Hypos and hypers

The key to controlling diabetes is to balance insulin injections with food and activity. But its not
always easy and, when the balance isnt right, hypoglycaemia (hypo when blood glucose drops
too low) or hyperglycaemia (hyper when blood glucose rises too high) can result.

Hypos

Hypoglycaemia (or hypo) means low blood glucose levels, i.e. when the blood glucose level drops
below 4mmol/l*. In people without diabetes, low blood glucose levels trigger the body to stop
producing insulin and to release stored glucose to keep the body going. But, in people with Type 1
diabetes, while this mechanism still works, its not so effective because the insulin they have
injected cant be switched off. So it will continue to work, even though blood glucose is too low.
Spotting the symptoms

Hypos can come on quickly and your child will tend to develop symptoms that warn them their
blood glucose levels are dropping too low. Everyone has different symptoms, but common ones
are:

feeling shaky
sweating
hunger
tiredness
blurred vision
lack of concentration
headaches
feeling tearful, stroppy or moody
going pale

*Millimoles per litre: a measurement of the concentration of a substance in a specific amount of

liquid.

Why do hypos happen?

Theres no hard and fast rule why they happen, but some things can mean its more likely that your
child has a hypo:

too much insulin

a delayed or missed meal or snack
not enough carbohydrate food
unplanned physical activity
if they are old enough, drinking large quantities of alcohol or alcohol without food
and sometimes there just is no obvious cause.

The main types of insulin

There are seven main types of insulin:

Rapid-acting analogues should ideally be injected just before food and have a peak action at
between 0 and three hours. They tend to last between two and five hours and only last long
enough for the meal at which they are taken. They are clear in appearance.
 Long-acting analogues tend to be injected once or twice a day to provide background insulin
lasting approximately 24 hours. They don't need to be taken with food because they don't have a
peak action. They are clear in appearance.
Very long-acting analogues are mainly used by people who are unable to inject themselves as
they can provide background insulin for up to 42 hours. Although they can be injected once every
42 hours (three days), they are usually injected once a day. They don't need to be taken with food
because they have a peak action. They are clear in appearance.
Short-acting insulins should be injected 1530 minutes before a meal to cover the rise in blood
glucose levels that occurs after eating. They have a peak action of twosix hours and can last for
up to eight hours. They are clear in appearance.
Medium- and long-acting insulins are taken once or twice a day to provide background insulin or
in combination with short-acting insulins/rapid-acting analogues. Their peak activity is between four
and 12 hours and can last up to 30 hours. They are cloudy in appearance.
Mixed insulin a combination of medium- and short-acting insulin.
Mixed analogue a combination of medium-acting insulin and rapid-acting analogue.

Diabetes complications

People living with diabetes may have to deal with short-term or long-term complications as a result
of their condition.

Short-term complications include hypoglycaemia diabetic ketoacidosis (DKA), and hyperosmolar

hyperglycaemic state (HHS).
Long-term complications include how diabetes affects your eyes (retinopathy), heart
(cardiovascular disease), kidneys (nephropathy), and nerves and feet (neuropathy).

People living with diabetes may have to deal with short-term or long-term complications as a result
of their condition.

Short-term complications include hypoglycaemia diabetic ketoacidosis (DKA), and hyperosmolar

hyperglycaemic state (HHS).
Long-term complications include how diabetes affects your eyes (retinopathy), heart
(cardiovascular disease), kidneys (nephropathy), and nerves and feet (neuropathy).

Impact on overall health

Long- and short-term complications can impact on a wide variety of parts of the body including
eyes, heart, kidneys, nerves and feet. Read through the links and get to know the 15 healthcare
essentials to find out more about complications, and how to reduce the risk of developing them.
With all complications, keeping blood glucose, blood pressure and blood fat levels under control
will greatly help to reduce the risk of developing complications. Regular check-ups are essential to
help manage the condition.

Hypos and hypers

Diabetes is a manageable condition, but key to successfully living with diabetes is balancing
medication and insulin injections with food and activity. When that balance isnt right, one of two
things will happen: either blood glucose drops too low and hypoglycaemia (a hypo) results, or
blood glucose rises too high and hyperglycaemia (a hyper) occurs.

