Hi all. My partner’s mother is 79, T2D currently on lantus, humalog, and metformin, also with Addison’s disease and an essential tremor (she can currently manage her own injections, but it doesn’t look super easy). She’s a very nice woman, but not technologically inclined, and neither is her husband really (my partner gets asked regularly to fix fairly basic issues with their smart phones etc that are confusing them). I’m not sure what her current A1c is, my best guess is well above 7, possibly in the 8s? Anyway, her team apparently just suggested a pump, I’m pretty sure the 670G (I’m getting this info second-hand, and no one remembers the details), and if so, that would also be adding a CGM, which she has expressed curiosity about (I’ve shown her my Dexcom). She’s in the category of control that stands to benefit from it, so that part seems good. My and my partner’s concern is how hard is this going to be to learn and adjust to? I know pumps generally come with support and classes at the beginning, but then how much work and tech ability will this require? My partner would try to go with her mom to the appts, but we don’t live right by them, so can’t give continuous support either. My partner tries to see them about 1-2x a week, but sometimes it’s less often. I’ve never used a pump, so I offered to ask you all for thoughts and suggestions.
She has some respiratory problems (not sure what exactly), otherwise I might advocate for Tresiba/Afrezza, which seems like it might be a much easier approach given all the other factors in play. Still might encourage asking about it just in case.
There was a little boy in my neighborhood diagnosed as Type 1 the other year. His parents are significantly older than the norm for having a five year old (Vietnam veteran dad and English as a second language mother).
I frequently would go to their house to provide tech support with their Omnipod anytime their doctor’s office told them to make basal changes or preprogrammed bolus calculation changes. They were flummoxed often on how to reprogram things, but they were very active and involved in his care.
I would be concerned about putting so much technology in front of someone who might not have the experience or instincts to navigate menus without someone in the home to help support them. Just my two cents after seeing what different design features in the Omnipod menus completely confused the couple I helped. People who grew up with technology seem to have more intuitive understanding of these things.
I use the older 530 g/with enlite so I can’t speake first hand. I hear the 670 is really involved and requires alot of work, but @Nickyghaleb is up on this pump and I would imagine her and others will join in. I am in the process of going to omnipod and dexcom g-5.
Hmmm, so when starting the 670g, you’re set up with a trainer. The training sessions for just using the pump I think the first one was 3 or 4 hours. Then there are follow-ups with the trainer to see how it’s going and I think a follow-up session or two for automode. For me, I had email and phone access to my trainer. I texted her a decent amount in the beginning with questions, and I would still feel comfortable talking with her if something popped up (not that I would but it would still feel appropriate). So from my experience, medtronic’s trainer was helpful and went through each part of using the pump and technology.
HOWEVER, using a medtronic 670g is not intuitive (in my opinion, coming from using an animas pump, which I felt to be very simple and intuitive - this being a 22 year’s olds opinion for context). To work through the menus and get to the right spots can take a decent amount of button clicking, and the settings seem to be tucked away under menus even I can’t always guess at. That being said, I wouldn’t say that for this 79 year old woman she completely won’t be able to navigate the pump. It may not be easy at first, but after the learning curve I think that if she knows the basics (how to bolus, how to see her blood sugar on the screen, etc) then the pump works just fine and won’t be too too tricky.
I would worry that automode would be hard for her to navigate on a daily operating basis (because of neediness of guardian sensors and constant alarms). But I would worry that having to use the phone for dexcom and the 670g for just pumping may be a lot to figure out too…I don’t know diabetes is a lot already to keep everything straight in one’s head.
I have no experience with other pumps besides animas and the 670g so I don’t have any other frame of reference.
I personally think that the button clicking would be a major pro of getting the 670g as compared to the t-slim x2 and its touch screen for this individual, given the tremor and older age. But you do say she has a smart phone already…
Have you asked her opinion on any of the aspects of having a pump? Maybe pulling up pictures and videos of the options can help her visualize what she would be working with
I feel like the 670G is a tricky pump to just jump into the deep end with. My dad is 80 and it’s really hard to imagine him safely managing that himself; he’d need a caregiver to do most everything.
I’m not really sure a pump would necessarily be the best option for her, but who knows…
I was honestly kind of shocked that anyone is suggesting a pump to her, period. She had expressed no interest in a pump that I’m aware of prior to someone suggesting it, so I’m pretty sure this is a case of an endo assuming that the 670G’s auto mode makes things super easy to get tighter control for a diabetic and thus being worth it and ultimately easier for her. I don’t know how much all endos really understand what that looks like in practice and how complex the day to day can be.
I haven’t had a chance to have any convos with her directly yet since the pump came up, so far just passing along info.
