Difficult conversations: adults with diabetes and the discussion of microvascular complications.

AIMS: To investigate the experiences among adults with diabetes of discussions of microvascular complications and provide recommendations for providers. METHODS: We performed a qualitative study in 148 adults with Type 1 and Type 2 diabetes (56% women, 95% white, mean age 60±13 years, 65% with Type 1 diabetes, 71% with ≥1 microvascular complication). Data were analysed using content analysis. RESULTS: At their first discussion of microvascular complications, 93% of participants (138/148) recalled providers using a preventative approach including clinical suggestions, factual information and warnings. At complication diagnosis, 78% of participants (82/105) perceived provider support through comprehensive interactive education, specific self-care guidance, reassuring messages, and referrals and follow-ups. In response to complication diagnosis, 48% (50/105) felt scared, 46% (48/105) had 'a wake-up call', and 86% (90/105) reported increasing ≥1 specific area of self-care. Participants recommended providers offer factual and complete information, specific self-care guidance, and positive honesty, with an individualized and collaborative approach that includes psychosocial assessment and referrals and lacks 'scare tactics' and blame. CONCLUSIONS: Adults with diabetes want to learn about diabetes microvascular complications and apply preventative strategies as early as possible. Paradoxically, the diagnosis of a diabetes microvascular complication in itself may represent a unique learning opportunity because 86% of participants improved diabetes self-care after this event. Recommendations offer providers simple but important clinical approaches to improve these difficult conversations and thus support necessary behaviour changes and psychosocial well-being. Training is needed to help providers discuss the threat of diabetes complications with honest but positive messages so that people with diabetes can be fully informed but also maintain hope in the face of complications.

Which aspects of executive dysfunction influence ability to manage diabetes in older adults?

AIMS: To examine whether different aspects of executive function as measured by different assessment tools are associated with glycaemic control and other clinical characteristics in older adults with Type 2 diabetes. METHODS: We performed a cross-sectional study of older adults aged ≥ 70 years with Type 2 diabetes at a tertiary care diabetes centre. The Dysexecutive Questionnaire was used to measure self-reported executive dysfunction. Objective tests of executive functions included a modified clock drawing test (Clock-in-a-Box), Trail Making Tests (parts A and B) and verbal fluency. Demographic and clinical information was collected using questionnaires and surveys. Glycaemic control was measured by HbA(1c). RESULTS: We evaluated 145 patients [average age 77 ± 5 years, diabetes duration 15 ± 11 years, mean HbA(1c) 56 ± 11 mmol/mol (7.3 ± 1.1%)]. Poor performances on objective tests (low scores on Clock-in-a-Box and verbal fluency; and high scores on Trail Making Tests A and B) but not on the subjective test (the Dysexecutive Questionnaire), were associated with poor glycaemic control (r = -0.23, P < 0.005; r = -0.17, P < 0.04; r = 0.20, P < 0.01, r = 0.22, P < 0.008, r = -0.07, P < 0.42, respectively). In a multiple regression model (r(2) = 0.39), high Dysexecutive Questionnaire scores were associated with higher diabetes-related distress (P < 0.0004), depressive symptoms (P < 0.004), number of falls (P < 0.009), fear of falling (P < 0.01), less years of education (P < 0.0007) and fewer medications (P < 0.001). CONCLUSIONS: On the one hand, in older adults, executive dysfunction detected by objective tests is associated with poor glycaemic control and may be considered before prescribing complex treatment regimens. On the other hand, self-reported executive dysfunction is associated with risk and fear of falls, and more affective symptoms, which may indicate higher awareness of subtle deficits.

Biomedical risk factors for decreased cognitive functioning in type 1 diabetes: an 18 year follow-up of the Diabetes Control and Complications Trial (DCCT) cohort.

