Managing Clinical Problems in Diabetes, Case Study #5: Mrs. AV
Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath
Mrs. AV was referred to the endocrinologist for ‘assessment and advice’ by her GP. Mrs. AV is a 68-year-old Greek-speaking woman with type 2 diabetes of 20 years’ duration. She has a history of Bell’s palsy, osteoarthritis, glaucoma, blindness in her right eye, ‘progressive’ anaemia of unknown origin, and Helicobacter pylori. Her most recent fasting blood glucose was 16.8 mmol/;
weight is 70.8 kg….
- Amitriptyline 10mg at bedtime
- Diamicron (gliclazide — not yet available in US) 80 mg BD
- Metformin 1000mg daily
- Zantac (ranitidine) 20 mg/day
- Ramipril 5 mg/day
- Random blood glucose 450mg/dL. (25 mmol/L)
- HbA1c 7.5%
- Hemoglobin 10.4 (normal 11.5–16.5)
- Na 134 (normal 135–145)
- K+ 5.7 (normal 3.5–5.0)
- Urea 13.1 (normal 2.5–6.4)
- Creatinine 160 (normal 50–100)
On physical examination:
- She was very symptomatic, including nocturia 4-5 times per night
- Disturbed sleep
- No oedema
- BP 160/80
- She appears to be depressed.
This woman is clearly having a tough time of things, with multiple comorbidities for which she is on multiple medications. It is no surprise that her sleep is disturbed and she appears depressed. These two issues are probably related (disturbed sleep being a symptom of depression) and could be having a substantial impact on her health. The evidence is now considered relatively unequivocal, in that:
- depression is about 1.8 times more common in people with type 2 diabetes than in the general population (Ali et al. 2006);
- depression is predictive of heart disease (Bunker et al. 2003); and
- depression is associated with elevated blood glucose and complications (de Groot et al. 2001).
The good news is that the research also indicates that treating depression improves people’s mood and can help improve metabolic outcomes (Lustman et al. 2000), and the extra cost of treating depression is offset by the reduction in other health care costs (Katon et al. 2006).
Therefore, exploring Mrs. AV’s emotional well-being is a good place to start and could be undertaken using a validated questionnaire. However, questionnaires do not replace attentive listening and asking Mrs. AV how she feels emotionally because symptoms of depression can be similar to those of other medical conditions. As well as assessing for depressed mood, we need to find out why she lacks positive emotions and why she has lost interest in things she used to find interesting.
If the health professional and Mrs. AV agree that she is depressed, there are a number of options available to help her. These include medication, which can be discussed, but should not be forced. The main reason to consider medication is that symptom relief is rapid, usually 2-3 weeks after starting treatment. Once her mood and interest in things improve, psychological therapies can be included and it will be easier for her to participate in such therapies, which increases their effectiveness.
It is worth noting that Mrs. AV is already on amitriptyline 10mg. at bedtime, but it is not clear from the referral whether it was prescribed for depression or to treat painful peripheral neuropathy. The prescribed dose is lower than would be usual for depression; therefore it may be worth considering increasing the dose to levels shown to be effective in depression, which would avoid adding another medicine to her regimen. If she cannot tolerate the common side effects at higher doses, other antidepressant medications should be considered. It is also important to monitor the effect of the medication and encourage Mrs. AV to keep taking it for at least 3 weeks before deciding whether it is helping. It is common for people to have to try a second or third antidepressant before they find the one that works for them.
If Mrs. AV wishes to undertake a psychological therapy, cognitive behavior therapy (CBT) has a good evidence base. A trained psychologist or cognitive therapist should undertake CBT. However, finding a psychologist is often difficult and expensive and there may be a long waiting list. Another option to consider is bibliotherapy1. There are a number of well-designed self-help books available. Bibliotherapy is usually based on CBT and shows promising results. The main problems with bibliotherapy are that people who are depressed have low motivation levels, and will struggle to do the homework that is key to its effectiveness.
Regular appointments or telephone calls can be an effective way to support Mrs. AV, to help maintain her motivation and monitor her progress.
The HbA1c results may not be accurate in patients with anemia, as evidenced here by the lack of concordance with the patient’s glucose results. This is a critical point to address because increasingly patients themselves as well as doctors are too focused on HbA1c to the exclusion of doing enough of their own glucose monitoring. A pitfall seen in Mediterranean-origin patients is thalassaemia2 minor, which can result in errors in the HbA1c assay through either increased red blood cell turnover and false low results, or cross reactivity of hepatic blood flow (HBF) in the assay with high-pressure liquid chromatography (HPLC)-based methods. Fructosamine estimation is the preferred method in these cases. For this woman I would recommend hemoglobin electrophoresis to investigate whether she has thalassaemia2.
There is no indication whether Mrs. AV speaks and understands English although we are told she is Greek-speaking. She may need an interpreter, particularly to discuss possible depression. It is not desirable to use family to interpret in such circumstances. If she has mild depression rather than severe depression, St John’s Wort may be worth considering if there are no likely medicine interactions.
In addition to the obvious need to determine her mental status and ensure it is adequately treated and monitored, her physical condition needs to be considered. She appears to have elevated creatinine and urea, which could indicate renal disease, which is likely, given her long duration of diabetes. If so, her medications may need to be reviewed and insulin may be simpler for her to manage.
Her blood pressure is high and needs to be investigated and treated given her cardiovascular risks. Her hemoglobin is slightly below normal. Her HbA1c is acceptable considering her comorbidities. However, it may be lower than actual because of her anemia.
Mrs. AV is Greek and may have a hemoglobinopathy such as thalassaemia2 and it might be worth having a fructosamine level measured, given that she is ‘very symptomatic.’ Mrs. AV illustrates some of the pitfalls of using HbA1c as the only indicator of metabolic control (Tran et al. 2004).
Anemia may also be contributing to her tiredness, and folate supplements may be indicated. If she does not have thalassaemia2 (not helped by iron) she might also require iron supplements. Bone densitometry is indicated.
Her symptoms may be due to hyperglycemia but a urinary tract infection needs to be excluded, so a micro urine and culture is indicated. Nocturia is likely to be disturbing her sleep and could exacerbate her lowered mood.
1 Bibliotherapy is an adjunct to psychological treatment that incorporates appropriate books or other written materials, usually intended to be read outside of psychotherapy sessions, into the treatment regimen. The goal of bibliotherapy is to broaden and deepen the client’s understanding of the particular problem that requires treatment. The written materials may educate the client about the disorder itself or be used to increase the client’s acceptance of a proposed treatment. Many people find that the opportunity to read about their problem outside the therapist’s office facilitates active participation in their treatment and promotes a stronger sense of personal responsibility for recovery. In addition, many are relieved to find that others have had the same disorder or problem and have coped successfully with it or recovered from it. From the therapist’s standpoint, providing a client with specific information or assignments to be completed outside regular in-office sessions speeds the progress of therapy.
Bibliotherapy has been applied in a variety of settings to many kinds of psychological problems. Practitioners have reported successful use of bibliotherapy in treating eating disorders, anxiety and mood disorders, agoraphobia, alcohol and substance abuse, and stress-related physical disorders.
Note: Bibliotherapy is not likely to be useful with clients suffering from thought disorders, psychoses, limited intellectual ability, dyslexia, or active resistance to treatment. In addition, some clients may use bibliotherapy as a form of do-it-yourself treatment rather than seeking professional help.
2Thalassemia describes a group of inherited disorders characterized by reduced or absent amounts of hemoglobin, the oxygen-carrying protein inside the red blood cells. There are two basic groups of thalassemia disorders: alpha thalassemia and beta thalassemia. These conditions cause varying degrees of anemia, which can range from insignificant to life threatening.
All types of thalassemias are considered quantitative diseases of hemoglobin, because the quantity of hemoglobin produced is reduced or absent. Usual adult hemoglobin is made up of three components: alpha globin, beta globin, and heme. Thalassemias are classified according to the globin that is affected, hence the names alpha and beta thalassemia. Although both classes of thalassemia affect the same protein, the alpha and beta thalassemias are distinct diseases that affect the body in different ways.
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: Another Case Discussion
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