@cardamom, I’ll just pitch in that the 670G could be perfect for her. It really could be. Especially if she’s not got great control to begin with and is not overly concerned about a slow return to a good blood sugar and all of that. The real problem is that it could also be a disaster. If anyone could guarantee the sensor would work right, one could hope for decent results for her— and it might be just what she needs. But having a working sensor is far from guaranteed, and when this thing acts up, it can really do some damage. In my opinion. As far as training goes, @LarissaW, it sounds like you had an excellent arrangement. Mine was nothing like that. I got a 2 hour initial session, an exchange of emails for about a week… and one more one on one about 3 weeks later. And that was to talk about infusion sets. There are a number of people in our group who never even heard from their trainer… and then there are those who have made fiends with theirs. My point, I think, is that there are no guarantees there either. Maybe that’s my point overall— there aren’t a lot of guarantees when you take on the 670G. It is not intuitive, at least it wasn’t in my case, and can really do a number on your sleep. In no way, believe it or not, am I saying it’s not the pump for her—I’m just highlighting some of the problems you might not hear about from your endo or your local Medtronic rep.
As far as a tremor goes, I’ve got one that is mild most of the time but can border on moderate. So I do think about pump operations. If she has a significant one, she would really need to determine for herself which is an easier handle. If it’s negligible, I would think she could do the t:slim if she currently has a touchscreen phone. I do a touch and swipe and am nailing almost everything now. And, if I may add… at this point, I think the t:slim and G6 is a far lower maintenance combination than the 670 and Guardian. Basically no calibrations and Basal-IQ is a beauty. The cartridge change potentially could be something she might need assistance with, but I’m not sure if that’s the case.
I shared your feedback with my partner, and also sat down with her and gave her insulin pump 101 (I realized she had no real clue how they worked—she understands what I do with my MDI pretty well, but has no reason to have learned that). She was already concerned about her mom, but after that, she was really concerned that this would not be a good fit. She talked to her mom, whose main thought about it all seems to be that the endo is switching her to this protocol because that’s how the office tends to do things, which seems like… not a great reason.
I went over with my partner several much smaller changes her mom could take to potentially improve control/reduce burden: switch from Lantus 2x/day to Tresiba 1x/day; start prebolusing her Humalog injections, since she eats lots of carbs but doesn’t do that; possibly try a faster acting insulin if she can get one covered; meet with a nutritionist to determine if she’s carb counting accurately/effectively (which would be important for a pump too); try a CGM like a Libre or Dex for even a week or two just to get data to make treatment decisions from with her team even if she doesn’t use it all the time, etc. Those all seem like steps worth trying before upending everything, especially since her mom’s take on it all is that things are going pretty well but control could be tighter. This is also seems like exactly when a nurse educator would be possibly way more useful than an endo, so asking my partner to ask about that. Either way, my partner and her mom are going to schedule an appt and go together; I may go with as well if I can manage around my work schedule.
Hey all, an update: my partner went with her mom to see the nurse educator. Not surprisingly, within a couple of min, the nurse educator nixed the idea of the pump. They are going to move forward instead with a Dexcom, which I think could be really useful, and also, if tech fails, won’t disrupt insulin delivery. Turns out as I suspected, there are also a lot of issues around carb counting (i.e., it’s not really happening) and diet that need addressing if she’s going to tighten control regardless of insulin delivery method, so she’s also going to see the nutritionist and hopefully have another f/u with the nurse education.
Based on the additional info my partner got, from what I can tell, I suspect her mom is having overnight lows at present because, for a while, she’s been taking too much basal to compensate for under-bolusing for carbs during the day, and then recently when she shifted slightly lower carb, probably resulting in going to bed in range instead of high, and is now ending up drifting low overnight. Of course, now she’s blaming low carb for the lows, but hopefully the Dex will help clarify things and, if I’m right, get her toward a lower basal and more bolus insulin, as well as demonstrating that things like sweet drinks or snacking on grapes when you’re not low are just going to be tough to contend with and often not worth the hassle. I am a little concerned about the system’s tendency to exaggerate lows and its lag on that, and the potential for that to drive overcorrections, but we will have to see how it goes.
Glad it is working itself out. Hopefully the patient wants to be part of the solution. That always seems like the weak link in the system, i.e. sugary drinks without proper dosing etc.
Yeah, I’m not sure how that’s going to go. I think it’s where the Dexcom is potentially valuable, because it makes it way more clear what the cost to those behaviors are, which might otherwise seem like more reasonable indulgences (which they can be, but it takes a bit more sophisticated approach to insulin, and/or saving them for lows). I know for me, getting a Dex motivated me to acknowledge the extent to which the whole “you can eat whatever, just dose for it!” is highly misleading, at least in how it was presented to many of us when the short-acting analogues first came out.
Yes, as the CGM has showed, you can eat anything you want, just in moderation with a sometimes complicated application of insulin i.e. pizza. Or, run marathons and stuff.
Right, or if you want a glass of juice when not low, you need to take insulin ahead of time and wait until you are dropping and then drink it, which I suspect is a level that she is not going to get to. She’s having trouble with just regular pre-bolusing, which the nurse educator did encourage her to do when possible.
And, if I may add… at this point, I think the t:slim and G6 is a far lower maintenance combination than the 670 and Guardian. Basically no calibrations and Basal-IQ is a beauty. The cartridge change potentially could be something she might need assistance with, but I’m not sure if that’s the case.