blood glucose awareness training an introduction to the research and use of neuroglycopenic cues...
TRANSCRIPT
Blood Glucose Awareness Training
An Introduction to the Research
and Use of Neuroglycopenic Cues
John Zrebiec, MSW, CDE
Joslin Diabetes Center
BGAT-What is it?
• Recognition, prediction & prevention
of extreme blood glucose
• Active & personalized learning experiences
• Usually group format
Who Is BGAT For?
Adults Taking Insulin
• Frequent hypoglycemic episodes• Hypoglycemic unaware• Too afraid or lack a fear of hypoglycemia• Frequent motor vehicle accidents or violations• Family conflict due to BG• Trouble at work due to BG• Attempting intensive insulin therapy• Pursuing pregnancy
BGAT History
• NIH funded research for past 25 years• 15 US and international studies• Translated into 5 languages• Hypoglycemia, Anticipation, Treatment and Training (HAATT)• www.healthsystem.virginia.edu/bmc/ bgathome • BGAT for Parents
Reduction of Risk for Severe Hypoglycemia through Psychobehavioral Intervention
Linda Gonder Frederick, PhD, Daniel Cox,
Phd, Boris Kovatchev, PhD, William Clark,
MD and John Zrebiec, MSW
• University of Virginia, Charlottesville
• Joslin Diabetes Center, Boston
Effects of BG on Cognitive Function in School-Aged Children with T1DM:
A Field Study
Linda Gonder-Frederick PhD, John Zrebiec MSW,* Andrea Bauchowitz PhD, Daniel Cox PhD, Lee
Ritterband PhD, Jarim Lee BA,* Boris Kovatchev PhD, and
William Clarke MD
University of Virginia
and
*Joslin Diabetes Center, Harvard Medical School
Research supported by NIH R01DK60039 and Abbott Diabetes Care, Inc.
Within-Subject Results
• Question: How many children show a clinically significant deterioration in performance with mild hypoglycemia?
• Clinically significant defined as: Performance on the math task more than one SD poorer on > 50% of trials during mild hypoglycemia as compared to euglycemia.
• Result: 17% of children
BG Detection in School-Aged Children with T1DM and their Parents
Linda Gonder-Frederick, Ph.D.
John Zrebiec, M.A.*
Daniel Cox, Ph.D.
Boris Kovatchev, Ph.D.
Lee Ritterband, Ph.D.
William Clarke, M.D.
University of Virginia
*Joslin Diabetes Center at Harvard University
Research supported by NIH R01 DK 060039 and Abbott Diabetes Care, Inc.
EGA ResultsBG < 70 mg/dl (4.0 mmol/L) (n = 263)
0
5
10
15
20
25
30
35
40
Zone A Zone B Zone C Zone D Zone E
ChildrenParents
EGA ResultsBG < 50 mg/dl (3.0 mmol/L) (n = 65)
0
5
10
15
20
25
30
35
40
45
50
Zone A Zone D Zone E
ChildrenParents
EGA ResultsBG > 250 mg/dl (14 mmol/L) (n = 705)
0
10
20
30
40
50
60
Zone A Zone B Zone C Zone D Zone E
ChildrenParents
Conclusions
• School-aged children with T1DM and their parents show poor ability to recognize hypo- and hyperglycemia.
• Failure to detect extreme BG levels occurs as often or more often than accurate detection.
• Children and Parents are far more likely than adults to mistake low BG for high, and vice versa.
