Nursing home patients with diabetes treated with insulin and certain oral diabetes
medications (i.e. sulfonylureas and glitinides) are at increased risk for diabetic
hypoglycemia. As can be seen in the case report below, this can be fatal. A medical
expert witness with training in diabetes and endocrine disorders can help counsel
review comorbidities, care provided, and determine if the treatment at the nursing home
was below the standard of care.

Case Report:
Mary was a 60 year old female with a complicated past medical history including poorly
controlled insulin-requiring diabetes, diabetic complications of the retina, kidneys,
and peripheral nerves, severe depression, obesity, hypertension, peripheral vascular
disease, and osteoarthritis. She was prescribed two types of insulin for diabetes control,
and multiple oral medications for her other illnesses. Mary was admitted to a nursing
and rehabilitation facility for intense physical, occupational, and speech therapy,
psychiatric care, and psychotherapy.

Mary’s diabetes was treated with a combination of Lantus insulin (a long-acting insulin)
20 units every morning, and NovoLog insulin (a short-acting insulin) before each
meal and before bed. On several occasions during this admission Mary experienced
moderate to severe low blood sugar (i.e. hypoglycemia, defined as a blood sugar less
than 70 mg/dL). Mary’s diabetic hypoglycemia occurred without any typical symptoms
of hypoglycemia, a clinical scenario referred to as hypoglycemia without awareness. In
fact, she experienced a dangerously low blood sugar of 34 mg/dL at 0730 hrs on 4/28/2012.

On 5/3/2012 Mary was noted to have a markedly elevated potassium level and
worsening kidney function. At 2230 hrs on 5/3/2012 Mary was administered 10 units of
intravenous regular insulin with one ampule of intravenous 50% dextrose (D50), a usual
treatment for dangerously elevated potassium.

On 5/4/2012 at 0815 hrs Mary was difficult to arouse. When awake, she was alert
but oriented to her name only. Mary followed commands intermittently, had shallow
respirations 6 per minute (normal 15-18 per minute), and she was responsive to painful
stimuli. Her blood pressure at 0600 hrs was 87/51 mm Hg, lower than her prior blood
pressure at the nursing facility which ranged from 104/65 to 194/91. Repeat laboratory
studies demonstrated further worsening of her renal function and ongoing severe
elevation in her potassium. She was given her usual dose of long-acting insulin (Lantus
insulin 20 units), in addition to her usual dose of short-acting insulin (4 units of Novolog).
The patient was awake but drowsy, and at 1030 hrs she became lethargic. Since Mary
had previously been administered narcotics for pain, she was given a medication,
naloxone, to oppose the effects of narcotics in an attempt to increase her state of
arousal. Following the administration of the opiate antagonist naloxone, the patient
became agitated and combative. At 1040 hrs she received an additional 10 units of
intravenous regular insulin with one ampule of intravenous D50 in an effort to correct
her persistent, dangerous elevation in potassium. At 1130 hrs Mary remained confused
and combative, and she had visual hallucinations. Her blood glucose was 132 at this
time. Mary was then given the antipsychotic medication Haldol 1 mg and the antianxiety
medication Ativan intravenously. She was placed on 1:1 nursing supervision at her
bedside and it is stated in the record that she was continuously monitored. At 1330
hrs her respiratory rate was 11 per minute and her oxygen saturation was low at 88-
89% (normal >90%). Oxygen therapy 2 liters/min was initiated via nasal cannula and
a second dose of naloxone was given. At 1530 hrs the patient was in greater distress,
responded only to painful stimuli, and had a respiratory rate of 6 per minute. At this time
she was transferred to a hospital emergency room.

On 5/4/2012 at the nursing facility blood pressure was not reassessed after 0600 hrs,
and blood glucose was not monitored after 1130 hrs.

According to documentation from the hospital emergency room Mary arrived
unconscious on the evening of 5/4/2012 with a glucose of 4 mg/dL (normal 70-110
mg/dL). She was given two ampules of intravenous D50 with no improvement in her
mental state. Despite normalization of her blood glucose levels, intravenous antibiotics,
intravenous fluids, intubation, anti-seizure therapy, and aggressive supportive
management in the hospital ICU, Mary remained comatose and unresponsive. She died
on 5/17/2012.

Mary’s family filed a lawsuit on her behalf against the nursing facility depicted above,
claiming medical malpractice and deviation from the standard of medical care.