No matter how much you know about diabetes or how careful you are, if your diabetes is treated,
you are likely to experience some hypos or hypers. Check with your diabetes healthcare team if
you are not sure if the treatment you are on is likely to cause hypos or hypers.

Hypoglycaemia (hypo)

Hypoglycaemia means low blood glucose levels less than 4 mmol/l*. This is too low to provide
enough energy for your bodys activities.
Symptoms

Hypos can come on quickly and everyone has different symptoms, but common ones are: feeling
shaky, sweating, hunger, tiredness, blurred vision, lack of concentration, headaches, feeling tearful,
stroppy or moody, going pale.
Why do hypos happen?

Theres no rule as to why they happen, but some things make it more likely: excess insulin,
delayed or missed meal or snack, not enough carbs, unplanned physical activity, and drinking large
quantities of alcohol or alcohol without food. Sometimes there just is no obvious cause.

Diabetes is a manageable condition, but key to successfully living with diabetes is balancing
medication and insulin injections with food and activity. When that balance isnt right, one of two
things will happen: either blood glucose drops too low and hypoglycaemia (a hypo) results, or
blood glucose rises too high and hyperglycaemia (a hyper) occurs.

No matter how much you know about diabetes or how careful you are, if your diabetes is treated,
you are likely to experience some hypos or hypers. Check with your diabetes healthcare team if
you are not sure if the treatment you are on is likely to cause hypos or hypers.

Treating a hypo
If you become unconscious
Severe hypos
Preventing a hypo
Blood glucose and hypos
Hypers

Hypoglycaemia (hypo)

Hypoglycaemia means low blood glucose levels less than 4 mmol/l*. This is too low to provide
enough energy for your bodys activities.
Symptoms

Hypos can come on quickly and everyone has different symptoms, but common ones are: feeling
shaky, sweating, hunger, tiredness, blurred vision, lack of concentration, headaches, feeling tearful,
stroppy or moody, going pale.
Why do hypos happen?

Theres no rule as to why they happen, but some things make it more likely: excess insulin,
delayed or missed meal or snack, not enough carbs, unplanned physical activity, and drinking large
quantities of alcohol or alcohol without food. Sometimes there just is no obvious cause.
How to prevent a hypo

Dont miss a meal.

Eat enough carbohydrate.
Eat extra carbohydrate if you are more active than normal.
Take your tablets and/or insulin injections correctly.
Dont drink alcohol on an empty stomach or drink too much alcohol.

Treating a hypo

If you are conscious, treat your hypo immediately with 1520g of fast-acting carbohydrate:

Small glass of sugary (non-diet) drink

At least three glucose tablets
Five sweets, such as jelly babies
Small carton of pure fruit juice
Glucose gel.

How to recognise and treat a hypo

Glucose gel may be used if you are feeling drowsy and someone can help you, but it should not be
used if you are unconscious. Glucose gel is available on prescription if you are treated with insulin.
Some people may need to follow this treatment with a snack of 1520g of slower-acting
carbohydrate to prevent their blood glucose levels getting low again. This snack could be a
sandwich, piece of fruit, cereal or some biscuits and milk or even your next meal, if its due.

Its recommended that you retest your blood glucose levels after 1520 minutes and re-treat if your
blood glucose levels are still less than 4mmol/l.

The choice of hypo treatment is up to you, so youll need to decide how much and which treatment
works best for you.

Note: Dont treat your hypo with foods that are high in fat such as chocolate and biscuits because
the fat will delay the absorption of the glucose and wont treat the hypo quickly enough.

If you become unconscious

If you have a severe hypo and become unconscious you will need help from someone to treat the
hypo. They will need to:

Put you into the recovery position (on your side with your head tilted back and knees bent)
Give you a glucagon injection - some people with insulin treated diabetes are prescribed
glucagon injections. Ask your diabetes healthcare team if you need one
Call an ambulance if you dont have a glucagon kit available or you have not recovered within
ten minutes of receiving the glucagon injection. If no one is trained to give a glucagon injection an
ambulance should be called immediately.

