Essaying the Situation
Monday, April 12, 2004
Medicating Rhythm
    The last few days provide an excellent example of what I mean by "judicious" administration of medication. This evening while I was altering her diabetic medication routine to take into account a healthy cobb salad and a slice of rich lemon mousse cake I realized that fellow caregivers of the elderly might gain some courage in their approach to their ward's health care if they could watch me walk through a couple of exemplary days that kept me hopping. Since physicians are, at the moment, a bit too distracted to help caregivers truly get the hang of and the philosophy behind thoughtful medication administration, us caregivers need to distribute this information among ourselves.
    Before I begin describing how I calculated my mother's diabetic medication over Easter and today, it is important for you to take the following conditions into consideration:    The two days previous to Easter conformed to our recent pattern of normalcy: Late breakfasts but before noon (barely); normal to just-above-normal blood sugar readings. If below 90, she received 425 mg metformin in addition to her 10 mg glipizide. If above, 500 mg metformin. Always a 1/4 tsp cinnamon on her toast. Both days she had a reasonable interim snack and 425 mg metformin with an additional 1/4 tsp cinnamon in V-8 juice. Easter Eve her evening reading was 108. She received 500 mg metformin at dinner at 2115 and another 500 mg with a slice of lemon mousse cake at 2245 [I knew ahead of time that the lemon mousse cake was to be served. So did my mother.]
    Easter morning her blood sugar was 85 at 0603. Her hunger was vigorous. She asked for 2 pieces of toast. As she took her morning breathing treatment and I doled pills I took into consideration that she would not eat again for at least 4 hours but would then snack and eat almost constantly from about 1400 on. Knowing that most of this eating would be at MPS's home where the snacking includes a variety of salsas and pickles (vegetables, sodium, tomatoes) corn chips and crackers (both refined and unrefined grains), cheese spreads, etc., dinner would include a bountiful salad and I'd only be able to get one 1/4 tsp dose of cinnamon in that day I decided from the morning to make sure she ingested the maximum amount of metformin allowed her, 2000 mg, in 500 mg increments throughout the day. I knew that after the one opportunity in the morning to correctly administer her 10 mg glipizide that would be it. I was sure that in the evening there would be no chance to establish a proper fast ahead of her second glipizide. I'd give it to her anyway before dinner but would save her last 500 mg dose of metformin until dessert for an added insulin sensitivity punch.
    I also resolved not to take her blood sugar. I don't recommend this unless you're intimately familiar with your charge's blood sugar behavior and diabetic profile, including where within the development of the disease your charge is traveling. Certainly, insulin dependence changes the rationality of dismissing blood sugar testing on those days when you know there is little you can do to control your charge's blood sugar.

    On Easter Sunday she took her second 500 mg dose of metformin at 1130 when MCF served her a sinful peanut butter chip, Rice Krispy, coconut, butter confection. Her third was at dinner around 1700, a half hour after her glipizide. Her last 500 mg dose of metformin, accompanied by a slice of peach pie, was administered at 1915. Before retiring last night at 2330 she had a piece of toast to wash down two acetaminophen. I was able to give her 1/4 tsp cinnamon on that slice but no other medication.
    This morning at 1009 her blood sugar was 134. She asked for two pieces of toast again. I factored in the high but not-worrisomely-high reading, the two slices of toast and the orange juice and gave her an 850 mg dose of metformin with her 10 mg dose of glipizide and 1/4 tsp cinnamon. Although not particularly active this morning, not interested in playing Sorry for instance, she didn't want any acetaminophen, remained awake either in the dinette or the kitchen until about 1300, refused food but drank plenty of fluids including tea and the peculiar cranberry juice we drink then asked for acetaminophen as she announced she had decided to take a nap. I gave her a piece of toast with the pills and some instant decaf coffee.
    She slept until just before 1700. During sleep she had a watershed which led to her second sink bath and bed change of the day. AT 1815 her blood sugar was 82. I made robust Cobb salads which included very lean pastrami, a combination of grated Swiss and sharp Cheddar cheeses, half a boiled egg, a colorful variety of vegetables on a bed of all dark greens with croutons and her favorite dressing which, while not terribly sweet is very creamy. That earned 500 mg metformin with her 10 mg glipizide. An hour and a half later she wanted "a little taste of something sweet". The lemon mousse cake. Another 500 mg metformin, making a total of 1850 mg metformin today.