BGAT Patient Benefits
• Improves detection of extreme BG • Reduces occurrence of extreme BGs • Preserves Counter-Regulatory Response during intensive insulin treatment• Reduces sequeli of extreme BG 1. DKA 2. Severe hypoglycemia 3. Motor vehicle accidents & violations
BGAT PATIENT BENEFITS
Average Accuracy
Before 45%
After 75%
Most Accurate: Trained in Internal and External Cues
BGAT Patient Benefits
• Improves driving decisions
81% choose not to drive when low
• Million miles driven:
7 accidents BGAT
29 accidents non-diabetic
• Swerve first, then slow down
BGAT Patient Benefits
• Psychological benefits–Improves knowledge about diabetes
–Reduces fear of hypoglycemia
–Reduces depression
–Reduces family conflict
–Improves quality of life
Benefits for Physicians and Diabetes Educators
• Saves professional time dealing with hypoglycemia prevention
• Reduces emergency telephone calls• Reduces time spent with anxious family
members• Improves BG control• Educates patients about how to recognize
and treat extreme BG
Risk Factors Associated with Hypoglycemia
•Male
•Long Duration of Diabetes
•History of Severe Hypoglycemia
•History of Recurrent Mild Hypoglycemia
•Going to sleep with BG <100
Most Common Causes of Hypoglycemia
1. Taking Too Much Insulin
2. Delaying Eating
3. Delaying Treating
Most Common Symptoms of Hypoglycemia
• Trembling
• Pounding Heart
• Difficulty Concentrating
• Uncoordination
• Only 50% report these symptoms• 50% report non-specific symptoms• Only 50% actually recognize symptoms
Research Findings
• 50% lows occur while asleep• Average episode of nocturnal
hypoglycemia lasts 86 minutes• 50% higher risk for next 24 hours • 25% higher risk for next 48 hours• Autonomic symptoms are significantly
depressed for next 72 hours
NeuroglycopeniaThinking & Performance Cues
• BG primary fuel of brain
• Brain sputters with low fuel
• Neuroglycopenia disrupts thinking and coordination
Things To Look For
• Informal performance cues–fine motor–gross motor
• Formal performance cues–fine motor –gross motor
Common Informal Mental Performance Cues
• Following directions
• Doing simple arithmetic
• Making change
• Following conversations
• Thinking of the correct word
• Having difficulty reading
• Having difficulty concentrating
Informal Gross Motor Performance Cues
• Walking quickly and turning
• Walking
• Climbing stairs
• Standing up
• Bending over at your waist
• Dancing
Informal Fine Motor Performance Cues
• Writing a check or addressing an envelope
• Hammering a nail or turning a screw
• Unlocking a door
• Typing
• Tying a knot, shoelace, or tie
Formal Performance Cues
• Doing a tongue twister
• Mental subtraction by 3’s
• Thinking of words that begin with a certain letter of the alphabet
• Flipping a dime
Other Common Neuroglycopenic Symptoms
• Fuzzy thinking• Slight confusion• Trouble talking• Uncoordinated• Dizzy or lightheaded• Unusual fatigue or sleepiness• Visual problems• Feeling “heavy” in arms or legs
Hypoglycemia and Driving
• Mid 50’s disrupts driving
• Accidents 3x more common among T1DM
• For every accident there are 5 episodes of severe hypoglycemia
• Judgment to drive is poor
Driving Performance Cues
• Difficulty steering in a straight line• Driving slower than usual to
compensate for bad driving• Difficulty finding your way• Running stop signs or red lights• Tailgating• Stopping too soon before a stop line or
a parked car• Other drivers honking at you
Rules of the Road
• If you think you might be low, CHECK BG before starting the car
• If you are low while driving, STOP immediately
• TREAT immediately
• WAIT to continue driving until BG rises
Good News about Driving
• BGAT improves judgement when not to drive
• Judgement to drive significantly correlates with crash record
• BGAT reduces crashes and motor vehicle violations
Daily Diary sample
Date Time BG Cues, Internal and External Est Actual Zones Causes, BG<70>180 6/22 7:30a Feel funny, headache in forehead, kind of sleepy, worked hard
raking leaves 49 41 A Usual food and
insulin, but more exercise than usual
BG Diary / Summary Sheet Analysis
1. Find every actual low BG 2. List each individual and different cue3. List BG values occurring with each cue4. Find the average
ExampleSymptom / Average BG Irritable 53+66+64+61+49= 293 / 5 = 58