Care of People with Diabetes

PROFESSOR TRISHA DUNNING, AM, RN, MEd, PHD, CDE, FACN (DLF), is a Registered Nurse and credentialed Diabetes Educator. She is the Chair in Nursing at Barwon Health and Deakin University Partnership in Geelong, Australia. PROFESSOR ALAN SINCLAIR, MSC, MD, FRCP, is Director of the Foundation for Diabetes Research in Older People (FDROP) at Diabetes Frail, and Visiting Chair in Diabetes Care, King's College London, London, UK.

Foreword xiii

Preface xv

Acknowledgments xvii

List of Abbreviations and Symbols xix

1 Diagnosing and Classifying Diabetes 1

Key points 1

What is diabetes mellitus? 2

Prevalence of diabetes 2

Classification of diabetes 3

Overview of normal glucose homeostasis 3

Brain‐centric model of glucose homeostasis 10

Metabolic syndrome in children and adolescents 13

Types of diabetes 14

Diagnosing diabetes 22

Preventing diabetes 26

Managing diabetes mellitus 29

Key points 29

Complications of diabetes 36

Aims and objectives of diabetes care 38

Technology and diabetes management 40

A sobering final comment 42

References 43

2 Holistic Personalised Diabetes Care 49

Key points 49

Rationale 49

Shared decision‐making (SDM) 50

Holistic diabetes care 51

Communication and the power of language 52

Reading fiction to improve empathy and communication skills 53

Care models 53

Characteristics of an holistic health history 55

References 58

3 Assessing and Monitoring People with Diabetes 61

Key points 61

Rationale 61

Key issues to consider in comprehensive assessments 62

Monitoring glucose levels 62

Monitoring 1: Blood glucose 64

Key points 64

Insulin pumps 75

Monitoring 2: Urine glucose 76

Key points 76

Monitoring 3: Additional assessment 78

Self‐care 82

The annual review 83

Summary 83

References 83

4 Nutrition and Weight Management 87

Key points 87

Rationale 87

The importance of good nutrition 88

Malnutrition and undernutrition 88

Method of screening for dietary characteristics and problems 90

Principles of dietary management for people with diabetes 92

Goals of dietary management 95

Overweight and obesity 95

Methods of measuring weight 99

Managing obesity and diabetes 100

Dietary management: overweight and obesity 101

Factors associated with making dietary changes 103

Key points 104

Alcohol 107

Exercise/activity 107

References 108

Further reading 112

5 Medicine Management 113

Key points 113

Introduction 114

QUM 114

QUM and diabetes 114

GLM 117

Medicine interactions 129

Combining GLMs and insulin 130

When should insulin be initiated in Type 2 diabetes? 131

Challenges to initiating insulin therapy 134

Some strategies to overcome the barriers 135

Insulin therapy 136

Types of insulin available 136

Storing insulin 139

Injection sites and administration 140

Mixing short/rapid acting‐ and intermediate‐acting insulins 141

Commonly used insulin regimens 141

Interpreting morning hyperglycaemia 143

CSII 143

Continuous blood glucose sensors 144

Subcutaneous insulin sliding scales and top‐up regimens 145

Uses of insulin infusions 147

Insulin allergy 149

Pancreas transplants 150

Stabilising diabetes 150

Stabilising diabetes in hospital 150

Community and outpatient insulin stabilisation 151

Lipid‐lowering agents 153

Monitoring lipid medicines 157

Antihypertensive agents 158

Antiplatelet agents 159

Medication safety, adherence, and medication self‐management 161

Enhancing medication self‐care 163

Example protocol for outpatient stabilisation onto insulin 166

References 167

6 Hypoglycaemia 175

Key points 175

Rationale 175

Introduction 176

The counter‐regulatory response 178

Definition of hypoglycaemia 179

Recognising hypoglycaemia 182

The brain and glucose homeostasis 183

Causes of hypoglycaemia 183

Preventing and managing hypoglycaemia 184

Hypoglycaemic unawareness 185

Prevalence of HU 186

Nocturnal hypoglycaemia 187

Relative hypoglycaemia 189

Medicine interactions 189

Objectives of care 190

Treatment 190

Prolonged hypoglycaemia 191

Patients most at risk of hypoglycaemia 192

Psychological effects of hypoglycaemia 193

Guidelines for administering glucagon 194

Adverse reactions 195

References 196

7 Hyperglycaemia, Acute Illness, Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycaemic States (HHS), and Lactic Acidosis 199

Key points 199

Rationale 200

Prevention: proactively managing intercurrent illness 200

Self‐care during illness 202

Hyperglycaemia 202

Diabetic ketoacidosis (DKA) 204

Brittle diabetes and hyperglycaemia 211

Euglycaemic DKA 211

Hyperosmolar hyperglycaemic states 212

Lactic acidosis 214

References 216

8 Long‐Term Complications of Diabetes 219

Key points 219

Introduction 220

Diabetes and complexity 220

Pathophysiology of diabetes complications 221

Cardiovascular disease and diabetes 223

Key points 223

Cerebrovascular disease 236

Diabetes and eye disease 237

Diabetes and renal disease 243

Peripheral and autonomic neuropathy 255

Autonomic neuropathy 266

References 270

9 Management in Hospital, Surgery, and Investigations 279

Emergency department 279

Key points 279

Surgical procedures 280

Key points 280

Preoperative care 284

Postoperative care 289

Guidelines for informing people with diabetes about what they should do prior to surgical procedures 290

