Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath
Mrs. MJ was referred to a diabetes centre by her GP. Mrs. MJ, a 60-year-old woman with type 2 diabetes since 2000, presents with…
- Random blood glucose 398mg/dL. (21.9 mmol/L)
- Fasting glucose 323mg/dL.(17.8 mmol/L)
- HbA1c 14.3%. Her HbA1c has steadily increased over the past 18 months
- Total cholesterol 159mg/dL.(4.1mmol/L)
- HDL 68.64mg/dL.(1.76mmol/L)
- LDL 78mg/dL( 2.0mmol/L.)
- Trigs 71.2mg/dL.( 0.8mmol/L.)
- BP 140/80.
I have been suggesting she start insulin for the past 12 months but Mrs. MJ repeatedly refuses insulin.
- Gliclazide (Starlix) 2 mg BD
- Atenolol 2.5 mg BD
- Frusemide 40 mg
- Actos (pioglitazone) 45 mg
- Ramipril 5 mg BD
- Simvastatin 40 mg BD
- Aspirin 1/2 tablet daily
- She was on DiaBeta in the past but said it caused headaches and chest pain and stopped taking it, at which point she was commenced on gliclazide.
- She refuses to take metformin because it gives her diarrhea.
- Her diet is not ideal (she loves chocolate) and she does not exercise.
- Weight 60.9 kg (steady).
- She has known ischemic heart disease, no other complications detected.
- Left cataract surgery in 2000 and has had a retinal hemorrhage.
- She varies her gliclazide dose or does not take it according to how she feels and her BGLs.
Mrs. MJ has been commenced on many medicines for diabetes and other diseases but reports ‘side effects’ shortly after starting each one, e.g. Plaquenil (hydroxychloroquine) ’causes headaches’. This was prescribed for a longstanding history of polymorphous light eruption. She has regular dermatology appointments for this condition.
Mrs. MJ is understandably, like many other individuals, reluctant to use insulin, an issue that is referred to by some authors as ‘psychological insulin resistance’. It is important to note that this is not injection or needle phobia. The published literature indicates that needle phobia is rare, less than 1% of people with diabetes, and usually only found in individuals who have other concurrent phobias (Mollema et al. 2001). It is important to acknowledge that most people feel apprehensive about starting insulin and to identify the origins of such apprehension. Undoubtedly, it partly arises from fear about injections generally, because many people associate injections with needles into a muscle or blood vessel with pain and are worried that insulin injections will be painful.
However, the patient’s anxiety about insulin is not solely related to fear of pain. Healthcare professionals frequently, although unintentionally, give the message that people should be afraid of insulin and that it should be avoided if possible. For example, at diagnosis a health professional may say: ‘Don’t worry, you do not have the type of diabetes that needs insulin,’ which subtly conveys the message that insulin is something to be worried about. Later in the life of the person with diabetes, it is relatively common to hear health professionals say: ‘If we do not get your blood glucose levels down we are going to have to put you on to insulin.’ When insulin (or anything else) is used as a threat to motivate change the implication is the person should be scared (Hunt et al. 1997; Lauritzen and Scott 2001). Taking the time to enquire about Mrs. MJ’s concerns about insulin, taking care to elicit all her concerns, and talking through each one with her, are all vital. Supporting her to insert a needle into herself may help overcome her fear that the injection will be painful.
The information provided in the referral letter suggests a more general additional challenge, with her history of trialing different medications, reporting side effects to most of them, and her history of discontinuing treatment. It is also noteworthy that she only takes her gliclazide according to what she ‘feels’ her blood glucose levels are, which suggests she only takes her medication when she is symptomatic. Therefore, she may make inappropriate decisions because people do not accurately predict their blood glucose levels. However, these actions are not unusual behaviors by people with diabetes (Murphy and Kinmonth 1995) and people with hypertension (Baumann and Leventhal 1985), which suggests Mrs. MJ may vary her antihypertensive medication doses as well.
There is a great deal of literature about people’s medication and illnesses beliefs. A common feature in the literature is that people struggle to understand their health condition, and take it seriously, if they do not have some kind of concrete evidence of its existence such as a sign or symptom they can relate to. Therefore, when people take medication, they generally expect to experience an alleviation of some indicator of their condition, and frequently manage their illness accordingly. Unfortunately, many symptoms are incorrectly attributed and sometimes interpreted as medicine-related side effects.
So how can we address these potential factors and incorporate Mrs. MJ’s obvious attention to her health and wellness into a management plan? The first step is to identify:
- her diabetes beliefs;
- what she considers to be the problem with her body;
- what she thinks caused the problem;
- her understanding of the different treatments she has tried or is using and their mode of action; and
- how she tells what her blood glucose levels are (high or low).
Once you understand her knowledge of and beliefs about her diabetes, you are in a better position to identify and address misconceptions. If you do identify a misconception, it is important to enquire about the factors and/or experiences that led to her beliefs. Only when you understand her and her beliefs, will you be able to provide effective education and support. So take time to listen before taking time to explain.
