Night time alarms

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Pandy8

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Hi folks, could you please give me a steer on what is normal for you? T1 husband with Libre often has multiple alarms, high and low overnight. His overall figures are good with +90% in range. He says it must be because he isn’t managing BG well enough. I am concerned about the impact on sleep. How do others manage things overnight, please?
 
Hi. I can relate to interrupted sleep being a concern. I use the original Libre which doesn't have alarms and I sleep really soundly and my diabetes is managed well like your husband's and I average about 90%TIR. When I have to change over to the Libre 2 at the end of this year because they are phasing out the model I use, I fully intend to disable the alarms because I don't want my sleep disrupted. Having said that, I have confidence in my body waking me up if my levels drop too low or go too high, which happens from time to time despite my best efforts. I accept this genuine disruption as being part of my diabetes and I am thankful that it usually only affects me and not my partner, but I think Libre 2 generates a quite a few erroneous alarms (as do most alarm systems with cars, houses etc,) sometimes due to lying on the sensor arm and causing a compression low, so I think you have to weigh up your individual circumstances and figure out whether you need the benefit of an overnight alarm and live with the erroneous ones or if you can safely trust your body to tell you if it needs assistance during the night. I would hate to think that my Libre alarm was unnecessarily disturbing my sleep and even more so if it was impacting my partner, but if you have impaired hypo awareness then obviously it is a necessary evil.
 
Rebrascora is right about false alarms, especially 'compression lows'. When the low-glucose alarm goes off in the night, does your husband check his blood glucose? If that often shows a higher reading, he could try putting the sensor in a slightly different position?

More broadly: What has he set his alarms at, and why? ... I only use the low-glucose alarm. Originally, it was set at 3.9, and I got a lot of alarms. Then my DSN recommended setting it, for nighttime at least, at the lowest level, 3.3. Since then, I've had very few nighttime alarms; and I'm still alive. ; )
 
Spathiphyllum said:
Rebrascora is right about false alarms, especially 'compression lows'. When the low-glucose alarm goes off in the night, does your husband check his blood glucose? If that often shows a higher reading, he could try putting the sensor in a slightly different position?

More broadly: What has he set his alarms at, and why? ... I only use the low-glucose alarm. Originally, it was set at 3.9, and I got a lot of alarms. Then my DSN recommended setting it, for nighttime at least, at the lowest level, 3.3. Since then, I've had very few nighttime alarms; and I'm still alive. ; )
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Really very interesting that your DSN recommended setting the low level alarm so much lower at night. I think that may be a very good idea but I can imagine a lot of DSNs and consultants would have a fit at such a suggestion. 😱 The fact of the matter is that non diabetic people drop below 4 during the depths of the night sometimes. And of course, for many people Libre reads slightly lower than BG anyway. It usually reads about 1mmol lower than BG in my case, so a 3.3 would actually be about 4.3 which is absolutely fine.
Dropping to low levels is a reasonably natural bodily function in the depths of sleep and I find I sleep most soundly when my Libre shows my levels have been quite low (often a bit in the red) and stable for several hours..... of course, excursions into the red at night are usually after taking more exercise the previous day, so maybe that exercise is what makes me sleep better rather than the low levels...🙄.
 
rebrascora said:
Really very interesting that your DSN recommended setting the low level alarm so much lower at night. I think that may be a very good idea but I can imagine a lot of DSNs and consultants would have a fit at such a suggestion. 😱 The fact of the matter is that non diabetic people drop below 4 during the depths of the night sometimes. And of course, for many people Libre reads slightly lower than BG anyway. It usually reads about 1mmol lower than BG in my case, so a 3.3 would actually be about 4.3 which is absolutely fine.
Dropping to low levels is a reasonably natural bodily function in the depths of sleep and I find I sleep most soundly when my Libre shows my levels have been quite low (often a bit in the red) and stable for several hours..... of course, excursions into the red at night are usually after taking more exercise the previous day, so maybe that exercise is what makes me sleep better rather than the low levels...🙄.
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As it happens-- my DSN who suggested 3.3 is non-diabetic, but she wore a Libre 2 for two weeks, just so she knew what it was like! Which is great; all DSNs and diabetes consultants should do this (my diabetes consultant has done it too). And when suggesting 3.3 she told me that her glucose reading had dipped below 4 in the middle of the night a few times.
 