Note: Make sure your family and friends are aware that they mustnt give you anything by mouth if
you are unconscious or unable to swallow. Always tell your diabetes healthcare team if you have a
severe hypo.

Should I keep my blood glucose levels high to avoid hypos?

No. It can be harmful for you if you try to run your blood glucose levels consistently very high. You
may start to feel thirsty, go to the toilet frequently and feel tired. In the long term, prolonged high
blood glucose levels can lead to complications such as blindess, heart attack, stroke, kidney
disease and lower limb amputations.

How do hypos affect my blood glucose levels?

After youve had a hypo, your blood glucose level may actually rise. If you are on insulin, dont be
tempted to increase your dose. The rise may happen because you felt incredibly hungry during the
hypo and ate to correct this. Your levels may also rise because hypos cause the body to mobilise
its own glucose stores.

Why do some people have severe hypos without any warnings?

Research suggests that people who keep their diabetes very tightly controlled may have problems
in recognising hypo warnings, and that if they have one severe hypo without warning, theyre more
likely to have repeated episodes. People whove had diabetes for a long time may also lose their
hypo warnings signs; however, they can often regain them by adjusting their diabetes treatment. If
youre having problems, talk them through with your diabetes healthcare team.

Things to remember: hypos

Keep hypo treatments with you at all times.

If youre having night-time hypos, test your glucose levels before you go to bed and during the
night ask your healthcare team about the best times to test.
Make sure you carry some form of identification such as an identity card, bracelet or necklace
so that if you ever become unwell and are unable to communicate, people are aware that you
have diabetes and can help.

Severe hypos

If a hypo is untreated there is a risk of losing consciousness and/or having a fit. While this is not
common, if someone you are with has a severe hypo there are some key things to remember:

Never give food or drink by mouth because there is a danger of choking. Place them in the
recovery position (on their side with their head tilted back).
If you have been given a glucagon injection and shown how to use it, inject it as you have been
instructed. If not, or the person with diabetes has not recovered within 10 minutes of giving the
glucagon injection, phone an ambulance.
We recommend that all parents of children with diabetes should have glucagon and be trained
how to use it.
Call an ambulance if you don't have a glucagon kit available.

Will hypos affect my quality of life?

Hypos should not be frequent or severe. If they are, contact your diabetes healthcare team. Try to
build a picture of any hypos you have to see if there are any trends and patterns. If there is, you
may need to alter your diabetes treatment with the help of your diabetes healthcare team.

Night-time hypos

Low blood glucose levels do happen at night, and some people with diabetes may not be woken by
the mild symptoms of a hypo. This means that your blood glucose level may drop further and the
hypo may become more severe. If the hypo hasnt woken you, you may feel very tired the next
morning, or have a headache (a bit like a hangover).

The best way to confirm if night-time hypos are happening is to do a blood test during the course of
the night. If a night-time blood test appears to shows night-time hypos your insulin dose may need
to be adjusted.

Hyperglycaemia (hyper)

At the other end of the scale is hyperglycaemia or hypers. This happens when your blood glucose
levels are too high usually above 7mmol/l before a meal and above 8.5mmol/l two hours after a
meal. There are several reasons why this may happen. It may be that you:

Have missed a dose of your medication

Have eaten more carbohydrate than your body and/or medication can cope with
Are stressed
Are unwell from an infection
Or from over-treating a hypo.

Symptoms may include:

Passing more urine than normal, especially at night

Being very thirsty
Headaches
Tiredness and lethargy.

Treating hyperglycaemia

Treatment of hypers will depend on what caused them. If they are a regular occurrence, contact
your diabetes healthcare team for a review of your medications and/or lifestyle. If your blood
glucose level is high for a short time, emergency treatment wont be necessary. But if it stays high
you need to take action:

Drink plenty of sugar-free fluids.

If you are on insulin, you may need to take extra insulin.
If you are feeling unwell, especially if you are vomiting, you must contact your diabetes
healthcare team for advice.

How to prevent a hyper

Be aware of your carbohydrate portions and how they may be affecting your blood glucose
levels.
When you are ill, continue taking your diabetes medication even if you arent eating, and contact
your diabetes healthcare team if you need more information.
Be as active as possible.
Remember to take your insulin and diabetes medication, and always take them correctly.
You may need more medication discuss this with your diabetes healthcare team.

