Module 3 Flashcards
Language matters, why?
- Role of healthcare professionals
- a way to encourages and motivates
- focus on postitivity
- has an impact on motivation, behaviour and outcomes
- reduce negativity in language which can affect psychosocial well-being
Use these words - people with DM I/O diabetic people
- non- compliant/ compliant XXX I/O adherent/ non-adherent
- perfect diabetic XXX
Patient empowerment focuses on four main points.
AADE and the American Diabetes Association convened to develop these guidelines using four guiding principles:
1]Diabetes is a complex and challenging disease involving many factors and variables.
2]Every member of the healthcare team can serve people with diabetes more effectively through a respectful, inclusive, and person-centred approach.
3]The stigma that has historically been attached to a diagnosis of diabetes can contribute to stress and feeling of shame and judgement.
4]Person-first, strengths-based, empowering language can improve communication and enhance motivation, health and well-being of people with diabetes.
How to change these words? -diabetic people -Disease -Normal, healthy blood glucose levels -Obese, normal weight he or she is … poorly controlled, cooperative, uncooperative -Poor control, good control, well controlled -Control -Should, should not, have to, can’t, must, must not -Failed, failing to -Compliance, compliant; non-compliance, non-compliant; adherence, adherent, nonadherent
-people with DM
-Condition
-People without
diabetes; target,
optimal blood
glucose
-Unhealthy, healthy
weight
-‘his or
her blood glucose
is high’
-Stable / optimal
blood glucose levels,
within the optimal
range, or within
the target range;
suboptimal, high/low
-Manage, influence
-You could
consider…, you
could try…, consider
the following
options…, you could
choose to…
-Did not, has not,
does not.
-Words that describe
collaborative
goal-setting
Patient empowerment focuses on four main points.
- they need to understand their role in care
- need to know enough to take care of themselves and work with HCP
- need skills
- environment need to be supportive
Definition of Patient Empowerment
A process in which patients understand their role, are given the knowledge and skills by their health-care provider to perform a task in an environment that recognizes community and cultural differences and encourages patient participation.
Behaviours influence outcome
family eating patterns to the design of neighbourhoods to workplace and national health policies
motivational interviewing
self-management education: problem solving therapy , cognitive behavioural and related psychotherapeutic approaches, family approaches, and group interventions
Ecological model of health behaviour
goverment, policies, large system > organization, communities, culture > family, friends small group > individual biological psychological
EPF campaign
- person-center choices
What is Health Literacy?
a measure of patients’ ability to read, comprehend, and act on medical instructions
[Source: Schillinger et al.]
Outlets for Health Literacy promotion?
health and edu sys media marketplace home work place community policy making
Ophelia approach ?
consist of ?
a system that supports the identification of community health
literacy needs, and the development and testing of potential solutions. It allows easy
application of evidence-based health promotion approaches to the field of health literacy
Ophelia means Optimizing Health Literacy and Access to health information and services
Psychology and Behavioral Challenge that patient face?
1]changing their behaviour is difficult - approach - motivational interviewing
2]range of factors can influence - approach - organisational approaches
Behavioural Changes
eating, exe, smoking, alcohol, taking tablets, taking insulin, self care ( feet, eyes)
But why do some patients not want to change their behaviour?
quantity and quality of life
- not aware of the seriousness of the situation
- don’t like a new habit
- refuse to accept the situation
The burden of DM?
- chronicity
- self-management
- complex
- lifestyle changes
- complications
- multiple treatments
- additional health problems
- lack of reward
- progressive
- loss of freedom
- lack of support
- social barriers
- treatment is aversive
- fear of complications ( blindness, amputation)
- self-blame
5 C intervention for a behavioural approach
Constructing a problem definition
Collaborative goal setting
Collaborative problem solving
Contracting for change
Continuing support
Barriers for behavioural change ?
cognitions, e.g., beliefs that treatments are not effective
emotions, e.g., lack of self-efficacy
social networks, e.g., lack of support
resources, e.g., lack of time or money
physical environment, e.g., lack of facilities
def of Self-efficacy?
confidence in one’s ability to perform health behaviors—increases the performance of those behaviors
emotional problems
Identify patients who are suffering from diabetes-related distress.
Apply effective treatments to relieve diabetes-related distress.
Identify patients who are suffering from psychiatric disorders.
Refer patients for specialized mental health care when appropriate.
how to identify diabetes distressed patient?
Are you having trouble accepting your diabetes?
Do you feel overwhelmed or burned out by the demands of diabetes management?
Do you get the support you need from your family for diabetes management?
Do you worry about getting diabetes complications?
