Diabetes mellitus is a chronic, incurable disorder of carbohydrate metabolism. It involves an imbalance of the supply and demand for insulin. Food ingested is eventually converted to glucose (sugar) when it is carried in the blood to nourish all cells of the body. In diabetes mellitus insufficient insulin is available to meet this need because of:

(1)Failure of the islets of Langerhans to produce enough insulin

(2)The destruction of the insulin before it can be used, or

(3)Inability of body tissues to use the insulin

When cells are unable to use glucose large amounts accumulate in the blood and the condition called hyperglycemia results. Due to the concentration of glucose the kidneys excrete large amounts of water and the patient wants to drink large amounts of water. In addition, a loss of energy derived from food which is eaten results in compensation by increasing food intake. The body metabolizes its own store of fat and protein and a substance called ketones is produced. A toxic level of ketones can cause a condition called ketosis which can cause a coma.

Type I or insulin-dependent diabetes is the most severe form of this disease. Insulin is the essential therapy and it must be injected into the subcutaneous, fatty layer of tissues. The goal of insulin therapy is to maintain the blood sugar levels as close to the normal range as possible. To avoid frequent injections some patients use an insulin pup which provides a slow, continuous subcutaneous infusion  of insulin throughout the day.

In Type II or non-insulin dependent diabetes the body produces insulin but not enough to meet the body’s total needs. Insulin is not required and treatment includes dietary management, exercise, and medication that helps the body make better use of the available insulin.

Diabetic diets are individualized based on such factors as age, weight and daily activity level. Adherence to the diet is essential. Exercise is also essential but must be coordinated with the use of insulin in Type I diabetics.

Diabetic coma occurs when there is too much circulating glucose in the blood. The onset may be gradual. Few symptoms may be evident until levels become severely elevated. Individuals may become confused, drowsy, have difficulty breathing, nausea, vomiting and flushing of the skin. Diabetic coma is a medical emergency that can result in death without treatment.

Insulin shock is the opposite of diabetic coma, occurring when there is too much insulin in the blood. It may result from injecting too much insulin or from an unusual amount of exercise that burns up glucose normally available. Individuals may feel weak, hungry and nervous. They patient may perspire although the skin is cold to the touch. Confusion and personality changes may occur. If not treated the patient may become unconscious and brain damage and eventually death may occur.

Complications from diabetes can affect a number of body systems and result in major disability. Vascular changes can contribute to myocardial infarction or cerebrovascular accident. Circulation problems can result in peripheral vascular insufficiency so that even minor injuries are prone to become so severely infected that amputation becomes necessary. Deprivation of blood supply to the kidney can result in kidney failures. There can also be changes in the nervous system and changes in the peripheral nerves that result in loss of sensation and pain sensations.

In Type 2 diabetes lifestyle changes can be of great value and the psychologist’s knowledge of motivation and adherence can be of great help. The key to self-regulation in diabetes is testing blood sugar each day and for optimal effect more than once a day. Self-testing is rare in  Long Term Care but it remains important that the patient be engaged and keeps track of levels even if the nurse does the testing.

adherence to the medical regimen of monitoring glucose levels, dietary changes, exercise and medicine

One service that the Primary Care Psychologist should provide is Motivational Interviewing to promote  (e.g. especially for Type I). Behavioral strategies aimed at enhancing motivation and self-regulation have been shown of great value. Also, hypoglycemia can be very frightening and many patients remain hyperglycemic as an avoidance strategy. The psychologist’s knowledge of fear and the management of fear can be of value.

Stress coping and affective regulation are important in management of diabetes. Depression has been shown to lead to failure of adherence to the medical regimen. Improved ability to manage stress has been shown to enhance the management of the disease. A well designed personalized program for better management of stress can result in:

• Improved psychological well-being
• Improved blood glucose control and thus reduced risk of complication
• Reduced insulin regulation
• Fewer emergency episodes.

