son keep a diary of her daily readings.

At a second visit four weeks later, she was ecstatic to tell me that her home testing was showing that her blood sugar levels were much better – in the 16 -18 (mmol/L).

I was shocked, but tried to understand why she believed this to be good news. She told me that most of the older patients who attended the clinic and did testing at home were in the same range, but cheated on clinic days.

She was also excited that the dizzy spells had stopped, but the “poking and rubber pads” under her feet were getting worse. What she was referring to was peripheral neuropathy (see below).

It was at that stage that I had to have a discussion with her and the family to educate them more about diabetes and the importance of proper care.

First, diabetes is a life-long condition, but it can be treated, and the complications of the disease can be minimised and sometimes avoided with proper care and discipline.

The normal range of blood glucose in non-diabetic people is between 4 and 7 mmol/L (4 and 7 on the “sugar machine”). This is also considered the target range for diabetic patients.

Patients with other health concerns, such as hypertension and cardiac problems, need more aggressive care and closer monitoring.

The reason for this extra care and stricter discipline is simple. Blood circulation in the body is to a large extent a closed loop system.

An increase in blood pressure, as in the case in hypertensive patients, puts a strain on the entire circulatory system, including the brain and the heart (as the pump).

When the blood glucose level increases beyond the normal range, it is similar to adding sugar to a glass of water. The more sugar in the liquid, the thicker the liquid – or in this case, the blood.

This thicker blood becomes harder to pump within the circulatory system, and puts further strain on the heart itself, which can lead to cardiac complications.

The high glucose in the blood also begins to deposit itself in the blood vessels and in the capillaries near the nerves endings in the limbs and other organs.

These deposits over time cause the nerve endings to die off, and result in loss of sensation and pain in the limbs known as peripheral neuropathy.

The first areas that experience this are the feet, due to gravity.

The next major system that is affected is the eyes. The retina of the eye is very vascular and is quickly affected by high blood glucose levels.

The complications result first in blurry vision due to diabetic retinopathy, and eventually blindness, due to retinal detachment.

In the gut (digestive system), these complications can also lead to damage of the autonomic nerve system, which can lead to a condition known as gastroparesis.

This partial paralysis of the stomach and digestive system can result in increased heartburn, a feeling for fullness after only a few bites of food, palpitations, and lack of appetite.

Diabetics also have poor wound healing and therefore even a needle prick or thorn in the skin can become a complicated medical concern.

These are only some of the key major complications of diabetes.

They can be avoided by proper care, regular medication and testing, and a controlled diabetic diet.

Older patients need understanding and support to ensure that they are adhering to their treatment, diets and checkups.

If in doubt, please visit your family doctor for more advice and support.

*Name changed for confidentiality

- DR TERRENCE KOMMAL