20 item PAID ( problem areas in diabetes) questionnaire
enhance= emotion-focused coping cognitive behavioural therapy (CBT).
help people identify the negative, usually unrealistic, thoughts that lead to distress, diminished motivation, and less-active self-care (e.g., “I’ll never be able to do anything right.”
helps patients find more positive realistic perspectives
encouraging more active self- care
DSM-IV diagnostic criteria for depression
PHQ-9 (9-item Patient Health Questionnaire)
cardinal diagnostic criteria mood and anhedonia)
Rx In depressed patients who are not in good control of their diabetes?
- counselling ( CBT) alone (or) with medication
Vulnerable groups in behavioural change?
- elder age group
- literacy
- less amount of time to learn disease
- mental illness
- adolescent
Factors Affecting Behavioral Change?
motivation social support literacy good/poor relationship with HCP culture age lack of DM education additional health problems vulnerable groups psychological distress: anxiety, depression, eating disorder, trauma.
the stages of change model?
-tool to help motivate patients
1]precontemplation(unaware or unwilling to change) > 2]contemplation ( considering to change)( face barrier)> 3]preparation( experiment with small change)> 4]action> 5]maintenance and replapse prevention
1 to 5 = progress
5 to 1 = relapse
developed in the USA in 1980
Questions for Patients in the Precontemplation
Precontemplation stage
Goal: patient will begin thinking about change.
“What would have to happen for you to know that this is a problem?”
“What warning signs would let you know that this is a problem?”
“Have you tried to change in the past?”
Questions for Patients in the Contemplation Stages
Contemplation stage
Goal: patient will examine benefits and barriers to change.
“Why do you want to change at this time?”
“What were the reasons for not changing?”
“What would keep you from changing at this time?”
“What are the barriers today that keep you from change?”
“What might help you with that aspect?”
“What things (people, programs and behaviors) have helped in the past?”
“What would help you at this time?”
“What do you think you need to learn about changing?”
Two techniques useful in the primary care setting ?
the Readiness to Change Ruler (simple, straight line drawn on a paper that represents a continuum from the left “not prepared to change” to the right “ready to change and ask patient to mark their current position )and
the Agenda-Setting Chart (useful when multiple lifestyle changes are recommended for long-term disease management (e.g., diabetes or prevention of heart disease)
Diabetes Stages of Change (DiSC) study
compared diabetes Treatment As Usual (TAU) with Pathways To Change (PTC)
Transtheoretical Model of Change (TTM) - applied to health behaviour change interventions - computerized system- delivered by phone and mail, with or without personal contact
ITT ( intention to treat)
Result = PTC better than TAU in SMBG, healthy low-fat food choice, stop smoking-> improve metabolic control
Restriction: labour-intensive, time consuming
patient-centred care:
Individualized Education
An Assessment Process
Educational Support
Formal Training
principles of behaviour change interventions used in patient-centred care;
goal setting
motivational Interviewing
behaviour change strategies
feedback monitoring
Motivational Interviewing Principles technique
Requires Empathy Recognizes Individuals Is Non-confrontational Recognizes that Change Comes from Within Develops Discrepancy Supports Self-Efficacy
Def: Motivational interviewing
taught, empirically based consultation style that focus on facilitating and engaging intrinsic motivation within the patient in order to change behavior.
4 core component of motivational interviewing
1]Rapport ( need empathy, active listening, question style, warm and understanding personalities)
2] Agenda( objective or purpose)
3] Importance ( a good reason)( come from within)
4] Confidence
Motivational interviewing approach
patient centred contractual process how we say it listening active/active flexible & skilful rapport essential collaborator
WHO Framework Convention on Tobacco Control.
The 6 MPOWER measures
Monitor tobacco use and prevention policies
Protect people from tobacco use
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco advertising, promotion and sponsorship
Raise taxes on tobacco.
The role of physical activity in the management of type 2 diabetes mellitus
DAFNE
DESMOND
Dose Adjustment for Normal Eating
Diabetes Education and Self Management for Ongoing and Diagnosed
X-PERT Prevention of Diabetes program
MNT
in USA DSME(Diabetes Self Management Education)
The Programs - DAFNE 1]What is it? 2]Where is it? 3]What does the program do? 4]How is it delivered?
1]not-for-profit organization delivering structured educational programs to people with T1DM in 2002.
2]75 sites in the UK and Ireland.
3]to give knowledge, skills and confidence, to assess diet and accurately adjust insulin
4]delivered through an intensive five-day course facilitated by specialist nurses and dieticians, improve self-management of diabetes and quality of their life, model first used in Germany and Austria in the 1980s and 1990’s
DAFNE participation improves glycaemic control in Type 1 diabetes with benefits being sustained for 5 years.