Diabetes is a silent killer that steals away life and well-being. At least one out of every five residents of skilled nursing facilities has diabetes. Its impact is evident by looking behind the curtains of heart disease, strokes, kidney disease and other illnesses, that might have happened, but much later, if at all, were it not for the impact of high blood glucose on the human body. In SNFs diabetics have an average of 6.4 diagnoses in contrast to 2.4 for non-diabetics. They are much sicker than other residents. In fact one of the best predictors of eventual placement in a SNF may very well be poorly controlled diabetes. A person with diabetes can expect to lose ten years of life. Before it kills, through its proxies, diabetes can rob LTC patients of their sight and even their limbs. Variations in blood glucose levels can lead to mental confusion and increase the instability of mood. In addition, the patient faces an emotional dilemma which can give the patient the Sisyphean choice of choosing between compromising health rapidly today, by risking hypoglycemia, or compromising health slowly tomorrow, as hyperglycemia ravages their body.

Hyperglycemia is a condition of too much glucose in the blood. This can be a product of either the pancreas’ loss of capacity for production of insulin, as is the case in type 1 diabetes, or resistance that prevents the insulin from being used as effectively and efficiently in its role of moving glucose into the cells to create energy, as is the case with type 2 diabetes. Hypoglycemia is the opposite. In hypoglycemia there is too little glucose in the blood to maintain bodily functions. Type 1 diabetics require insulin for life itself since the pancreas no longer produces it. However, the traditional distinction between insulin dependent and non-insulin dependent diabetes has been dropped. Type 2 diabetics may also need insulin. Elderly type 2 diabetics are more likely to require insulin as a management tool. Most type two diabetics are older and of those with diabetes 90% are type 2.

The primary medical treatment goal for both types of diabetes is to normalize blood sugar levels. Poorly controlled diabetes accelerates the aging process. There is evidence that it not only speeds coronary artery disease but may very well accelerate dementia. Complications of high blood sugar include:

• End stage renal disease
• Loss of vision
• Myocardial infarction
• Stroke
• Peripheral vascular disease
• Peripheral neuropathy
• Lower extremity amputations

There is strong evidence that lowering hyperglycemia can have a very positive effect in delaying the onset of complications, even in seniors.

The goals of any nutritional aspects of diabetes care are:

• To approximate normal blood sugar levels
• Optimum serum lipid levels
• Maintain appropriate body weight
• Prevent acute and chronic complications

While diabetics may check their own blood level when living in the community, or nurses may check the level in SNFs, the gold standard measure is called the Hemoglobin A1c. The red blood cells of the body actually keep a record of glucose levels and those levels can be measured to determine the history of blood sugar levels over that last 3 to 4 months. Normal levels for the HbA1c is below 7% in general and below 5% to 6% for tight management.

Even under close supervision, as few as 5% keep blood sugar within prescribed limits. If hyperglycemia is so damaging, and diabetics know that is the case, then why is adherence such a problem? One reason is that the medical regimen is very complex and it intrudes into so many spheres of life. Still another reason is diabetic burnout, a diagnosis specific form of depression. Characteristics include:

• The patient feels diabetes is in control of life
• They feel overwhelmed with the demands of the medical regimen
• Experiences bitterness and anger over diabetes
• Feels alone in their battle. Others do not understand.
• Feels resigned to poor glycemic control
• Avoids discussing the illness or symptoms with health professionals
• Ambivalence about increasing self-care role
• Too often in LTC they turn over all responsibility to the staff

Hypoglycemia is considered a blood sugar level below 70 mg/dl (normal is from 90 to 114). With mild hypoglycemia symptoms appear such as shaking, sweating and slowed thinking, but the patient can still treat themselves by eating. With severe hypoglycemia neuroglycopenic symptoms, such as lethargy, mental stupor and unconsciousness can occur, and the person must have help from others. It is an aversive experience and can be a source of embarrassment for the patient. Thus some patients avoid hypoglycemia by remaining hyperglycemic. To understand how patients could develop a fear of this condition, that can take on many characteristics of a phobia, consider these autonomic symptoms of very low blood sugar:

• Pounding heart
• Fast pulse
• Flushed face
• Trembling and shaking
• Sweating
• Queasy stomach
• Temperature changes
• Weakness
• Tingling
• Headache
• Rapid breathing

These mood changes can occur:

• Nervousness
• Irrational
• Worried
• Frustrated
• Angry
• Sadness
• Giddy
• Euphoric
• Jittery

At very low levels these neuroglycopenic symptoms can really scare a patient:

• Slowed thinking
• Dizziness
• Trouble concentrating
• Slurred speech
• Blurred vision
• Difficulty reading
• Sleepiness
• Numbness
• Lack of coordination

These kinds of symptoms can occur from too much insulin and too little food intake in type 1 or from skipping meals for type 2. Most type 1 diabetics have some experience with this condition.  Unfortunately one way to avoid the negative experience is to stay hyperglycemic, in spite of the long term risks, by eating foods that keep sugar levels high. It is a short term solution with severe longer term consequences. Those with a history of anxiety disorders are particularly susceptible.

False alarms can also play a negative role. Some of the symptoms of low blood sugar are also products of exercise. Like many panic patients, diabetics may avoid exercise for fear of the symptoms. Since losing even a small amount of weight can be of great value in controlling diabetes this fear can also have a very negative impact. The fact that exercise can indeed produce hyperglycemia makes solutions more of a challenge. By staying in what seems the safe territory of hyperglycemia and avoiding exercise such patients are creating the conditions for maximizing complications.

Some patients experience symptoms at 70 mg/dl and others do not do so until it falls below 50 mg/dl. So one of the first things that must happen is to find the risk point for particular patients. The key to finding the risk points is frequent checks by the patient or by the nursing staff. The minimum number of checks is four per day. Six to eight checks a day is not uncommon particularly if there is a history of high risk episodes. Patients learn to better discriminate changes by checking their blood sugar when they have what they believe are symptoms. In a successful program called Blood Glucose Awareness Training (BGAT) patients keep a diary that compares their estimates of blood glucose with actual numbers. Cox et.al. (2001) have reported that BGAT with type 1 diabetics learn to better recognize and react to variations in blood glucose fluctuations and such training “…has sustained, sustained, and broad ranging benefits.”

Fear of hypoglycemia is not a totally irrational fear. There is risk. So the goal is to attenuate the fear while realistically managing the risk. All type 1 diabetics and those type 2 diabetics who are on a tight control regimen should carry items like crackers, glucose tablets or gels with them at all times. Once they have learned how to recognize the symptoms they can easily resolve any symptoms by eating or perhaps drinking a little orange juice. If the protective habit is in place the psychologist can help with the fear by using the same methods that might be employed for a simple phobia—desensitization. Have the patient learn deep relaxation and set up a hierarchy that steps through the symptom experiences, and not just the external conditions. Some patients are more fearful in some circumstances than others and thus the desensitization should give emphasis to those. Always include in the imagery actually treating the symptoms with some food intake and have the symptoms fade away after that, replacing the tension with calm and relaxation.

Any time a diabetic presents as depressed it is useful to evaluate whether that depression is a manifestation of diabetic burnout. And it is essential to include in the assessment of a diabetic an exploration of the history of hypoglycemic episodes and the patient’s perceptions of that aspect of the illness.

References

Bradley, C. (Ed) Handbook of Psychology and Diabetes, Psychology Press, New York, 2003.

Cox, Daniel J. et. al. Blood Glucose Awareness Training, Diabetes Care, Volume 24, Number 4, April 2001, pp. 637- 642.

Saudek, C.D., et. al.  The Johns Hopkins Guide to Diabetes, John Hopkins Press, 1997.

Snoek, F.J and Skinner, TC. Psychology in Diabetes Care, John Wiley and Sons, 2005.