Definition and Description of Hypoglycemia:
Hypoglycemia is defined as a blood glucose less than 70 mg/dL. Under non-
starvation conditions the brain utilizes glucose and no other fuels to supply energy for
maintenance and sustenance of cellular activity and brain function. Since the brain
absolutely needs glucose to remain functional and viable, mild hypoglycemia leads
to altered brain function, while severe hypoglycemia can cause brain death. In a non-
diabetic individual and in most patients with diabetes, hypoglycemia is almost always
associated with so-called neurogenic symptoms such as tremors, sweats, palpitations,
hunger, paresthesias (“pins and needles” sensations), anxiety, and/or arousal. In
the vast majority of people these symptoms prompt the individual to seek food and
ward off any damage from hypoglycemia. If the blood glucose drops to 40-50 mg/
dL the individual develops neuroglycopenic symptoms such as confusion, behavioral
abnormalities, and abnormal psychomotor activity (i.e. mental and physical functions).
These symptoms often interfere with the ability of the individual to adequately and
rapidly respond to hypoglycemia. By the time blood glucose levels approach 20-30 mg/
dL the individual experiences seizures and coma. When blood glucose levels remain
below 15-20 mg/dL for some period of time, brain function ceases and crucial parts of
the brain die.

In conclusion, since insulin administration can provoke severe diabetic hypoglycemia,
insulin treatment can potentially cause death in a diabetic patient as a result of
irreversible damage to brain tissue. In a nursing facility it is the responsibility of the
entire health care team to avoid such a catastrophic outcome in patients treated with
insulin.

Factors Increasing the Risk of Diabetic Hypoglycemia in Inpatients:
The precise incidence of hypoglycemia in nursing homes in not well established.
According to a 2013 workgroup of the American Diabetes Association and the
Endocrine Society studying hypoglycemia and diabetes: “The risk factors
for inpatient hypoglycemia include older age, presence of comorbidities, diabetes,
increasing number of antidiabetic agents, tight glycemic control, septic shock, renal
insufficiency, mechanical ventilation, and severity of illness.” In the case of Mary
described above, worsening renal function, multiple injections of insulin within a
short period of time, and worsening clinical status (i.e. altered mental status including
hallucinations, low blood pressure, and severely elevated potassium level) increased
her risk of diabetic hypoglycemia.

Glucose Monitoring of Patients with Diabetes During Inpatient Care:
Based upon her prior medical history Mary had diabetic hypoglycemia without
awareness, a dangerous condition that prevents the patient from sensing severely
low blood glucose. A patient like Mary may not exhibit any symptoms of diabetic
hypoglycemia until her blood glucose is sufficiently low enough to cause coma,
seizures, brain damage, and death. Clearly a patient like Mary needs to have her blood
sugars consistently and carefully monitored at all times. Accurate and timely blood
glucose monitoring is especially crucial when the patient’s clinical condition is unstable,
as was Mary’s on the evening of 5/3/2012 and on 5/4/2012. Within a reasonable
degree of medical certainty, if Mary’s blood glucose had been regularly monitored in the
nursing facility between 1130 hrs and 1530 hrs diabetic hypoglycemia would have been
detected and treated well before hypoglycemia claimed her life.

Dietary Monitoring of Patients with Diabetes during Inpatient Care:
It is clear that patients at high risk for hypoglycemia need to eat three regular meals
and three snacks daily (one snack between each meal and one snack at bedtime). If a
patient such as Mary is receiving insulin regularly, she must be fed frequently in order
to avoid diabetic hypoglycemia. If she is eating very little of the food provided her, the
medical staff must decrease her doses of insulin in order to prevent hypoglycemia. On
5/4/2012, the day of her life-ending hypoglycemic episode Mary was eating very little,
since she was lethargic and/or combative. On 5/4/2012 despite her reduced food and
drink intake Mary was administrated her usual doses of insulin in addition to one dose of
intravenous regular insulin given to treat her elevated potassium level.

Conclusion:
In summary, Mary suffered a severe and fatal hypoglycemic event in the nursing facility
due to multiple factors. Her clinical condition had become unstable and increasingly
complicated during the last two days of her admission. She had been known to have
severe diabetic hypoglycemia without awareness earlier in her stay. She was eating and
drinking much less. Failure to adequately monitor her vital signs, blood glucose, and
diet during the final 4 hours of Mary’s nursing facility admission led to severe and fatal
diabetic hypoglycemia.

This case was settled by the parties involved.

About the author;
David Madoff, MD, Ph.D., is a board certified endocrinologist and a consultant
and expert witness in matters relating to diabetes and endocrine disorders. He
is a part-time assistant professor of medicine at The Johns Hopkins University
School of Medicine and is the Director of The Woodholme Center for Diabetes
and Endocrine Disorders. More information is available at www.seakexperts.com. Dr.
Madoff can be reached at dmadoff1@jhmi.edu.