Treatment

If your blood glucose level is high for just a short time, emergency treatment wont be necessary.
But if it stays high you need to take action to avoid developing diabetic ketoacidosis.
Check your blood or urine for ketones if your blood glucose level is 15mmol/l or more. If ketones
are present it is likely that you do not have enough insulin in your body, so you may need to
increase the dose or give an extra dose. Talk to your diabetes team about how to do this. Make
sure you drink plenty of sugar-free fluids. If you have ketones and are unwell, especially if you are
vomiting, you must contact your diabetes team for advice.

Note: The best way to avoid hypos and hypers is by checking your blood glucose level regularly,
and even more closely if:

you have not eaten as well as expected

you have done a lot of physical activity
you are unwell
there has been any change in the routine that might upset your diabetes management.

Keep something to treat a hypo or hyper with you at all times. Carry diabetes ID to alert people to
your diabetes and help them to help you if you are having a hypo. Make sure people close to you
know what your hypo symptoms are and how to treat a hypo or hyper.

*Millimoles per litre: a measure of the concentration of a substance in a specified amount of liquid.

Cardiovascular disease

Damage to the heart and blood vessels is collectively known as cardiovascular disease and people
with diabetes have a higher chance of developing it. The term cardiovascular disease (CVD)
includes heart disease, stroke and all other diseases of the heart and circulation.
Cardiovascular problems

Your major blood vessels consist of arteries which carry blood away from your heart, and veins
which return it. Damage to these vessels is referred to as macrovascular disease.

Capillaries are the tiny vessels where the exchange of oxygen and carbon dioxide takes place.
When damage occurs to these vessels its referred to as microvascular disease.

When fatty materials such as cholesterol form deposits on the walls of the vessels (known as
plaque), furring up the artery and reducing the space for blood to flow, this is described as
arteriosclerosis or atherosclerosis. If the plaque ruptures the artery walls, blood cells (called
platelets) try to repair the damage, but this will cause a clot to form. Over time, the walls of the
blood vessels lose their elasticity. This can contribute to the development of high blood pressure or
hypertension, which can cause more damage to the blood vessels.

The force of the blood being pumped from the heart can make the clot break away from the artery
wall and travel through the system until it reaches a section too narrow to pass through. If this
happens the narrow section will become partially or completely blocked.

Blockage of an artery leads to the part of the body it supplies being starved of the oxygen and
nutrients it needs. This is the cause of heart attack or strokes (affecting the brain).

Narrowing of the blood vessels can affect other parts of the body, such as the arms or legs. This is
called peripheral vascular disease (PVD). PVD may produce intermittent claudication (pain in the
calf muscle). If left untreated, amputation of the limb may eventually be necessary.

What causes cardiovascular disease?

Blood vessels are damaged by high blood glucose levels, high blood pressure, smoking or high
levels of cholesterol. So, it is important for people with diabetes to manage these levels by making
lifestyle changes such as eating a healthy diet, taking part in regular activity, reducing weight if you
are overweight and stopping smoking.

Steps you can take to help prevent CVD

If you smoke, ask for help to stop.

Eat a healthy, balanced diet.
Be more physically active.
If you are overweight, try to get down to a healthy weight. Any weight loss will be of benefit.
Take your medication as prescribed.
Get your blood glucose levels, blood pressure and blood cholesterol checked at least once a
year and aim to keep to the target agreed with your healthcare team.
If you have any chest pain, intermittent pain when walking, impotence or signs of a stroke, such
as facial or arm weakness or slurred speech, you should contact your doctor as soon as possible.

Eyes (retinopathy)

Diabetic retinopathy or retinopathy is damage to the retina (the 'seeing' part at the back of the
eye) and is a complication that can affect people with diabetes. Retinopathy is the most common
cause of blindness among people of working age in the UK.
What causes retinopathy?

To see, light must be able to pass from the front of the eye through to the retina, being focused by
the lens. The retina is the light-sensitive layer of cells at the back of the eye the seeing part of
the eye. It converts the light into electrical signals. These signals are sent to your brain through the
optic nerve and your brain interprets them to produce the images that you see.