Insulin pump therapy in patients undergoing surgery 292

Emergency procedures 292

Bariatric surgery 293

Investigative procedures 293

Key points 293

The objectives of care 294

General management 294

Eye procedures 295

Complementary medicines and other therapies during surgery and investigative procedures 298

Preoperative phase 298

Postoperative phase 299

Implications for care 299

References 300

Example Information 2(a): Instructions for people with diabetes on oral glucose-lowering medicines having procedures as outpatients under sedation of general anaesthesia 301

Example Instruction Sheet 2(b): Instructions for people with diabetes on insulin having procedures as outpatients under sedation or general anaesthesia 302

10 Conditions Associated with Diabetes 303

Key points 303

Introduction 303

Enteral and parenteral nutrition 304

Diabetes and cancer 309

Smoking, alcohol, and illegal drug use 315

Brittle or labile diabetes 326

Oral health and diabetes 328

Diabetes and liver disease 329

Haemochromatosis 332

Diabetic mastopathy 333

Diabetes and coeliac disease 334

Cystic fibrosis−related diabetes 336

Incontinence 338

Sleep disturbance and diabetes 340

Diabetes and tuberculosis 341

Diabetes and HIV/AIDS 342

Diabetes and hearing loss 343

Diabetes, musculoskeletal disease, and osteoporosis 345

Corticosteroid medications and diabetes 347

Key points 347

Diabetes and driving 350

Diabetes and fasting for religious observances 359

Education and counselling 359

References 360

11 Sexual and Reproductive Health 371

Key points 371

Rationale 371

Sexual health 372

Sexual development 373

Sexual problems 374

Possible causes of sexual difficulties and dysfunction 374

Sexuality and older people 375

Women 376

Men 377

Sexual counselling 380

Role of the clinician 383

References 383

12 Diabetes and Older People 385

Key points 385

Rationale 386

Introduction 386

Determining functional status 392

Geriatric syndromes 394

Cognitive functioning and dementia 395

Depression and older people with diabetes 400

Dementia 400

Caring for older people with diabetes 401

Education approaches 408

Self‐care 409

Factors that can affect metabolic control 410

Overall care strategies 417

References 418

13 Diabetes in Children and Adolescents 425

Key points 425

Rationale 425

Introduction 426

Impact of hyper‐ and hypoglycaemia on brain development and function 429

Managing children and adolescents with diabetes 430

Aspects of care that apply to both type 1 and type 2 diabetes in children and adolescents 430

Managing type 1 diabetes 431

Managing type 2 diabetes 433

Medicine self‐management 436

Other conditions associated with diabetes 436

Strategies for enhancing adherence during adolescence 437

Ketoacidosis in children 438

Complementary therapy use in children 438

References 439

14 Women, Pregnancy, and Gestational Diabetes 443

Key points 443

Rationale 443

Polycystic ovarian syndrome 444

Contraception options for women with diabetes 447

Pregnancy 449

Gestational diabetes 455

Menopause and diabetes 459

References 462

15 Psychological and Quality of Life Issues Related to Having Diabetes 467

Key points 467

Rationale 468

Introduction 468

Clinician factors 469

Adjustment and spirituality 472

Diabetes: reputation and myths 473

Diabetes‐related distress 474

Quality of life 474

Diabetes and depression 476

Mental health and type 1 diabetes 480

Mental health and type 2 diabetes 480

Psychological distress and cardiovascular disease 481

Psychiatric disorders, diabetes, and antipsychotic medicines 482

Diabetes conversations and language 483

References 486

Further reading 490

16 Diabetes Education 491

Key points 491

Rationale 492

Introduction 492

Learning styles 495

Education and other theories/models 497

Communication – having good conversations 500

Teaching: an art and a process 503

Health literacy 504

Survival skills 507

Empowerment 508

Special issues 509

The clinicians’ role in diabetes education 509

Documenting diabetes education 512

Evaluating diabetes education 515

References 517

Further reading 521

17 Managing Diabetes at the End of Life 523

Key points 523

Introduction 524

Explanation of terms: values, life limiting illness, palliative care, terminal care, and end‐of‐life care 524

Palliative care 525

General management considerations for managing diabetes at the end of life 531

Diabetes‐specific considerations 532

Medicine management 534

Type 1 diabetes 534

Nutrition and hydration 536

Diabetogenetic medicines 537

Supporting family/carers 538

Withdrawing treatment 539

Diabetes education 539

References 540

18 Complementary Medicine 543

Key points 543

Rationale 543

Introduction 544

CAM philosophy 546

Integrating complementary and conventional care 547

Can Complementary Therapies Benefit People with Diabetes? 549

Spirituality 552

CM and surgery 552

Herb/medicine interactions 556

How can CM be used safely? 556

Clinician responsibilities 560

Identifying quality health information on the internet 561

Recommended resources 563

References 563

Index 567