AIMS/HYPOTHESIS: In patients with type 1 diabetes, there has been concern about the effects of recurrent hypoglycaemia and chronic hyperglycaemia on cognitive function. Because other biomedical factors may also increase the risk of cognitive decline, this study examined whether macrovascular risk factors (hypertension, smoking, hypercholesterolaemia, obesity), sub-clinical macrovascular disease (carotid intima-media thickening, coronary calcification) and microvascular complications (retinopathy, nephropathy) were associated with decrements in cognitive function over an extended time period. METHODS: Type 1 diabetes patients (n = 1,144) who had completed a comprehensive cognitive test battery at entry into the Diabetes Control and Complications Trial were re-assessed at a mean of 18.5 (range: 15-23) years later. Univariate and multivariable models examined the relationship between cognitive change and the presence of micro- and macrovascular complications and risk factors. RESULTS: Univariate modelling showed that smoking history was modestly associated with decrements in learning, memory, spatial information-processing and psychomotor efficiency; hypertension was associated with only psychomotor slowing. Multivariable modelling demonstrated that HbA(1c) level, and retinal and renal complications were each independently associated with decrements in psychomotor efficiency. In contrast, no macrovascular risk factors were significant after correcting for multiple comparisons. No interactions were found between these predictors and sex, severe hypoglycaemic events or presence of the APOE ε4 allele. CONCLUSIONS/INTERPRETATION: In relatively healthy, middle-aged adults with type 1 diabetes who had been followed for an average of 18.5 years, long-term metabolic control and microvascular factors are independently associated with a decline in cognitive function specifically affecting measures of psychomotor efficiency. TRIAL REGISTRATION: ClinicalTrials.gov NCT00360893.

Perceived challenges and priorities in co-morbidity management of older patients with Type 2 diabetes.

AIMS: To explore older patients' perceived impact of chronic co-morbid conditions on Type 2 diabetes self-management. METHODS: We used purposive sampling to select 32 mentally alert community-dwelling adults, aged 60 years or older, diagnosed with Type 2 diabetes and at least one other chronic health condition to participate in focus groups. We summarized the discussions following each focus group and identified codes to describe the overarching themes. RESULTS: We conducted eight 90-min focus groups, each consisting of two to six patients. Three themes emerged. (i) Diabetes complications as a motivator: managing co-morbid conditions made health an important focal point in the lives of older patients. Most patients acknowledged the positive effect complications had on their diabetes self-management by motivating them to pay greater attention to their diabetes to diminish the progression of these complications. (ii) Prioritizing health conditions: patients reported prioritizing health conditions and selectively attending to the management of those conditions based on perceived severity or importance. Further, many patients perceived some conditions as more serious than others and admitted to prioritizing another health condition over their diabetes. (iii) Emotional impact of co-morbidity management: patients described feeling frustrated, confused, and overwhelmed in response to conflicting treatment recommendations, particularly for diet, physical activity and medication regimens. CONCLUSIONS: Complications and co-morbidities may have differential impacts on the diabetes self-management of older patients. Addressing the perceived impact of co-morbidity on diabetes self-management may improve patients' outcomes; however, the most effective method of utilizing this information in clinical practice needs to be examined.

Psychosocial factors associated with use of continuous glucose monitoring.