A delicate network of blood vessels supplies the retina with blood. When those blood vessels
become blocked, leaky or grow haphazardly, the retina becomes damaged and is unable to work
properly. Retinopathy is damage to the retina.
Risks to your eyes

Persistent high levels of glucose can lead to damage in your eyes. To reduce the risk of eye
problems, blood glucose, blood pressure and blood fats need to be kept within a target range,
which should be agreed by you and your healthcare team. The aim of your diabetes treatment, with
a healthy lifestyle, is to achieve these agreed targets.

Smoking also plays a major part in eye damage so, if you do smoke, stopping will be extremely
helpful.

Types of retinopathy

There are different types of retinopathy: background retinopathy, maculopathy and proliferative
retinopathy.
Background retinopathy

The earliest visible change to the retina is known as background retinopathy. This will not affect
your eyesight, but it needs to be carefully monitored. The capillaries (small blood vessels) in the
retina become blocked, they may bulge slightly (microaneurysm) and may leak blood
(haemorrhages) or fluid (exudates).
Maculopathy
Maculopathy is when the background retinopathy (see above) is at or around the macula. The
macula is the most used area of the retina. It provides our central vision and is essential for clear,
detailed vision. If fluid leaks from the enlarged blood vessels it can build up and causes swelling
(oedema). This can lead to some loss of vision, particularly for reading and seeing fine details, and
everything may appear blurred, as if you are looking through a layer of fluid not quite as clear as
water.
Proliferative retinopathy

Proliferative retinopathy occurs as background retinopathy develops and large areas of the retina
are deprived of a proper blood supply because of blocked and damaged blood vessels. This
stimulates the growth of new blood vessels to replace the blocked ones. These growing blood
vessels are very delicate and bleed easily. The bleeding (haemorrhage) causes scar tissue that
starts to shrink and pull on the retina, leading to it becoming detached and possibly causing vision
loss or blindness.

Once the retinopathy has reached this stage it will be treated with laser therapy. Beams of bright
laser light make tiny burns to stop the leaking and to stop the growth of new blood vessels.

Kidneys (nephropathy)

Kidney disease can happen to anyone but it is much more common in people with diabetes and
people with high blood pressure. Kidney disease in diabetes develops very slowly, over many
years. It is most common in people who have had the condition for over 20 years. About one in
three people with diabetes might go on to develop kidney disease, although, as treatments
improve, fewer people are affected.
What is kidney disease?

The kidneys regulate the amount of fluid and various salts in the body, helping to control blood
pressure. They also release several hormones. Kidney disease (or nephropathy to give it its proper
name) is when the kidneys start to fail.

If the kidneys start to fail they cannot carry out their jobs so well. In the very early stages there are
usually no symptoms and you may not feel unwell, this can mean there are changes in blood
pressure and in the fluid balance of the body. This can lead to swelling, especially in the feet and
ankles.

As kidney disease progresses, the kidneys become less and less efficient and the person can
become very ill. This happens as a result of the build up of waste products in the blood, which the
body cannot get rid of. Kidney disease can be a very serious condition.

Why are people with diabetes more at risk?

Kidney disease is caused by damage to small blood vessels. This damage can cause the vessels
to become leaky or, in some cases, to stop working, making the kidneys work less efficiently.
Keeping blood glucose levels as near normal as possible can greatly reduce the risk of kidney
disease developing as well as other diabetes complications. It is also very important to keep blood
pressure controlled.

How does my doctor check for kidney disease?

As part of your annual health care review you should have a blood and urine test. Your urine will be
checked for tiny particles of protein, called 'microalbumin'. These appear during the first stages of
kidney disease, as the kidneys become 'leaky' and lose protein. At this stage, kidney disease can
often be treated successfully, so this test is very important. The blood test will measure urea,
creatine, and estimated glomerular function (eGFR) showing how well the kidneys are working.

I had protein in my urine but now the test is negative.

How can this happen?

