Diabetes and Low-Sugar Emergencies: A Family Plan

What is a low?

Blood sugar below the normal range. Doctors commonly treat a reading below about 70 mg/dL (3.9 mmol/L) as low, and below about 54 mg/dL as seriously low, but your doctor may set a different level for your parent. Lows can occur with insulin and with some tablets that push the body to make more insulin; they are far less likely with some other diabetes tablets used on their own, but ask the doctor which applies. Lows can also occur in people without diabetes, from illness, alcohol, fasting or other causes.

Signs of low sugar

Early: sweating, shakiness, hunger, fast heartbeat, anxiety, tingling lips, headache, pallor, dizziness.

Later: confusion, difficulty concentrating, slurred speech, blurred vision, weakness, unusual behaviour (irritability, aggression, silliness), unsteadiness, drowsiness.

Severe: unable to swallow or help themselves, seizure, unconsciousness.

Older adults may have few early signs, or only confusion or a fall, and some heart medicines mask the shaking and fast heartbeat. A person who is suddenly confused, drowsy or behaving oddly, particularly one with diabetes, should have their sugar checked, if a meter is available, or treated as a low if in doubt and safe to swallow. Remember that confusion with other causes needs a doctor; see delirium in older adults.

The family plan: step by step

1. Recognise and check. If you suspect a low, check sugar with a meter if one is at hand and it takes seconds; see how to test blood sugar at home. Do not delay treating for long if the person is symptomatic.

2. If the person is awake, can swallow and can sit up: treat now. - Give 15 to 20 grams of fast-acting sugar. In practical terms, doctors often suggest options such as glucose tablets as directed on the pack, about half a glass (about 100 to 150 ml) of fruit juice or a sugary drink, or three to four teaspoons of sugar dissolved in water. Confirm the amount with your doctor. Avoid chocolate, biscuits or fatty foods for the first treatment, since they act slowly. - Wait 15 minutes and recheck. - If still low, repeat the treatment. - When sugar is back to normal, give a snack or meal with carbohydrate and protein (a slice of bread, roti with curd, biscuits with milk) if the next meal is more than an hour away, to prevent another low. - Rest, and do not drive or exercise for a while. - Tell the doctor the same day.

3. If the person is drowsy, confused and cannot swallow safely, is having a seizure or is unconscious: call 112 immediately. - Do not put food, drink, sugar or honey in the mouth, which can cause choking. - Lay the person on their side (recovery position), tilted slightly forward so that fluid drains from the mouth, and keep the airway clear. - If an emergency injection kit has been prescribed for this person and you have been trained, use it as taught, and call 112 anyway. - Stay with the person, note the time, loosen tight clothing and protect from injury during a seizure (do not hold them down or put anything in the mouth). - Tell the ambulance crew: the person has diabetes, what medicines they take, and the last meal time. - After recovery, the person still needs a medical check, since the cause must be found, and some lows can recur.

4. If you cannot check the sugar: if the person is awake and able to swallow and has diabetes with symptoms, treat as a low. The risk of giving sugar to someone whose sugar is actually high is small compared with the risk of not treating a low. If unsure, get help.

Who is at risk

• Those on insulin or on tablets that can cause lows.
• People with kidney disease, as medicines build up.
• Those who eat irregularly, skip meals, have poor appetite or dementia; see dementia, eating and weight loss.
• Frail and very old people.
• Those who live alone or are alone for long periods.
• People with a history of lows, or who do not feel early signs.
• Those who drink alcohol, particularly without food.
• Those with liver disease, adrenal or thyroid problems.
• People who exercise more than usual; see exercise with diabetes.
• People who are ill, vomiting, have diarrhoea or fasting; see fasting, festivals and older adults.