AIMS: To identify psychosocial factors associated with the use of continuous glucose monitoring by adults with Type 1 diabetes. METHODS: Twenty adult patients (aged 45 +/- 15 years, diabetes duration 25 +/- 19 years, 50% female) followed at our site in the multi-centre Juvenile Diabetes Research Foundation continuous glucose monitoring trial were divided into three groups: Glycated haemoglobin (HbA(1c)) Responders who demonstrated an improvement in glycaemic control with continuous glucose monitoring (baseline HbA(1c)> or = 7.0%, HbA(1c) reduction greater than or equal to 0.5%), Hypoglycaemia Responders (baseline HbA(1c) < 7.0%) who demonstrated decreased time < 3.9 mmol/l while remaining within target HbA(1c), and HbA(1c) Non-Responders (baseline HbA(1c)> or = 7.0%, HbA(1c) reduction less than 0.5%). Subjects participated in semi-structured interviews focusing on their psychosocial experiences with continuous glucose monitoring. RESULTS: Three major themes were identified that differentiated Responders (including both the HbA(1c) and Hypoglycaemia groups) from Non-Responders: (i) coping with frustrations-Responders used self-controlled rather than emotions-based coping when faced with continuous glucose monitoring frustrations; (ii) use of information-Responders used retrospective pattern analysis, not just minute-by-minute data analysis, in glycaemic management; (iii) 'significant other'/spousal involvement-Responders endorsed interest, encouragement and participation by their loved ones. Both Responders and Non-Responders expressed body image concerns when wearing continuous glucose monitoring devices. CONCLUSIONS: This qualitative study points to the importance of coping skills, retrospective review of data, and 'significant other' involvement in the effective use of continuous glucose monitoring. These findings will inform clinical initiatives to improve patient selection and training in the use of this new technology and have served as the basis for development of quantitative surveys to be used in clinical practice.

The associations of apolipoprotein E and angiotensin-converting enzyme polymorphisms and cognitive function in Type 1 diabetes based on an 18-year follow-up of the DCCT cohort.

AIMS: Specific polymorphisms of the apolipoprotein E (APOE) and angiotensin-converting enzyme (ACE) genes appear to increase risk for Alzheimer's disease and cognitive dysfunction in the general population, yet little research has examined whether genetic factors influence risk of cognitive dysfunction in patients with Type 1 diabetes. The long-term follow-up of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) population provides an opportunity to examine if specific genetic variations in APOE and ACE alter risk for cognitive decline. METHODS: Neurocognitive function in Type 1 diabetic subjects from the DCCT/EDIC study was assessed at DCCT entry and re-assessed approximately 18 years later, using a comprehensive cognitive test battery. Glycated haemoglobin (HbA(1c)) and the frequency of severe hypoglycaemic events leading to coma or seizures were measured over the 18-year follow-up. We determined whether the APO epsilon4 and ACE intron 16 indel genotypes were associated with baseline cognitive function and with change over time, and whether they conferred added risk in those subjects experiencing severe hypoglycaemic events or greater glycaemic exposure. RESULTS: None of the APOE or ACE polymorphisms were associated with either baseline cognitive performance or change in cognition over the 18-year follow-up. Moreover, none of the genotype variations altered the risk of cognitive dysfunction in those subjects with severe hypoglycaemic episodes or high HbA(1c). CONCLUSIONS: In this sample of young and middle-aged adults with Type 1 diabetes, APO epsilon4 and ACE D alleles do not appear to increase risk of cognitive dysfunction.

Blood glucose awareness training and epinephrine responses to hypoglycemia during intensive treatment in type 1 diabetes.