This woman needs insulin therapy and intensive education about the fact that her feelings are not a good guide to her blood glucose levels, which is a common misconception or excuse. It would be useful to regularly download her meter information and confront her with this evidence. It has been found to be useful, with psychological insulin resistance, to emphasize:
- insulin is the most powerful drug we have for controlling glucose;
- insulin injections hurt less than finger-pricks;
- most people have more energy when commenced on insulin because of improvement in their glucose levels; and
- starting insulin does not lock her in to insulin therapy — if she stops it, she will be no worse off than before.
I agree with the psychologist’s insightful comments and these issues need to be addressed before the physical issues such as the high HbA1c and lipids can be corrected. Polymorphous light eruption (PMLE) has a substantial psychological and social impact, especially in women (Richards et al. 2007), which could compound Mrs. MJ’s diabetes related anxieties.
Mrs. MJ clearly does need insulin. The slow progressive nature of type 2 diabetes may never have been explained to her and she may blame herself for ‘failing’ or feel guilty that she has not managed to control her diabetes despite ‘listening’ to her body. Given her PMLE insulin may represent another burden to bear. Explaining what is happening to her body may help her accept insulin as a necessary replacement rather than a punishment, especially if she can stop her oral medicines. It is important that she is well informed about the risks and benefits of not starting insulin and that health professionals listen to her reasons for not wanting insulin.
Health professionals commonly focus on the negative aspects of a situation, as the psychologist implied. Focusing on the positive aspects of insulin is important. Mrs. MJ has probably been told repeatedly that she needs insulin to prevent complications (she already has several and a long-standing inter-current illness). I would ask her to think about just one positive thing about insulin and to write it down so we could discuss it at her next appointment. Commencing insulin for people like Mrs. MJ is a slow process and health professionals need to allow time, and respect her opinion. It is also worth considering that a patient ‘not listening’ could be a cue to the health professional to change their approach.
Medicine side effects are more common than health professionals realize and are a common reason for stopping medicines. Health professionals often refer to ‘mild side effects’ — they may be far from mild to the person experiencing them. Mrs. MJ may have been commenced on a high dose of metformin initially and it may well have caused diarrhea or other gastrointestinal symptoms. Combining metformin and insulin in people with type 2 diabetes is often effective and it would be worth explaining these issues to Mrs. MJ in the hope she might agree to try metformin again at low doses and gradually increase to tolerance.
However, given her eye disease and macrovascular disease she probably also has renal damage and oral glucose-lowering agents may be contraindicated. Her renal status needs to be established as part of the decision-making process. She was prescribed Plaquenil for her PMLE. Retinopathy is an absolute contraindication to Plaquenil. Given the fact that she has had a retinal hemorrhage alternative treatments may be required. I would suggest the GP refers her to her dermatologist and advises him or her about the retinal hemorrhage.
If she does agree to take insulin, it would be very important not to cause hypoglycemia, and to make the regimen as simple as possible. A long-acting analogue is the insulin of choice. Mrs. MJ has known cardiovascular disease and the chest pain may have occurred coincidentally when she took Diabeta, but she may have been experiencing hypoglycemia, which could cause the headaches she described. It is not clear whether her chest pain was investigated to exclude angina or MI and this should be considered. She is also on a statin, which may cause muscle aches, which Mrs. MJ could mistake for chest pain. She is also on Actos, which could be causing oedema and discomfort and may be contraindicated depending on her degree of heart disease.
Her love of chocolate could be used positively. Small amounts of dark chocolate have a similar effect on platelets as aspirin (Faraday 2006) and could be included in her diet. A dietary review would be useful. Mrs. MJ was probably told to wear protective clothing when she is outside and is most likely deficient in vitamin D, which increases her risk of osteoporosis.
Considering her age and blood glucose control and inter-current illnesses, it is important to ensure she has influenza and pneumonia vaccinations each year and any grandchildren should also be vaccinated if they regularly come into contact with her.
I would enquire into her social situation, which may affect her decisions. She could be depressed and her mood and cognitive functioning need to be assessed. Given her random blood glucose level of 395mg/dL (21.9 mmol/L) it is likely that is also contributing to her lethargy and lowered mood and may affect her ability to make decisions. These factors, in addition to those raised by the psychologist, may affect her medicine-related decision-making.
Mrs. MJ’s feet need to be assessed to determine whether she is at risk of foot ulcers given her history of suboptimal glucose control and the presence of micro- and macrovascular disease.
Psychological Issues and Quality of Life
- It is imperative that psychological, spiritual, and social aspects of an individual’s life are considered when developing management plans.
- These factors affect whether or not ‘good’ metabolic control is achieved.
- Listening is a key health professional skill.
- Health professionals need to understand themselves and their beliefs and attitudes.
- Depression is common in people with diabetes and is often undiagnosed.
- Mental health assessment should be part of annual complication screening programs.
The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The speciﬁc health professionals who provide comments about each case depend on the speciﬁc clinical issue; and (3) stimulate thought and discussion.
The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.
Next Week: Case Discussion
For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetes
Copyright © 2008 by Blackwell Publishing Ltd, UK
Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath