Clearly, BGAT has many implications for future directions in clinical application and research in patients with diabetes. As stated in the introduction, we do not consider BGAT to be a finished product. In fact, it requires almost constant revision to incorporate new research findings and training methods that are relevant to BGATs goals. More research is needed to understand the mechanisms of BGATs efficacy, its differential benefits across patient groups, and the exciting possibility that it may preserve the integrity of counter-regulatory hormonal response and symptoms without jeopardizing tight metabolic control. Just as importantly, BGAT needs to be adapted for younger type 1 populations and their care givers. Although research shows that BGAT can provide a wide range of benefits across many patient groups, one of its most important positive features may be the ability to evolve and accommodate discrete patient populations and problems in diabetes management. For this reason,...
It is extremely important that patients and caregivers understand the basis for the test and how to use the information. Rather than have fixed goals for all patients based on the studies discussed so far, it is better to individualize the approach. The ability of the patient to participate in the treatment program is crucial for optimal control. Focusing only on the HbA1c levels without addressing such issues as, the stresses of adolescence, puberty, the home environment, ageing, depression, and economic issues, will create a counterproductive situation. This is especially important when setting goals in the elderly where comorbidities and many psychosocial and economic issues will determine the goals (42). Caregivers also need to be aware that the glycohemoglobin values we use today to set the goals of treatment come from the DCCT and only assays that are referenced to this method are valid. Other assays cannot be used in the same way since they lack the data showing a relationship...
The specific signs and symptoms a patient experiences depend on the affected classes of nerve fibers. When large-diameter myelinated sensory nerve fibers are lost, a patient experiences loss of vibratory and position sense in a distal to proximal gradient. In severe cases, large myelinated motor fibers are affected, producing a pattern of distal weakness. Frequently, large-fiber loss is asymptomatic and is detected by a health care-giver during a foot exam. The depressed vibratory sensation and position sense is accompanied by diminished or absent Achilles tendon reflexes. In contrast, loss of small thinly or unmyelinated sensory fibers leads to a loss of pain and thermal sensation. When this class of fibers is predominantly involved, a patient often experiences neuropathic pain, dysesthesias, and or paresthesias (4,15,96). There are patients who experience a loss of both large and small sensory and motor function and who remain
In women with diabetes, several warning signs may suggest the presence of either depression or an eating disorder. These include the following overall deterioration in psychosocial functioning (including school attendance and performance, work functioning and interpersonal relationships) worsening in metabolic control increasing neglect of diabetes management, including blood sugar monitoring, insulin titration and adherence to other medications erratic clinic attendance significant weight gain or weight loss increased concern about meal planning and food composition and somatic complaints, including low energy, fatigue, disrupted sleep and increased worries about physical health. In some cases, family members will raise concerns about depression or disturbed eating before the individual with diabetes does so. If worsening metabolic control is due to intentional insulin omission, the individual may appear surprisingly unconcerned, and may initially deny that she has engaged in this...
Are younger than age 10, unless you have motivated and supportive parents and or caregivers are elderly, with other health problems or impairments have cardiovascular disease, angina, or other medical conditions that can be aggravated by hypoglycemia have severe complications of diabetes have conditions such as debilitating arthritis or severe visual impairment that would functionally limit intensive management
In order to obtain blood glucose control and to maintain this on a daily basis, it is essential for patients with diabetes to do SBGM. The DCCT and other studies clearly demonstrated the importance of this approach and it is now considered as one of the cornerstones of therapy. However one of the findings of the DCCT was that with intensive therapy the number of severe hypoglycemic episodes increase. The data obtained from monitoring are used to assess the efficacy of the treatment program and the frequency of hypoglycemia, to make adjustments to the program that will involve medication change as well as reviewing medical nutrition therapy and the effects of exercise. A great deal of progress has been made in the accuracy and ease of use of the glucose monitoring equipment. Monitors are now available that need very small amounts of blood and can record and store many blood glucose results with date, time of test and even provide 14-day averages of selected tests. Some of the monitors...
Quite often, children this age participate in their diabetes management by helping with glucose monitoring and choosing foods. This is also the age when parents will need to involve other caregivers or school staff in the diabetes management. The ADA has set out recommendations on how schools and day care centers should respond (see Resources) and how to set up a Diabetes Health Care Plan for your child. In addition to providing all the supplies (insulin and syringes, log book, glucose meter, testing strips, glucagon injection, ketone testing strips, and glucose tablets or gel) for caring for your child's diabetes, you should also provide the following information to the caregivers at your child's day care or school
Chronic disease, such as diabetes, during adolescence mitigates against untroubled passage through this period. The additional specific tasks faced by an adolescent with diabetes are as follows the shift of responsibility for disease control from caregiver to self the maintenance of good metabolic control in the face of the endocrine vagaries of puberty the incorporation of an increasingly less regimented lifestyle into their diabetes control and the maintenance of an active, normal lifestyle. Diabetic adolescents also encounter the reality of the risks of diabetes-related complications with the clinical advent of regular complication screening.