    I expect a lower-than-90 blood sugar reading tomorrow morning. If she asks for a heartier breakfast than normal she'll receive 500 mg metformin with breakfast as well as cinnamon. Otherwise I'll administer 425. I expect her to have more energy and I'll be arousing her at a decent hour (although it is important to note that she roused herself early this morning, much to her surprise and my delight) rather than letting her sleep in so I'm sure lunch will be involved and that will include anywhere from 425 to 500 mg metformin depending on whether she wants cottage cheese (the lower) or a sandwich (the higher). She'll also have 1/4 tsp cinnamon in her V-8 juice. Regarding using cinnamon, it appears that a daily amount of over 1/2 tsp, which is the "recommended" dosage, neither hurts nor helps my mother's cells' ability to respond to the insulin she produces. This echoes the information I read on cinnamon and Type 2 diabetic management.
    There are meals at which she will get 3/4's of an 850 mg pill; or 1/2 a 1000 mg pill and 1/4 of an 850 mg pill; or 3/4's of a 1000 mg pill; or 1/2 of an 850 mg pill and 1/4 of a 1000 mg pill. It all depends on where her blood sugar falls. I'll administer the lower doses if she's between 100 and 110 and decides she wants preserves on one of two pieces of toast or two eggs or an extra piece of bacon. As she adds options I step up to the higher calculations. Very much the same strategy works at lunch and dinner. She never receives over 2000 mg a day. Her average is 1500 but if, for instance, we eat lunch or dinner out and she orders a high starch or sugar meal then I mix and match quarters and halves of her metformin tablets. I see to it that we always have a stash of both 1000 mg and 850 mg pills.
    While it's true that it took me months and my mother's completely unnecessary blood pressure crash to provoke me to 'manage' her medications rather than simply give them to her, it's also true that if you decide to investigate this approach it is important to be vigilant and expect the process to be dynamic on a daily basis. You may also find your charge's physicians exhibiting nervousness about utilizing this approach until they are able to see the results and be assured that you are not mismanaging your charge's health. It helps to rely on any non-alternative and alternative healers as information resources as well as to aid your healing abilities. I am living proof that good research and vigilant observation can short circuit almost any provider's reluctance to accept this type of medicine management. I'm also living proof that some physicians will dismiss not only what you're doing but dismiss your charge as their patient. I am, too, living proof that mistakes can be made. Any mistakes I've mad, though, have been errors on the side of caution, have not immediately endangered her life and have been easiily reversible. I cannot say this for the non-alternative medical community's prescriptive approach to my mother.

Addendum 1 written April 13, 2004:
    Yes, there is an addendum. Although I forecast, based on my most recent past experience, that my mother's blood sugar would be lower than 90 her actual blood sugar at 1024 was 133. I suppose I should have administered the entire 2000 mg yesterday. I'll know better, next time.
    She ate about 1100. Asked for two pieces of toast, one with preserves. I gave her 850 mg metformin to cover everything including the orange juice. She received 1/4 tsp cinnamon on one piece of toast. She was very tired today. Not much movement. Looked a little peaked but that doesn't necessarily mean anemia. No bowel movement today, which could have contributed to her afternoon sluggishness. I expected her to take a nap when I left for my acupuncture appointment but she decided to lay down at about 1330. That was a little too early for lunch. She wasn't hungry anyway.
    Although it was a sluggish day for her she hydrated well, ate some cottage cheese, V-8 juice with 1/4 tsp cinnamon, a few Doritos chips (very few) and I gave her 425 mg metformin. She was alert throughout our viewing of the DVD version of Signs, enough to be annoyed with it. At 1840, in preparation for dinner a half hour later, I measured her blood sugar at 106. We had tuna melts (with freshly grated parmesan cheese) and quick pickled beets (no sugar, although this has been a habit in our family forever).