Kidney disease is not the only reason for protein to appear in the urine. If you have a urinary tract
infection (UTI) this can lead to protein being passed out in the urine. People with poorly controlled
diabetes can be more prone to urinary tract infections because glucose in the urine provides a
breeding ground for bacteria. This might need treatment with antibiotics.

In some cases, if the infection persists, it can cause damage to the kidneys, so it is very important
for people with diabetes to visit their doctor if they develop a urinary tract infection.

What sort of treatment might be recommended?

This depends on the individual, the type of diabetes and other factors, such as blood pressure.
Keeping blood pressure under control is extremely important, and tablets for lowering blood
pressure are often used.

An increasingly common form of treatment for people with diabetes is ACE inhibitor or angiotensin
II receptor antagonists (AIIRAs). These are particularly successful as they not only lower blood
pressure but also help protect the kidneys from further damage. These medications are sometimes
used in people who have normal blood pressure, due to their protective effect on the kidneys. Your
doctor should discuss any treatment with you before starting you on it, explaining what it does and
how it will help.

What if kidney disease gets worse?

There are many ways of treating kidney disease if the kidneys are no longer able to function
properly. You may need to limit certain foods in your diet, such as protein foods or foods high in
potassium, phosphate or sodium. This aims to prevent waste products building up in your body. As
there may be a number of different things to consider, the diet can be quite complicated to follow. If
you need to make any changes to your diet, you should receive detailed advice from a registered
dietitian.

Controlling blood pressure is also very important. If the kidneys have been damaged, the filtering
and cleaning of the blood cannot be done normally.

In some cases, dialysis might be needed to do this job for the kidneys. There are various types of
dialysis, and your doctor will discuss with you which one would be best for you.

What can I do to look after my kidneys?

Taking care of your kidneys is an essential part of managing your diabetes.

Attend all your medical appointments.

Keep your blood glucose levels and blood pressure levels within your target range.
Have your urine tested for protein and a blood test to measure kidney function at least once a
year.
Get help to stop smoking.
Eat healthily and keep active.
Diabetic ketoacidosis (DKA)

Consistently high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA).
This happens when a severe lack of insulin means the body cannot use glucose for energy, and
the body starts to break down other body tissue as an alternative energy source. Ketones are the
by-product of this process. Ketones are poisonous chemicals which build up and, if left unchecked,
and will cause the body to become acidic hence the name 'acidosis'.
DKA is a life-threatening emergency

Although most common in people with Type1 diabetes, anyone who depends on insulin could
develop diabetic ketoacidosis. In exceptionally rare cases, people controlling their diabetes with
diet or tablets have been known to develop DKA when severely ill.

The most likely times for DKA to occur are:

At diagnosis. (Some people who do not realise they have Type 1 diabetes do not get diagnosed
until they are very unwell with DKA.)
When you are ill.
During a growth spurt/puberty.
If you have not taken your insulin for any reason.
DKA usually develops over 24 hours but can develop faster particularly in young children.
Hospital admission and treatment is essential to correct the life-threatening acidosis. Treatment
involves closely monitored intravenous fluids, insulin and glucose.

How to recognise DKA:

High blood glucose levels: DKA is often (but not always) accompanied by high blood glucose
levels. If your levels are consistently above 15mmol/l you should check for ketones.
Ketones in the blood/urine. Ketones are easily detected by a simple urine or blood test, using
strips available on prescription.
Frequently passing urine
Thirst
Feeling tired and lethargic
Blurry vision
Abdominal pain, nausea, vomiting
Breathing changes (deep sighing breaths)
Smell of ketones on breath (likened to smell of pear drops)
Collapse/unconsciousness.

What to do if you have symptoms of DKA

If you have high blood glucose levels and any signs of DKA you must contact your diabetes team
immediately. Left untreated, DKA can be fatal. If picked up early, it can be treated with extra insulin,
glucose and fluid.

Make sure you check for ketones if your blood glucose is over 15mmol/l.
You may need to take extra insulin.
You may need to test your blood glucose and ketone levels frequently (e.g. every two hours).
Drink plenty of unsweetened fluid.

If you are unable to eat, replace meals with snacks and drinks containing carbohydrate to provide
energy (e.g. sips of sugary drinks, sucking boiled sweets).

DKA prevention
DKA is usually avoidable. Making sure you always take your insulin in the right amounts for your
food and activity patterns, keeping a good check on your blood glucose levels and consulting your
healthcare team appropriately will help you to avoid episodes which are both life-disrupting and
life-threatening.

Hyperosmolar Hyperglycaemic State (HHS)

Hyperosmolar Hyperglycaemic State (HHS) occurs in people with Type 2 diabetes who experience
very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks
through a combination of illness (e.g.infection) and dehydration.

Stopping diabetes medication during illness (e.g. Because of swallowing difficulties or nausea) can
contribute, but blood glucose often rises despite the usual diabetes medication due to the effect of
other hormones the body produces during illness.

Symptoms can frequently include:

urination,
thirst
nausea
dry skin
disorientation and, in later stages, drowsiness and a gradual loss of consciousness.

HHS is a potentially life-threatening emergency

Hospital treatment for HHS aims to correct dehydration and bring blood glucose down to an
acceptable level by giving replacement fluid and insulin by an intravenous drip

It does not usually lead to the presence of ketones in the urine, as occurs in diabetic ketoacidosis
(DKA), which is why it was previously referred to as HONK (hyperglycaemic hyperosmolar non-
ketotic coma). Ketones develop when the blood glucose level is high due to lack of insulin which is
needed to allow glucose to enter the cells for energyy. Because people with Type 2 diabetes may
still be producing some insulin, ketones may not be created.
What you can do:

Always take your diabetes medication, even if you feel unwell and cant eat
If you monitor your blood glucose, you may need to test more frequently
Contact your healthcare team if your blood glucose levels remain high (>15mmol/l)
Drink plenty of unsweetened fluids
If you cant eat, replace meals with snacks and drinks, containing carbohydrate.

Older people and diabetes

Most areas of care in diabetes are relevant to all age groups but there are some specific changes
due to growing older which might affect your diabetes.
Food choices

In some cases dietary advice for the older person with diabetes may differ from general
recommendations. Older people in care homes are often more likely to be underweight than
overweight and there is a high rate of undernutrition. It may not always be appropriate to reduce
the fat, salt and sugar for every older person with diabetes. Poor or irregular eating can often be a
cause of hypos.

Poor oral health, effects of some drugs on the digestive system, limited mobility, dexterity or vision
can all cause discomfort associated with eating. Fluid intake is often lower in older people which
can cause dehydration, particularly during bouts of illness. People at risk should have a nutritional
assessment and individual advice from a dietitian to address areas of concern such as needing
extra calories, meal supplements and replacements, weight reduction, low salt diet or manageable
foods.
Person having a healthcheck with GP

Nutritional assessment and diet should form part of your individual care plan if you live in a care
home. Personal food preferences are important in any diet plan and older people with diabetes
should be able to continue to enjoy a wide variety of foods. Staff, including catering staff in older
people's care homes, should have training to give them an understanding of the specific needs of
individuals with diabetes.

Keeping active

Keeping active in later life helps to strengthen muscles, maintain mobility and balance and
improves insulin sensitivity. It can help you to continue to self-care, can improve your mental well-
being and prevent falls. You can aim to be as active as you are able.

Older people, including those with frailty, have been shown to benefit from light resistance and
balance training. Exercise to build limb strength and flexibility for those who are housebound and
confined to a bed or chair can be taught by a physiotherapist and supported by carers. Remember
to check with your GP before starting any new exercise.

Hypos

Hypoglycaemia or hypo occurs at blood glucose levels of less than 4mmols/l. Older people may
have added risk factors which can lead to hypo:

being prescribed five or more medications

chronic kidney problems
poor food intake
having other illnesses or conditions.

Many older people find their hypo warning symptoms become less obvious, and some have no
symptoms at all. This may mean that the first signs noticed by a carer are:

inability to concentrate
personality change
morning headaches
sleep disturbance.

Hypos which go unnoticed can cause very unpleasant symptoms:

confusion
speech and self-care difficulties
poor appetite
aggressive behavior
unsteadiness and falls
losing consciousness
cognitive damage
 heart attack or stroke.