The burdens of diabetes management present medical, cognitive, behavioral and psychosocial challenges for the child and family. Diabetes care requires families to learn and carry out complex treatment regimens. Children with diabetes and their parents must acquire a cognitive understanding of diabetes and learn self-management skills that include monitoring blood glucose levels, recognizing and treating hypoglycemia and hyperglycemia, and food and exercise regulation, along with insulin administration. In the case of a child, education for diabetes management is necessary for both the child and the parent(s) and or caregiver(s) and special considerations are necessary.
In young children, frequent blood glucose monitoring (BGM) is critical in order to navigate within acceptable targets of glycemic control by minimizing the risk of severe or frequent hypoglycemia. Usually five to six BGMs per day and two urine tests per day for urine glucose and ketone bodies are performed by parents or caregivers. Measurement of blood glucose level at the parents' bedtime must be encouraged in order to detect asymptomatic hypoglycemia or to give a snack when BG is below a specified level (15). Nocturnal hypoglycemia should be suspected in children under conventional therapy with frequent fasting BG values below 120 mg dL (15). It must be noted that systematic carbohydrate intake at supper did not consistently prevent nocturnal hypoglycemia (14).
Educator, psychologist, and social worker is needed to give adequate and continuing counseling and education to parents and caregivers of young children. Frequent contacts between the family and the pediatric team is a key to achieve good metabolic control without acute complications. A 24-h telephone hotline will help to minimize acute metabolic complications or hospitalizations. It must be noted that the expertise in the management of young diabetic children requires a sufficient number of patients in order to give age-group-adapted education and support for parents and children. Education must continue throughout childhood and adolescence, with guidance adapted to cognitive and psycho-affective levels of the family members. This enables a gradual transfer of some responsibilities of care to the child. Adapted education may also be given to the young children by using appropriate pedagogic tools. Our team contributed to the development and multicenter evaluation of an educational...
Risk of hypoglycaemia Excessive weight gain Risk of atherogenesis Increased healthcare costs Increased caregiver support Concerns about the ability of an elderly person to recognize and deal with hypoglycaemia are a major worry with sulphonylurea as well as insulin treatment. The avoidance of hypoglycaemia, particularly at night, should be a particular goal when starting insulin for elderly patients living alone. Although there will always be an emphasis on self-care, with elderly people it is often the formal and informal caregivers who bear the responsibility for identifying and managing hy-poglycaemia. When caregivers are not present, or are themselves elderly or infirm, these issues must be taken into account when establishing the goals of therapy and blood glucose targets.
Although insulin treatment is best started at home on a trial basis, it is important to involve the multi-disciplinary diabetes team from the outset since a coordinated package of care will be needed (Da Costa 1997). Although this usually involves hospital-based secondary care services, there is no reason why transferring a patient from oral therapy to insulin cannot be performed exclusively in the primary care setting. The key person is the diabetes specialist nurse who links medical support with the wishes and concerns of the patient and caregivers, while ensuring that insulin injection technique, blood glucose monitoring and insulin dosage adjustment are appropriate.
Instructions on how to keep a BP log. The patient or caregiver should learn to use an automated sphygmomanometer to measure BP with the patient supine and after standing for 1 minute. It is helpful to the physician if, for 2 or 3 days before a visit, recordings have been
Although not the primary focus of the studies, a few other studies have considered patient-doctor relations. Burns and colleagues81 found that adolescents who reported worse relations with their medical caregivers had worse glycated haemoglobin, but there was no association between control and the parents' reports of relations with medical caregivers. However, Bobrow and colleagues93 found no associations between how much adolescent girls liked their doctor, whether the doctor gave them enough time, or whether they thought the doctor encouraged questions and their adherence. Similarly, McCaul and colleagues63 found no association between adolescents' satisfaction with medical care and self-care.
Diabetes diagnosed during infancy has a profound effect on the parent-child relationship. For the first 2 years of life, the central psychological task is the establishment of a mutually strong and trusting emotional attachment between the infant and the primary caregivers12'13. The infant's psychological well-being depends on the predictable presence of an adult who meets the infant's physical needs, provides a stable environment, and responds to his her social advances. such as frequent urination, which would signal the need to seek medical attention. Due to such delays and misdiagnoses at diagnosis, infants and toddlers are more likely than older children to be in diabetic ketoacidosis (DKA) and require hospitalization in an intensive care unit. When hospitalized, infants endure disruptions of expected home routines and are often subjected to invasive medical procedures. Once home, the 'trusted' caregivers are required to give injections and perform painful fingersticks on infants...
Diabetes during the second through fourth years of life continues to have a profound effect on the parent-child relationship. At this developmental period, the toddler's two central psychological tasks are (a) to separate from the parent or primary caregiver and to establish him herself as a separate person, by developing a sense of autonomy, with more clearly defined boundaries between the child and the parent and (b) to develop a sense of mastery over the environment and the confidence that he she can act upon and produce results in the environment, including the people making up his her social environment12'13. The restrictions of diabetes management and parental fear stemming from diabetes stress the normal drive of toddlers to explore and master their environments. The toddler's sense of autonomy can be threatened by over-protective caregivers, who may be unable to let the child out of their sight. Out of fear, the parents may scold toddlers for exploring, which can lead to...