Common causes of lows

• Too much medicine for the amount eaten, a dose taken twice by mistake (a common problem in memory loss), or a change in dose.
• Skipped or delayed meals, or a meal with less carbohydrate than usual.
• Unplanned exercise or heavy activity such as long walks, gardening or travel.
• Alcohol.
• Weight loss or reduced appetite, which change medicine needs.
• Illness, vomiting, diarrhoea, fever, kidney decline.
• Wrong insulin technique, injecting into muscle, a different insulin or a missed check.
• Mix-ups of medicines in a pill box.
• Interactions with other medicines or herbal products; see supplements and medicine interactions.
• Hot weather, which can speed insulin absorption and reduce appetite; see heat stroke and dehydration in seniors.

Preventing lows

1. Agree individual targets with the doctor, which for older adults are often more relaxed to avoid lows; see diabetes at home after 60. 2. Eat regular meals and do not skip them; have a small snack ready. 3. Take medicines exactly as prescribed; use a pill organiser and a log to avoid doubling; see pill organiser guide and dementia and medicines at home. 4. Never change doses on your own; call the doctor when eating less, ill or losing weight, since doses may need adjusting. 5. Check sugar as advised, more often when ill, after changes, before driving, and at bedtime if on insulin. 6. Carry fast sugar always: in a pocket, handbag, car, bedside and on walks. 7. Wear identification that says "diabetes" and lists medicines; see emergency contact card and medical summary. 8. Plan for exercise: check sugar before, carry sugar, ask the doctor about snacks. 9. Limit alcohol, and never drink on an empty stomach. 10. Review medicines with the doctor regularly, particularly after hospital stays, weight loss or kidney changes; see polypharmacy and deprescribing. 11. Tell family, neighbours and attendants about the signs and what to do. 12. Keep a log of lows: time, reading, what was eaten, activity, medicine; show the doctor.

Night-time lows

Lows during sleep are common with insulin and can be missed. Signs: sweating, nightmares, restlessness, morning headache, unusual morning high readings, waking confused. Prevention: check sugar at bedtime and have a snack if the reading is below the doctor's threshold, avoid alcohol and late exercise without a snack, and talk to the doctor about insulin timing. A continuous sensor with alarms may help; see cgm sensors for older adults. If a carer shares the home, agree who responds at night. A bedside meter, torch, sugar and phone should be within reach; see night safety for a parent alone.

People who live alone

• Keep sugar and a meter within reach in every main room.
• Wear a pendant or watch; see panic pendant buying guide and fall detection watch guide.
• Arrange daily check-ins; see home safety for seniors living alone.
• Make sure someone can enter in an emergency; see key safe guide.
• Share the plan with a neighbour.

Technology that helps

• Glucose meters with large screens or voice output for poor eyesight; see glucometer buying guide and monitoring with poor eyesight or tremor.
• Continuous glucose monitors with low-glucose alerts; see cgm sensors for older adults; results need the doctor's guidance.
• Phone reminders for meals and medicines.
• Medical ID bracelets.

After a low

• Find the cause. Ask: Did he skip a meal? Take a double dose? Exercise? Drink alcohol? Is he eating less? Has the kidney function changed?
• Tell the doctor, who may adjust medicines. Repeated or severe lows mean the plan must change, but only the doctor should change it.
• Check for injury if there was a fall or seizure; see what to do after a fall.
• Review driving: after a severe low, the doctor may advise a break from driving.
• Reassure the person; lows are frightening and can reduce confidence.
• Update the family plan.

Very high sugar is also an emergency

Though this guide focuses on lows, very high sugar with extreme thirst, frequent urination, vomiting, abdominal pain, fast breathing, drowsiness or confusion needs urgent medical care. Call 112 or go to hospital. See diabetes at home after 60.

When to ask a professional

Ask the doctor or diabetes nurse for an individual low-sugar plan, targets and medicine review. A dietician can plan meals and snacks. A pharmacist can review medicines and explain meters and sugar products. A diabetes educator can teach family members. For senior services, call Elderline 14567. For unconsciousness, seizures or inability to swallow, call 112 at once.