Treatment

A hypo should be treated immediately in a conscious person with fast-acting glucose, such as a
sugary (non-hot, non-milky) drink or some glucose tablets and followed up with something starchy
like biscuits, a sandwich or the next meal. If someone is unconscious, call for medical help or an
ambulance.

For older people in care homes a personal hypo box with hypo treatments and instructions for
treatment can be kept at hand.
Prevention

To prevent hypos, it is helpful to have regular mealtimes and snacks containing carbohydrate and
to be aware of hypo symptoms and what to look out for in individuals who may be at risk. Target
levels for blood glucose control should not be too tight and medication must be right for the
individual. This is something to discuss with the GP.

Blood glucose monitoring can help to identify older people who may be at risk of hypos but must
always be looked at together with longer term blood results like HbA1c to give a clear picture.

Residential settings providing care for people with diabetes should have a diabetes policy which
includes management and prevention of hypos, diabetes care plans for individuals and diabetes
skills training for staff.

Mental health and well-being

Depression is more common in people with long-term conditions but may go unnoticed in older
people with complex health problems. Painful neuropathy, foot ulceration and adverse effects of
medication can all contribute to depression. The risk of dementia also increases with age. Anything
which affects your mental well-being may affect your ability to successfully manage your own
diabetes.

Simple tests are available from your GP to screen for depression or dementia. Recognizing these
issues at an early stage can help limit their longer term impact.

For older people living in care homes, screening on admission and annually is recommended. If
you are living with diabetes and dementia, Living with Diabetes and Dementia is a helpful guide
with practical tips.

Illness and hospital admission

Older people with diabetes, particularly those living in care homes may be more likely to be
admitted to hospital when they are unwell. This is because diabetes can have an additional effect
on the illness and the illness can impact on the diabetes.

Blood glucose can rise quickly during illness, particularly in older people who are dehydrated. Extra
monitoring and medication may be required and carers may need to give you extra support. It is
important that there is guidance for carers in your personal care plan. This should also show very
clearly when medical attention must be sought.

If you do have to go to hospital it is very helpful to take a copy of the care plan with you so that
staff can easily see your diabetes medical history and current treatment.

Managing self-care
Physical changes as you grow older may affect your ability to self-care. As changes can occur at
any time they may also indicate that something should be investigated as you may need a change
of medication.

Age is the most significant factor for common eye conditions like glaucoma, cataract and macular
degeneration. Failing eyesight and reduced mobility may lead to a reduced level of daily foot care,
meaning early problem signs are missed. Urinary incontinence can be a symptom of many
conditions, including poorly controlled diabetes and changes in kidney function.

It is easy to assume that symptoms are simply due to the ageing process or because you have
diabetes. However, it is important to seek advice for any new symptoms and to ask for support
where self-care and monitoring has become difficult for you.

Physical changes as you grow older may affect your ability to self-care. As changes can occur at
any time they may also indicate that something should be investigated as you may need a change
of medication.

Age is the most significant factor for common eye conditions like glaucoma, cataract and macular
degeneration. Failing eyesight and reduced mobility may lead to a reduced level of daily foot care,
meaning early problem signs are missed. Urinary incontinence can be a symptom of many
conditions, including poorly controlled diabetes and changes in kidney function.

It is easy to assume that symptoms are simply due to the ageing process or because you have
diabetes. However, it is important to seek advice for any new symptoms and to ask for support
where self-care and monitoring has become difficult for you.

Physical changes as you grow older may affect your ability to self-care. As changes can occur at
any time they may also indicate that something should be investigated as you may need a change
of medication.

Age is the most significant factor for common eye conditions like glaucoma, cataract and macular
degeneration. Failing eyesight and reduced mobility may lead to a reduced level of daily foot care,
meaning early problem signs are missed. Urinary incontinence can be a symptom of many
conditions, including poorly controlled diabetes and changes in kidney function.

It is easy to assume that symptoms are simply due to the ageing process or because you have
diabetes. However, it is important to seek advice for any new symptoms and to ask for support
where self-care and monitoring has become difficult for you.

Physical changes as you grow older may affect your ability to self-care. As changes can occur at
any time they may also indicate that something should be investigated as you may need a change
of medication.