In many respects, diabetes can act as an obstruction to adolescent passage. Diabetes is a potent touchstone for areas of potential conflict with parents and caregivers (such as the locus of control issues) (40,41). Diabetes may also increase the risk and likelihood of risk-taking behaviors (42) and may interfere with conformity to a peer group (43). In some cases, diabetes also impedes physical and sexual maturation (44). Poorly controlled diabetes is associated with subtle neuropsychological deficits that can impact on academic achievement and ultimately reduce career options and lifestyle choices (45,46). There is evidence that the deterioration seen in both psychological
Young children are highly dependent on their parents or caregivers. They cannot self-regulate or communicate the need for assistance in case of hypoglycemia. Ross et al. found that the symptoms of hypoglycemia in type 1 diabetic patients vary with age (36). They showed that behavioral symptoms are a valuable index of hypoglycemia in the younger age group and must be included in the initial education of parents and adult caregivers. This problem of recognition and treatment of hypoglycemia is a cause of major stress for parents when their child is not under their own supervision.
Both in clinical practice and in research settings, neuropsychological assessment typically has two aims the first is to contribute to the differential diagnosis of diseases or syndromes, the second is to provide information about cognitive strengths or weaknesses that can be used for decision-making with respect to treatment or care or educate the patient or his caregivers or significant others about neurocognitive changes that may be present. For making a reliable medical diagnosis, however, neuropsycholog-ical testing rarely contributes uniquely. While a low score on the MMSE is indicative for cognitive decline typically seen in Alzheimer dementia, a low performance may also be due to vascular cognitive impairments, Parkinson's disease, or even to problems in hearing. If cognitive tests or screening instruments are used for establishing medical diagnoses, information
The role of the practice nurse especially in managing older patients with diabetes includes (1) education of the patient and or his caregivers (2) advice on diet, smoking, exercise, taking tablets or insulin, self-care of the feet, recognizing and managing hypo- and hyperglycemia, and infection diseases (3) visiting housebound patients (4) extra attention for patients at higher risk for diabetic feet problems and visual problems and (5) communication with nurses and care managers in residential and nursing homes. Leadership in the team is taken by people most committed to the task.
Amputation remains a major complication of older people with diabetes, and so good footcare is essential as is a properly organized preventative care program. A 10 g nylon monofilament is a simple way to test for evidence of neuropathy in diabetes. Patients can be taught to use this simple device for themselves (Birke and Rolfsen 1998). Good education and adequate literature are important (Connor 1997). Diabetic patients need to be especially careful about footwear, which needs to be properly measured (Litzelman and Marriott 1997 Uccioli et al 1995). Early intervention is needed when problems are detected, to avoid amputation. This would include good vascular surgical support (Levin 1995). Many older people cannot manage to reach or inspect their own feet, so it is important that caregivers are also taught the appropriate techniques (Thomson and Masson 1996). The annual review is not only about detection and management of complications. Education and verifying comprehension of and...
Insulin treatment in general practice is a good option if the GP is well informed about the diverse range of insulins and syringes, the indications, complications and use of combination therapy. But it is essential that a nurse specialized in diabetes care be available to give intensive education to the patient and caregiver before starting the therapy. The advantage of starting insulin therapy in primary care is that the GP can follow his or her own patients and can manage the complications of the therapy. Patients fear insulin therapy because they believe that their disease is not mild but serious, and they exaggerate the pain of the injections and the difficulties of monitoring their blood glucose. The aim of insulin treatment in many elderly patients should be to
Menopause is associated with changes in body composition, including an increase in total fat mass and abdominal obesity, and these changes may increase risk for DM2. This change in body composition does not appear to be explained solely by an increase in body weight. The risk for DM2 increases with menopause, though how much of this increase in risk is due to the hormonal changes of menopause vs. the increase in BMI with aging is not clear. Existing studies support a decrease in risk for DM2 with HRT. Given the increase in cardiovascular risk with HRT, however, it should not be used for this indication. The mechanism for this decrease in risk is unclear at present. Future studies are needed to define whether the symptoms and pattern of hormonal changes characteristic of menopause differ in women with DM2. Women with DM2 and their caregivers should be aware that menopause and its treatments may affect diabetes risk as well as glucose control in women with DM2.
Elderly people may not have as many symptoms in response to hypoglycemia (tremor, sweating, fast heart rate, hunger), and so they may not recognize low glucose reactions as well as younger individuals do. This can cause a delay in treatment, and glucose levels can go dangerously low. If an elderly person is delirious because of an acute illness or is chronically confused because of dementia, his or her caregivers may have difficulty recognizing and treating low glucose reactions.
Advice on basic foot care including nail-cutting techniques, the treatment of minor injuries and the purchase of shoes should be given to the patient and caregivers. Nails should be cut after a bath or shower when they are softer. It is unwise to try to cut the whole nail in one piece. The patient should never try to cut out the corner of the nail or dig down the sides. Sensible shoes should be made of soft leather and have broad rounded or square toes, with a high toe box. The heels should be low to avoid excessive toe pressure on the forefoot and they should be either fitted with laces, Velcro, or buckle straps to prevent movement within the shoe.
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