Pandy8 said:
Hi folks, could you please give me a steer on what is normal for you? T1 husband with Libre often has multiple alarms, high and low overnight.
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Some thoughts:
Going from high to low alarms during one night, or vice versa, indicates over-responding. So perhaps softer (ie less strong) insulin correction ratio when too high, or less glucose when low (thus not rebounding so strongly).
If you meant on a particular night there are multiple low alarms, this could need a slightly different treatment, but first the alarm must be verified by a finger prick. Libre is not accurate enough to be trusted when either low (<4) or high (>10 or even 9). If the low is confirmed by a meter test result then try less glucose, PLUS some slower carbs, such as a biscuit of 6-10 carb content. That can provide a lift and a consolidation. But, also, one can get compression lows from sleeping on a Libre; these are false and readings bounce back pretty quickly. If not compression lows and there are multiple low alarms then the interstitial BG, which Libre is reading is unluckily bouncing to just above then just below the alarm threshold and back again. Depending on what that alarm threshold is and what the fp test is revealing, consider changing the alarm setting.
Similarly if there are multiple high alarms then the sensor is bouncing above and below that particular alarm setting; again after an fp, either take a correction bolus or if not actually warranted, then raise the alarm threshold.
Pandy8 said:
His overall figures are good with +90% in range. He says it must be because he isn’t managing BG well enough.
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At +90% in range your husband is doing brilliantly and, if I understand correctly, he's only been into this D malarkey less than 12 months - so beyond brilliant!! He clearly is managing his D well enough and he just needs some tips or tweaks to navigate around these things. Time and experiences (his own as well as from others) are a great help.

Have you come cross the threads that discuss the limitations of Libre? Libre (or any CGM sensor) is a massive game changer in managing one's D. But, like any tool, aid, device etc there needs to be some understanding of the technology, its limitations and what that tech can do for you (or the wearer).
Pandy8 said:
I am concerned about the impact on sleep.
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Yes, uninterrupted sleep is considered one of the most important things for long term health, physical and mental. There are many studies doing further research on sleep and health. So I think you are right to be concerned. And, of course, sleep deprivation affects one's behaviour and performance the following day.
Pandy8 said:
How do others manage things overnight, please?
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I think I've offered some answers. It's a judgement between just changing the alarm settings (!) or responding with slightly different treatments.

With your husband's 90% TIR, it is possible he is setting himself too demanding standards and targeting a too challenging mean target. It is simply impossible to achieve total control; and management to achieve above 70% TIR is the NICE Guidance, based on various studies and results promulgated in National and International papers and discussed at various Symposiums. If he'd been diagnosed only a few years ago and didn't have access to any CGM, he simply wouldn't know how well he was doing and yet the evidence is that many, many long term T1s are doing fine. That is not me saying we don't need the tech! But sometimes the tech can mislead us into leaning too heavily on the numbers (and the decimal points) and believing we can improve the results more than is practically achievable. At 90%TIR I would concentrate on tweaks learnt from others, but not become too obsessive about this. The odd foray into above 10 is fine, if not for days on end. Likewise close to 4 or slightly lower.

For this latter aspect it is worth remembering that the US led very early research and using their units of measurement they agreed that 70 mg/dl was a safe threshold; that round number was something less, rounded up to 70 for safety and ease as a round number. Conversion from US units to our metric nos means dividing by 18, so 70 becomes almost 3.9 mmol/L (rounded up from 3.888889) and then rounded up to 4 for simplicity. But the instruments doing the measuring (sensors or fp meters) are themselves subject to quite soft tolerances (+/-15%); manufacturing to greater accuracy would be prohibitively expensive and probably much heavier and cumbersome instruments. So it is also risky to try and manage to very tight margins; even if the research has got all the complex theory about metabolism and endocrinology comprehensively pinned down (which it hasn't!).
 
Pandy8 said:
Hi folks, could you please give me a steer on what is normal for you? T1 husband with Libre often has multiple alarms, high and low overnight. His overall figures are good with +90% in range. He says it must be because he isn’t managing BG well enough. I am concerned about the impact on sleep. How do others manage things overnight, please?
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Could be compression low but high alarm shouldn't go off unless his bg is actually high or has his high alarm set to low.

Have both alarms set on my phone, very rarely get woken but don't suffer from compression lows since using libre 2, wife is lighter sleeper than myself & she doesn't here alarms so know I'm not sleeping through any.
 
Thank you for your input. All of this is really helpful to me. Yes, I wonder if he is setting himself an unachievable target, It’s difficult because I want to support his efforts to manage his diabetes and long term risks, but can’t believe that sleep deprivation has to be part of the package.
So that I know, how likely is it that sleeping through a low would adversely affect him?
 