OBJECTIVE: To determine the effect of blood glucose awareness training (BGAT) on epinephrine and symptom responses to hypoglycemia in patients with type 1 diabetes enrolled in an intensive diabetes treatment (IDT) program. RESEARCH DESIGN AND METHODS: A total of 47 subjects with uncomplicated diabetes (duration 9 +/- 3 years: HbA1c 9.0 +/- 1.2%; reference range 4-6%) enrolled in a 4-month outpatient IDT program were randomized to classes in BGAT (n = 25) (BGAT group) or cholesterol awareness (n = 22) (control group). Subjects underwent stepped hypoglycemic clamp studies before and at completion of IDT. Plasma glucose was lowered from 6.7 mmol/l (baseline) to 4.4, 3.9, 3.3, 2.8, and 2.2 mmol/l over 190 min. Symptoms, counterregulatory hormones, and ability of the subject to estimate their glucose level were assessed at each plateau. At home, subjects used a handheld computer to first estimate and then measure and record blood glucose levels for 70 trials over a 4-week period immediately before IDT and again immediately following the educational intervention. RESULTS: HbA1c decreased in both BGAT group (9.1 +/- 1.4 to 7.9 +/- 1.1%; P < 0.001) and control group (9.0 +/- 1.1 to 7.8 +/- 0.8%; P < 0.001) (NS between groups). Frequency of hypoglycemia (< 3.9 mmol/l) increased in both groups, from 0.45 +/- 0.06 to 0.69 +/- 0.07 episodes per day (P < 0.001) in the BGAT group and from 0.50 +/- 0.08 to 0.68 +/- 0.06 episodes per day (P < 0.05) in the control group NS between groups). Epinephrine responses after IDT were greater in the BGAT group (repeated measure analysis of variance [ANOVA], F = 3.5, P < 0.05). A separate analysis of subjects n = 26) most at risk for hypoglycemia (HbA1c after IDT < 7.8% or an HbA1c improvement of > 2 percentage points) showed that frequency of hypoglycemia increased in both the groups: from 0.50 +/- 0.09 to 0.80 +/- 0.11 episodes per day (P < 0.01) in the BGAT group (n = 14) and from 0.43 +/- 0.11 to 0.75 +/- 0.07 episodes per day (P < 0.05) in the control group (n = 12) (NS between groups). However, the epinephrine response in control subjects decreased with IDT while the response in the BGAT subjects was preserved (repeated measure ANOVA, F = 4.4, P < 0.02). CONCLUSIONS: BGAT is a useful intervention to decrease blunting of counterregulatory responses associated with improved glycemic control and may modify the severity of hypoglycemia associated with improved glycemic control in type 1 diabetes.

Blood glucose estimation and symptoms during hyperglycemia and hypoglycemia in patients with insulin-dependent diabetes mellitus.

PURPOSE: To investigate hypoglycemic and hyperglycemic symptoms, accuracy of estimating blood glucose, and their relation to glycemic control and counterregulatory hormone levels in insulin-dependent diabetes mellitus. PATIENTS AND METHODS: During randomly ordered stepped hypoglycemic and hyperglycemic insulin clamps on two separate days, 42 patients with insulin-dependent diabetes mellitus rated the intensity of 40 moods and symptoms when glucose was 8.9, 5.6 and 2.2 mmol/L, and 8.9, 14.4 and 21.1 mmol/L. The subjects were blinded to their actual glucose levels and asked to estimate them at each step. Epinephrine, norepinephrine, cortisol, growth hormone, and glucagon were measured at each glucose plateau. RESULTS: Cluster analysis yielded five symptom groups during hypoglycemia: autonomic symptoms, negative moods, positive moods, feeling weak/dizzy, and feeling relaxed. At 2.2 mmol/L, mean scores for all five symptom groups and 11 of 17 unclustered symptoms differed from those reported at the baseline glucose of 8.9 mmol/L (P < or = 0.05), but 34% of patients reported no awareness of autonomic symptoms. The intensity of autonomic symptoms correlated positively with HbA1 (r = .43, P < 0.01), epinephrine (r = .59, P < 0.001), norepinephrine (r = .45, P < 0.01) and cortisol (r = .62, P < 0.001), and negatively with glucose estimation error (r = -.45, P = 0.01). Six patients (15%) were unaware of both autonomic and neuroglycopenic symptoms during hypoglycemia. At 21.1 mmol/L, only 5 of 40 symptoms differed (P < 0.05) from baseline. Seventeen percent of subjects made potentially serious errors when estimating glucose at 2.2 mmol/L, and 66% at 21.1 mmol/L. Many patients experienced symptoms different from those they reported as their usual manifestations of changing glucose levels. CONCLUSIONS: Since the majority of patients made clinically serious errors in glucose estimation, and many used symptoms that did not discriminate hyperglycemia and hypoglycemia, individualized training to increase awareness of glucose-related symptoms and glucose levels may help patients reduce the frequency or severity of hyperglycemic and hypoglycemic events.