The Programs - DESMOND
1]What is it?
2]who is it for?
3]How is it delivered?
1]national educational program origin was RCT
2] loose collection of programs and resources for people with both type 1 & 2 diabetes, also people at risk
3]6 hours of training for people newly diagnosed, delivery by trained trainers
a follow-up program of up to 6 x three-hour sessions
The Programs – X-PERT
1]What is it?
2]What does the program do?
3]How is the program delivered?
1] by Dr Trudi Deakin or the prevention and management of diabetes are based upon the theories of patient empowerment, discovery learning and patient-centred care.
2]develops the knowledge, understanding and confidence , a clinical trial recent audit of more than 100,000 participants
3]four X-PERT Programmes:
X-PERT Weight for anyone who wishes to lose weight
X-PERT Prevention of Diabetes (X-POD) for anyone at risk of developing the condition
X-PERT Diabetes for people diagnosed with Type 2 diabetes
X-PERT Insulin for people with Type 1 or Type 2 diabetes who require insulin to manage their condition
15 to 18 hours of education delivered over 6 to 12 sessions
launched in 2005, NHS in the UK
The Programs - DSME
1]What is it?
2]How is the program delivered?
1]used as a template and adapted within the United States
2]community-based lifestyle intervention program, added to a patient’s ongoing care plan, effective means of preventing chronic disease complications, requires a referral from a physician
who did not attend structured diabetes education found three main themes?
- lack of perceived benefit or lack of awareness about the program
- they did not like the model of delivery
- they felt shame or stigma at the diagnosis and did not wish others to know
Diabetes Prevention Program
What is it?
a large scale trial based in the USA in the early 2000s
aimed at preventing diabetes, especially prediabetes converting to diabetes
Finnish Diabetes Program
What is it?
large scale trial, providing guidance on diabetes management and prevention at a national level.
dietary and exercise interventions, the intensity of exercise increased included circuit training walking and hiking under a nutritionist resulted in long term changes in behaviour
Da Qing Studies
What is it?
1997 published in China
diet and exercise program significant decrease the incidence of diabetes in high-risk individuals over a 6 year period
Lifestyle Counselling result?
reduction in
- total cholesterol
- LDL
- systolic BP
- diastolic BP
- Fasting BG
- DM incidence
- weight
Walking
Why is it important?
- form of physical activity
- on their feet and walk, in and around their homes is an important first step before they can take part in more intense exercise.
what number of steps would be the right daily target for moderate-to-vigorous exercise?
- 8,000 to 10,000 steps daily(Japan)
- 3,000 and 4,000 steps per day(NHS)
- 7,000 to 10,000 daily steps[UK National Obesity Forum]
- 7,100 to 11,000 steps per day.[Computed translations of free-living physical activity]
patient’s education program must include?
- guidance on self-monitoring glucose levels
- hypoglycemia
- immunizations
- Sick day rules
- knowing what to do if unwell
- as HCP, ensure patients understand
Hypoglycemia
1.hypoglycemia unawareness?
Def: blood glucose level of less than or equal to 70 mg/dL (less than or equal to 3.9 mmol/L)
-4–10% of deaths with DM
Symp:
adrenergic/Autonomic [rapidly falling and changing glucose levels]
- inversely correlated to the developing rate of hypoglycemia
- most pronounced with acute onsets
- functioning as an early warning system
- feeling hungry
- feeling unsteady(shaking)
- sweating
- feeling warm
- palpitation
- dizziness
- tachycardia
neuroglycopenic[low central nervous system [CNS] glucose]
- feeling tired(drowsiness)
- Confusion
- lack co-ordination
- slurring speech
- atypical behaviour(aggression)
Ppl At Risk:
- Diabetic on insulin, sulfonylurea or glinides.
- Diabetic children
- Elderly people with diabetes(Age-related changes in hepatic and renal function )
- Women with pre-gestational and GDM(especially in the first trimester, does not affect the fetus,)
- Women on insulin are at a particularly high risk immediately after the delivery of the placenta, as the body’s insulin needs reduce dramatically.
- loss of adrenergic manifestation of hypoglycemia
Self-Monitoring(SMBG)
How and When to Test?
-Individuals may test as often as 6–10 times a day.
-frequent testing=better glycemic control
- demonstrate technique
-keep a record of the result
-set treatment goals
for T2DM
-who are on insulin and or sulfonylurea/glinide,
- good practice
for T1DM
- used at mealtimes (prandial testing)- allow for the regulation of the insulin dose
- to prevent or recognize asymptomatic hypo and hyperglycemic episodes.