Pandy8 said:
So that I know, how likely is it that sleeping through a low would adversely affect him?
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It depends if it is a real low (Libre may be showing he is hypo when he is actually in the 4s or 5s, so that would be no problem) and if he genuinely is low, then how low. I would not want to be going below 3.5 too often during the night but the odd 3.6-3.9 would not concern me. Also you have to take into account his hypo awareness.... is his body good at warning him when his levels are getting low or has he had incidents where his levels have dropped so low that he hasn't realised until it is too late and he has needed assistance or is fitting.

How long has he been diagnosed? People who have been diagnosed many years or decades are perhaps more at risk of losing their hypo awareness than someone newly diagnosed.

I think it is important to recognize that you can get obsessive about Libre statistics and even without Libre, some people feel a strong urge to get perfect results and that can impact on their mental health and lead to burn out as well as affecting their nearest and dearest. Balance is SO MASSIVELY important with diabetes and getting it right where you balance living life and enjoying it and yes, sleeping well and doing want you want to do and accepting that you can't do that and have perfect results takes time and practice and self-awareness. I think this forum really helped me to accept that perfection is not possible and to loosen up a bit.

If he is actually having real hypos through the night and his body is not waking him then I think the Libre is a valid intrusion for the sake of his overall health/wellbeing. Some people lose hypo awareness and can become unconscious and fit and even die from hypos so they should not be underestimated in their seriousness particularly nocturnal ones but if your body is responsive to them and wakes you up when you get too low then some of us do not feel a need for an alarm.
When I was first diagnosed I used to wake up throuh the night in a panic in case I was hypo. That was before Libre and I would regularly get out of bed and go into another room to finger prick test rather than disturb my partner. Then I had a week of repeated nocturnal hypos and each night my body woke up and I tested, dealt with it and went back to sleep. Now it is of so little consequence to me that I reach across to the bedside table, stuff a jelly baby in my mouth and I am back to sleep within seconds without even having to set foot out of bed or even barely turn over. I do my utmost to prevent them by adjusting my basal insulin but it happens. I can still average 90% TIR without alarms. I still try to get a personal best.... currently 97% Time in Range over 7 days.... when I get close to achieving that level but mostly I accept that 80-90% is still a very good everyday sort of achievement, so I don't get upset if my stats drop a bit occasionally.
 
Pandy8 said:
Thank you for your input. All of this is really helpful to me. Yes, I wonder if he is setting himself an unachievable target, It’s difficult because I want to support his efforts to manage his diabetes and long term risks, but can’t believe that sleep deprivation has to be part of the package.
So that I know, how likely is it that sleeping through a low would adversely affect him?
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If its a very deep low, then that can lead to seizures or even unconsciousness. Does he have an emergency Glucagon pen for you to use under such circumstances? But this at the extreme end of the spectrum.

Sleeping through a modest low is simply not good for one's body and potentially laying down longer term problems. I'm over 70 and less than 3 yrs diabetic, so my appraisal of how important is it for me to avoid long term problems would be different to your husband, or your child. But when I've slept through a low I recall feeling 'rough' on waking and out of sorts for part of the day.

Another 'but': set the Libre low alarm at a higher threshold, say 5.0 or even the top limit of 5.6. Then if this is triggered, address whether it needs a snack response or not, knowing there is plenty of 'margin'. For an alarm at 5 or 5.6 just eat a small biscuit regardless and go back to sleep; the sleep interruption is much less significant. Let those lower GI carbs nudge his BG up a bit, but without pushing him into hyper, or bothering to finger prick. Libre alarms can (should in my opinion) be used to tell you before you go low, not that you will imminently go hypo! That's what his natural hypo awareness should be doing. We get warnings from our car fuel guages that the tank is low, leaving some time to do something about it; out of fuel and stalled on the side of a road is akin to going hypo, after ignoring the warning signals from the high priced tech. [I'm old enough to remember driving around in dodgy elderly cars with fuel guages that were poorly calibrated or just didn't work and having a spare can in the boot (usually also empty) - with long walks to the nearest garage]. I try to use the Libre alarm as a caution, not an emergency response. Of course this strategy won't work if your husband is trying to micromanage his BG to be at an unduly low threshold! But under that circumstances perhaps challenge whether staying in an excessively low BG is less detrimental overall than repeatedly disrupted sleep patterns and long term mental health. It's all about BALANCE and COMPROMISES.

A further 'but': in steady state how much is the differential between sensor and fp and which is the higher figure? Despite another response earlier to the contrary, the vast majority of my sensors start 2-3 mmol/L ABOVE actual BG. So when Libre is behaving reasonably well and just leaving me to 'mentally manage the differential' my strategy for dealing with alarms is very different when the sensor is above, than when the sensor is below. Above or below differential I'm talking about in steady state, ie with horizontal trend arrows.

Sleep deprivation does not have to be part of the package. This could be put in the context of better BG management ..... more relevant alarm settings.
 
Yes, he has glucagon, thank you. His first anniversary of diagnosis is coming up shortly. He is worried about long term effects, though really he is talking about 30years, not 50 or 60.
It’s hard to know if he would wake up naturally with a low as he has his gadget, but I have pointed out that he survived the first few months with fp testing. He is resistant to the idea of adjusting his alarm levels as he is pleased with his stats - the DSN and GP have been cheering from the sidelines, though have no idea of the ramifications this end.
 
Proud to be erratic said:
We get warnings from our car fuel guages that the tank is low, leaving some time to do something about it; out of fuel and stalled on the side of a road is akin to going hypo, after ignoring the warning signals from the high priced tech.
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I disagree. A low in the mid to high 3s is not going to do me any damage (it is a natural level that a non diabetic person might see, particularly in the depths of sleep) and does not leave me conked out at the roadside. Yes, over time and numerous instances, it may erode my hypo awareness but it does not do me any physical damage at that level and I am able to function fine now that my brain and body don't panic about being that low. Normal people don't wake up at this level and don't feel rough after it. I wonder if you may feel hungover the next day because your body panics at this level and you get an adrenalin release, perhaps because you maintain your levels a bit higher than normal by setting that Libre alarm higher, which for you with no pancreas and therefore no liver back up system, makes absolute sense, but I think for most of us, a reading in the high 3s occasionally is no big deal nor should it be and may even be the body's way of resting properly. I certainly know that if my levels are up at 10 during the night I wake up having bad dreams and feeling restless and hot and uncomfortable, so that extra glucose is clearly causing issues in my body which is stopping it from resting properly. Around low 4s I get my best sleep, even if that is low 4s and high 3s for most of the night. I sleep well, no apparent dreams hardly move from the position I fell asleep in and wake up rested.... and this even happens if I wake up and have a JB or 2. I am back into that lovely deep sleep within seconds. No heart racing and sweating and feeling ill and no headache or hangover the next morning.

We are all different and each diabetic has to find what works for them and their body and their lifestyle.
Pandy8 said:
Yes, he has glucagon, thank you. His first anniversary of diagnosis is coming up shortly. He is worried about long term effects, though really he is talking about 30years, not 50 or 60.
It’s hard to know if he would wake up naturally with a low as he has his gadget, but I have pointed out that he survived the first few months with fp testing. He is resistant to the idea of adjusting his alarm levels as he is pleased with his stats - the DSN and GP have been cheering from the sidelines, though have no idea of the ramifications this end.
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I thought that might be the case with him being newly diagnosed and I do sometimes wonder if this tech will make us so reliant on it that we lose our ability to recognize hypos.
Does he ever take a break from the Libre? I find a week or 2 off every now and again really helps me to reset my perspective on my diabetes. Of course the first day or two are a bit scary because you feel like you are driving blind but it teaches you to listen to your body.

How frequently is the alarm going off? More than once a night most nights? Less or more? What does he do when the alarm goes off? Ie does he double check it with a finger prick or does he just treat it with some carbs or an injection? Does he leave the room to do that or put the light on and disturb you further? I always minimize any disruption to my partner if I have to do more than reach a jelly baby off the bedside table and chew it and I keep them in a pot so that there is no packet rustling. Can he set the Libre alarm to vibrate only and keep it in under his pillow so that the alarm doesn't disturb you. I keep my reader under my pillow and it is set to vibrate in the morning when my basal insulin dose is due and that works for me.
 
Does he have Glucagon because he has needed it before or has he just been routinely prescribed it and have you been taught to use it?
 
Pandy8 said:
Thank you for your input. All of this is really helpful to me. Yes, I wonder if he is setting himself an unachievable target, It’s difficult because I want to support his efforts to manage his diabetes and long term risks, but can’t believe that sleep deprivation has to be part of the package.
So that I know, how likely is it that sleeping through a low would adversely affect him?
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No he & you shouldn't accept that sleep deprivation is part of diabetes, it isn't. I like me sleep, in bed usually by 10pm wake around 6-7am, get up once for pee but that's about it, but do scan libre before going back to sleep.

Any consolation I've had type 1 for 40 years still have good hypo awareness, you can help keep awareness by not having to many hypo's & by not running bg levels to low.

Maybe he needs to review those alarm targets & test bg levels when he does wake up.
 
Pandy8 said:
He is resistant to the idea of adjusting his alarm levels as he is pleased with his stats
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I wonder what the alarms are saying? If he's going low most nights (or high, or both) that suggests something needs fixing. (If he's only going a bit low then the fix might just be to lower the low alarm a bit overnight as others have suggested.) Sleep is important for all of us (including you) so it's worth trying to improve things.