Cognitive function in patients with insulin-dependent diabetes mellitus during hyperglycemia and hypoglycemia.

BACKGROUND: To determine the impact of glycemic control, gender, and other relevant parameters on cognitive function during exposure to different blood glucose levels in patients with insulin-dependent diabetes mellitus (IDDM), we examined neuropsychologic function during experimentally induced periods of hyperglycemia and hypoglycemia. METHODS: We studied 20 men and 22 women, aged 18 to 44 years, with IDDM duration of 3 to 14 years and HbA1 values ranging from 5.8% to 18.0% (nondiabetic range 5.4% to 7.4%). We used a controlled experimental setting involving tests of sensory perceptual processing, simple motor abilities, attention, learning and memory, language, and spatial and constructional abilities at plasma glucose levels of 2.2, 5.6, 8.9, 14.4, and 21.1 mmol/L. Patients were blind to the glucose level. Tests used at each glucose level included reaction time (simple and choice), digit vigilance, trail making part B, word recall, digit sequence learning, and verbal fluency. RESULTS: All aspects of neuropsychologic function were diminished at 2.2 mmol/L when compared with basal levels of performance at 8.9 mmol/L, whereas no alterations were observed at 14.4 or 21.1 mmol/L. Tests involving associative learning, attention, and mental flexibility were the most affected during hypoglycemia. Glycemic control was not correlated with neuropsychologic function at any glucose level. Women demonstrated less of an impairment in neuropsychologic function than men at 2.2 mmol/L. CONCLUSIONS: Cognitive function in IDDM patients was generally well-preserved even at substantially elevated blood glucose levels. Deficits in all relevant areas of cognitive function occurred during hypoglycemia (2.2 mmol/L), irrespective of prior glycemic control, and women with IDDM were less cognitively impaired than men with IDDM during hypoglycemia.

The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus.

PURPOSE: Insulin-induced hypoglycemia and its sequelae of cognitive impairment may place patients with type 1 diabetes at risk when driving and when making decisions about driving. Little is known about the factors that influence judgments of safe driving ability during hypoglycemia in these patients. PATIENTS AND METHODS: Thirty men and 30 women with uncomplicated type 1 diabetes (age [mean +/- SD] 33 +/- 9 years, duration 9 +/- 3 years, hemoglobin A1c level 8.7% +/- 1.0%) underwent a stepped hypoglycemic insulin clamp. Serum glucose levels were reduced from 120 mg/dL to 80, 70, 60, 50, and then 40 mg/dL during 190 minutes. At each glucose plateau, patients completed a symptom questionnaire and neuropsychological test, estimated their glucose level, and reported whether they could drive safely. RESULTS: The proportion of patients judging that they could drive safely decreased as serum glucose levels decreased from 70% at 120 mg/dL to 22% at 40 mg/dL. Men and middle-aged patients were more likely to consider it safe to drive during hypoglycemia than women and those under 25 years of age. Those who were symptomatic and those who recognized hypoglycemia were less likely to report safe driving ability during hypoglycemia. Most patients who were cognitively impaired appeared to recognize this and reported that they could not drive safely at a serum glucose level of 40 mg/dL. CONCLUSIONS: Adults with type 1 diabetes need educational reinforcement of safe driving habits, particularly to check glucose levels before driving. Glucose levels less than 70 mg/dL should be treated before driving. This information is as important for middle-aged, experienced drivers as it is for younger, inexperienced drivers.

Adolescent views of diabetes-related parent conflict and support: a focus group analysis.