Testing -Intermittent sampling of blood glucose Recording test results -paper-based or machine Results analysis and interpretation
Home Glucose Testing: New Technologies
Barriers?
Glucose Meters
-better strips requiring smaller blood samples
-greater accuracy and reliability
-better in-built functionality such as bolus wizards
Flash Glucose Monitoring[Freestyle Libre]
- a sensor that is inserted into the upper arm to measure glucose levels—the sensor lasts for two weeks
-a reader or a mobile phone that you swipe over the sensor to get a glucose reading
-without finger pricks
-common option for type 1 and insulin-requiring type 2 diabetes
Continuous Glucose Monitoring(CGM)
- a sensor implanted into the skin to measure glucose levels
- transmitter that continuously connects the sensor and reader device
- allows the reader device to alarm when the glucose level is rising too high or falling too low
- linked to many insulin pump systems
- sensor reading will adjust the flow of insulin automatically.
Barriers
- cost
- access to appropriate testing equipment
Immunization
Different Types of Immunization
Influenza
- secondary prevention
- illness can raise your blood glucose to dangerously high levels.
Pneumococcal Pneumonia
-increased risk for death from pneumonia (lung infection),
-bacteremia (blood infection) and
-meningitis (infection of the lining of the brain and spinal cord).
Hepatitis B
-have higher rates of hepatitis B
Zoster Vaccine
-protect against shingles
Tdap Vaccine
-protect against tetanus, diphtheria and whooping cough
Sick Day Planning
Adults – Sick Day Rules
- for people using insulin, continue to take it
- type 2 diabetes not taking insulin, continue to take medication
Key principle
1.Have a plan[sufficient supplies]
- Keep taking insulin
- Monitor your levels[Blood glucose and ketone monitoring][for hyper and hypo glycemia and ketoacidosis]
- Differentiate between major and minor illness
- Keep hydrated
- Know when to seek help
Children and Adolescents – Sick Days
-similar to adult
Acute Complications of DM
Diabetic ketoacidosis (DKA) hyperosmolar hyperglycemic state (HHS)
Diabetic ketoacidosis (DKA)
Def: severe hyperglycemia, metabolic acidosis and raised total body ketone concentration
- develop in less than 24 hours.
- T1DM is more common
- rare but important side effect of SGLT inhibitor
- Kussmaul (sighing) breathing, acetone breath
- polyuria, polydipsia, vomiting weight loss, tachycardia, hypotension, dehydration and weakness, impaired mental
- young patient, abdominal pain
- deliberate discontinuation of insulin in young patient
The main triggers are:
-Insulin omission or dose reduction
-Acute illness – often severe
Dehydration
-Intense exercise
-Surgery
-Excessive alcohol intake
-Low-carb diet
USA: 65% of DKA hv T1DM China: 3-9% Malaysia: 49% 1% mortality rate, children in the US 5% mortality rate, adults in the US
-if resolve, maintained on Metformin and diet for months
immediate treatment
-admit to hospital -immediately
rehydration
-requiring initial treatment with insulin
hyperosmolar hyperglycemic state (HHS)
Def: hyperglycemia, and in addition hyperosmolality and dehydration but significant ketoacidosis is missing.
- develop over days and weeks
- blood glucose exceeding 600 mg/dl, (33 mmol/L)
- osmolality more than 320 mosmol/kg and
- arterial pH of 7.3 or more.
- higher glucose level than DKA
- polyuria, polydipsia, vomiting weight loss, tachycardia, hypotension, dehydration and weakness, impaired mental
- Severe neurological complications (coma, hemiparesis)
- much less common, but much more life-threatening
- In the US the mortality rate is 5-20%
- Elderly,co-morbidities at risk.
immediate treatment
-admit to hospital -immediately
rehydration
-may/not need insulin
Triggers for DKA
- illness, and infection
- missing insulin – for whatever reason
- the onset of type 1 DM
an atypical presentation of DKA
- normal blood glucose level (euglycaemia)
- taking SGLT-2 inhibitors
- (LADA) appear to be at greater risk
Causes of wide anion gap metabolic acidosis?
GOLD MARK
- Glycols (ethylene and propylene),
- Oxoproline,
- L-lactate, (lactic acidosis)
- D-lactate,
- Methanol,
- Aspirin, (salicylate toxicity)
- Renal failure, and
- Ketoacidosis (DKA)
Bicarbonate therapy is indicated in patients with diabetic ketoacidosis (DKA) when pH is less than___?
6.9