I find my slow acting insulin works really well at keeping me more or less steady overnight but that's not true for everyone. (And different insulins work better for different people.) And some people turn out to need a pump, though persuading his team that might need some work if he's showing good numbers. If he (and you) are having regular disturbed sleep it's important they know.

(I don't think it's worth worrying about hypo awareness while sleeping. I seem to remember there's a mechanism that makes that not work well for most people. Rather, hypo awareness while you're awake is the important one.)
 
Having developed some impairment of my hypoglycaemia awareness after 10-15 years of diabetes, in no small part because my Lantus background insulin was frequently keeping my BGs below 4 for hours on several nights a month, I’d advise against just accepting long overnight hypos as being ‘fine’.

I do agree that sleep is important, and that aiming for a good amount of time in range is a sensible precaution against long term problems, but keeping your hypo warning signs intact involves trying to keep your exposure to BG levels below 4 as low as you can within reason.

Has he come across the concept of basal testing? This might be really helpful in terms of making sure his background insulin (which is the one at most governs overnight BG levels) is as well balanced as it can be.

https://www.mysugr.com/en/blog/basal-rate-testing/
 
rebrascora said:
Does he have Glucagon because he has needed it before or has he just been routinely prescribed it and have you been taught to use it?
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No, he has never needed it. He actually asked for it as it was prescribed for our son (when he was in his steroid-induced diabetes phase and insulin dependent) so we thought it was standard. The slightly fierce though kindly nurse at his work place wanted a kit, too.
No, no instructions on use for me for either patient. I’ve had a look at it and decided the most important thing will be to find my glasses as the instruction leaflet print is tiny. I have to say, in these days of epipens and the like it seems old-fashioned and open to mis-handling. So let’s hope it’s never needed.
Bruce Stephens said:
I wonder what the alarms are saying? If he's going low most nights (or high, or both) that suggests something needs fixing. (If he's only going a bit low then the fix might just be to lower the low alarm a bit overnight as others have suggested.) Sleep is important for all of us (including you) so it's worth trying to improve things.

I find my slow acting insulin works really well at keeping me more or less steady overnight but that's not true for everyone. (And different insulins work better for different people.) And some people turn out to need a pump, though persuading his team that might need some work if he's showing good numbers. If he (and you) are having regular disturbed sleep it's important they know.
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Sometimes high, sometimes low. Sometimes bouncing along a threshold. Not unusual to have four alarms overnight. Is it possible to silence Libre overnight?
 
Pandy8 said:
Is it possible to silence Libre overnight?
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I think you’d have to deactivate at bedtime, then reactivate in the morning.

What are the high and low alarm settings set at?
 
rebrascora said:
I disagree.
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I'm not clear what you are disagreeing with. I postulate that using the alarm as an advance caution not as a declaration of being almost hypo is akin to the fuel guage in your car warning you before running out of fuel. The rest of your post is basically stating that its OK sometimes to be below 3.9. I happen to be very uncomfortable with that reasoning.
Going hypo because you are caught unawares is one thing and was inevitable before we had visibility thanks to CGM. But to go hypo or very near because you elect to not use the technology that is available to reduce those instances makes no sense, in my opinion.
The 2019 symposium sponsored by the ADA, expressly documented that to not go below 3.9 was more important than not exceeding 10 and reflected that in their tables of acceptable time in range. Yes, we all will from time to time go hypo. But to convince yourself that it's OK from time to time is one small step from convincing yourself that it's OK when it's more frequent and is a slippery slope.
Going low seems, from all that I've heard and read in the last 18 months, to be more damaging than going high. If that is an incorrect understanding, why are the International consensus recommendations from the 2019 ADA Conference promulgating Clinical Targets for Continuous Glucose Monitoring for Time in Range as depicted in Figure 1? Notably under 4% below 3.9 and under 25% for above 10.0?


I do share your concerns over technology causing us to forget the basics and I see this almost every time I ask some young shop assistant to do the simplest of "sums" where they need a calculator to add 2 + 2, or similar. Thus your comment "I do sometimes wonder if this tech will make us so reliant on it that we lose our ability to recognize hypos". Hopefully the natural hypo awareness signs will override that scenario - unless "going hypo" is pretty well eradicated as the tech continues to develop.

I'd like to debate this further, but it's drifting away from the OP title of 'Night time alarms' and I've already got too much on as the recent political fiascos have made our house sale very wobbly; mortgage lenders profiteering and changing their original offers to buyers!
 
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