PURPOSE: To increase understanding of adolescent-parent diabetes-related conflicts and supports in the management of type 1 diabetes by means of a focus group research approach. METHODS: Twenty-four adolescents (10 boys and 14 girls, age 13-15 years; 97% white) participated in three same-sex focus groups at two diabetes summer camps. The focus group leader used a prepared set of open-ended questions to guide the 90-minute sessions. Sessions were tape-recorded, transcribed, and analyzed by a set procedure for qualitative analysis to identify the adolescents' perspectives on parent-adolescent sources of diabetes-related conflict and support. RESULTS: Adolescents reported the following sources of diabetes-related conflict: parental worry and intrusive behaviors; parental lack of understanding and blaming behaviors, and the parents focus on the future vs. the adolescent focus on the present. With regard to diabetes-related support, the teens identified parental understanding of the demands of diabetes and parental provision of reassurance about their child's illness and normative functioning. CONCLUSIONS: Adolescents' perceptions of parental worry, lack of understanding, and resulting intrusive and blaming behaviors are major areas of conflict that need to be addressed in the management of type 1 diabetes.

Psychosocial and quality of life correlates of glycemic control during intensive treatment of type 1 diabetes.

To identify emotional and attitudinal barriers to improved glycemic control (HbA1c) during intensive diabetes treatment, 55 patients attending a 4-5 month intensive diabetes medical/education clinic were followed. Subjects completed a battery of psychological surveys, had HbA1c and body mass index measured, and rated their attitude toward weight gain and the extent of problems with specific self-management behaviors before and after the medical intervention. Although HbA1c improved on average, 29% had only modest improvement and 16% showed no improvement. The number of diabetes-related annoyances, worry about hypoglycemia, and diabetes-related emotional distress diminished. Only the satisfaction subscale of the Diabetes Quality of Life survey, diabetes-related emotional distress, and problems with self-management behaviors correlated with HbA1c. Treatment-related frustration and emotional distress may initially act as motivators to improve glycemia but can later become barriers to that goal. Interventions designed to help patients overcome attitudinal barriers should be incorporated into medical programs geared toward improving glycemia.

The effects of type 1 diabetes on cerebral white matter.

AIM/HYPOTHESIS: Studies investigating the structure, neurophysiology and functional outcomes of white matter among type 1 diabetes patients have given conflicting results. Our aim was to investigate the relationship between type 1 diabetes and white matter hyperintensities. METHOD: We assessed white matter integrity (using magnetic resonance imaging), depressive symptoms and neuropsychological function in 114 type 1 diabetes patients and 58 age-matched non-diabetic controls. RESULTS: Only Fazekas grade 1 and 2 white matter hyperintensities were found among 114 long-duration, relatively young diabetes patients; the severity of lesions did not differ substantially from 58 healthy controls. White matter hyperintensities were not associated with depressive history or with clinical characteristics of diabetes, including retinopathy, severe hypoglycaemia or glycaemia control. CONCLUSIONS/INTERPRETATION: Our data do not support an association between diabetes characteristics and white matter hyperintensities among relatively young type 1 diabetes participants.

Responsiveness of the Problem Areas In Diabetes (PAID) questionnaire.

AIM: Responsiveness (sensitivity to change over time) is a key psychometric quality for an outcome measure. We examined the responsiveness of the Problem Areas In Diabetes (PAID) questionnaire, a measure of diabetes-specific emotional distress. METHODS: PAID data were obtained from seven diabetes intervention studies following a literature search that included both published papers and conference abstracts. To estimate responsiveness we used two indices: (i) a statistical test (the dependent t-test), and (ii) a commonly used effect size index (Cohen's d). RESULTS: Mean patient PAID scores improved from baseline to follow-up for all seven studies. Specifically, t-statistics ranged from t= 8.5 (P < 0.001) to t= 2.1 (P < 0.06). Effect size results ranged from 0.32 (i.e. small) for a disease management intervention to 0.65 (i.e. moderate) for an intensive medical/educational intervention. CONCLUSIONS: Despite the pilot nature of the studies, the pattern of findings provided strong support for the responsiveness of the PAID. Information on responsiveness helps clinical researchers select measures, accurately estimate sample size to ensure adequate statistical power, and prioritize outcomes to be assessed.