    She went to bed halfway through one of her and my favorite Star Trek: TNG episodes, the one about parallel universes and quantum realities leaking into other quantum realities. It didn't seem as though she'd drunk much fluid throughout the day. She retained it well during her nap and went to bed well hydrated. For the last two nights I've been giving her 2 mg Detrol but she's leaked through it and last night it appeared as though it was beginning to make her feet swell. I didn't give her one tonight. Chances are she'll shed but she'll be thirsty in the morning and I'm placing money again on her morning blood sugar reading being 90 or below.
    Today is the second day she's roused of her own accord but some of this, I think, might be my cheating. This is the season of direct morning sun through her bedroom window. Her bed is slightly out of the flow but she responds well to sunlight so I leave her window unshaded throughout the night and allow the sun to warm her into consciousness. She and I were talking this evening about how interesting and invigorating it is to have the luxury of living in a place that displays the seasons elegantly and that we have the added luxury of being able to allow our lifestyle to respond to the seasons four times a year. I have high hopes for this season.

Addendum 2 written April 14, 2004
    I couldn't help but follow up with a report on today. Her blood sugar settled a bit and I altered her diabetic medication slightly.
    At 0928 her blood sugar measured 113. That's right, folks, and that rising time was on her own. I was very pleased.
    She was no more hungry than normal and pretty congested, about which I decided to add a Guaifenex to her medication. This hastens dehydration so she'll need more water. I've noticed that the more water she drinks the lower her blood sugar. With a light breakfast and 1/4 tsp cinnamon on her one piece of toast I decided she'd only need 425 mg metformin this morning. We ate about 1030.
    At 1330 she wanted a light snack. Her FT appointment at 1430 was approaching. I decided this would be an appropriate way to get some sodium in her so that should would retain water. I gave her cottage cheese, V-8 juice (with 1/4 tsp cinnamon) some Doritos chips, about 10, and 425 mg metformin. Around 1500 I fleetingly wished I'd checked her blood sugar at her impromptu lunch but I've gotten out of the habit of measuring it at lunch.
    Her FT appointment at 1430 involved a lot of movement and she was very alert. When she was on her back I dialed her oxygen delivery to 5L/m. She did not take a nap today. When we returned from FT she sat up and read, we wandered out in the chill wind to water and inspect the roses while I pledged to have the remaining roses planted by Sunday evening. We watched the Dog Show. I snoozed on the floor through most of it. Afterwards we talked about when we'd head down to The Valley tomorrow and discussed How Bad Could It Be If Our Taxes Aren't Done, Courtesy of My Fault, and We Have Nothing To File Tomorrow; Ahhh...Fuck 'Em If They Can't Take A Joke. My mother can be confident and optimistic to an insane fault and sometimes it is fun to invite oneself to her party.
    At 1720 her blood sugar was 120. She requested tuna melts, "like [I] made last night." Unusual for her to want the same thing for dinner two nights in a row. With the melts we had bread and butter pickles, a few more Doritos Nachos Chips and I gave her 500 mg metformin with her meal. An hour later rummaged through the refrigerator and decided she wanted "just a little" piece of the lemon mousse cake. I gave her another 500 mg metformin on the spot. Luckily, this session ushered in the cake's demise. It makes me nervous to have that stuff around.
    She went to bed well hydrated at 2130 after a deep leg rub. She mentioned before retiring, surprising me that she remembered our impending trip to The Valley tomorrow, that if I wanted to wake her up earlier than 0700 I could. I may. It depends on when I get to bed.
    I don't think there'll be more addenda to this essay. I think it covers all syncopations of my Medicating Rhythm. If you are brave enough to follow my lead, remember: Remain alert and thoughtful; observe and use all the instruments and resources available to you including standing lab orders to determine dosage. Keep in mind that there are classes of drugs and if you have to be careful with one within a class chances are you'll have to be careful with all in that class. Monitor not only your charge's physician's prescriptions but prescriptions administered on a temporary and/or emergency basis by hospitals, urgent care centers, skilled nursing facilities, etc. Keep your ears open to promising alternatives including changes in diet and alternative treatments. For instance: Courtesy of a fleeting comment overheard when my mother was watching Dr. Phil one afternoon, my next step, I think, is to find a compounding pharmacist with whom to discuss and augment my (and various physicians' and healers') medication/supplement strategy toward my mother. I hope I can get Medicare/TriCare to cover these services.

Afterthought: If Medication Management sounds to you like a full time job, you're right.
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