Diabetes mellitus is a heterogeneous group of disorders characterized by high blood glucose levels (hyperglycemia). The World Health Organization has defined four major types: Type 1 Diabetes, Type 2 Diabetes, Gestational Diabetes and Diabetes secondary to other conditions. Type I is associated with low (or absent) levels of insulin, develops in childhood and requires daily insulin injections for survival. Type II usually develops in persons over 40 years of age and can be managed with lifestyle changes and oral medication.
Diabetes mellitus is a chronic, incurable disorder of carbohydrate metabolism. It involves an imbalance of the supply and demand for insulin. Food ingested is eventually converted to glucose (sugar) when it is carried in the blood to nourish all cells of the body. In diabetes mellitus insufficient insulin is available to meet this need because of:
(1) Failure of the islets of Langerhans to produce enough insulin
(2) The destruction of the insulin before it can be used, or
(3) Inability of body tissues to use the insulin
When cells are unable to use glucose large amounts accumulate in the blood and the condition called hyperglycemia results. Due to the concentration of glucose the kidneys excrete large amounts of water and the patient wants to drink large amounts of water. In addition, a loss of energy derived from food which is eaten results in compensation by increasing food intake. The body metabolizes its own store of fat and protein and a substance called ketones is produced. A toxic level of ketones can cause a condition called ketosis which can cause a coma.
Type I or insulin-dependent diabetes is the most severe form of this disease. Insulin is the essential therapy and it must be injected into the subcutaneous, fatty layer of tissues. The goal of insulin therapy is to maintain the blood sugar levels as close to the normal range as possible. To avoid frequent injections some patients use an insulin pup which provides a slow, continuous subcutaneous infusion of insulin throughout the day.
In Type II or non-insulin dependent diabetes the body produces insulin but not enough to meet the body’s total needs. Insulin is not required and treatment includes dietary management, exercise, and medication that helps the body make better use of the available insulin.
Diabetic diets are individualized based on such factors as age, weight and daily activity level. Adherence to the diet is essential. Exercise is also essential but must be coordinated with the use of insulin in Type I diabetics.
Diabetic coma occurs when there is too much circulating glucose in the blood. The onset may be gradual. Few symptoms may be evident until levels become severely elevated. Individuals may become confused, drowsy, have difficulty breathing, nausea, vomiting and flushing of the skin. Diabetic coma is a medical emergency that can result in death without treatment.
Insulin shock is the opposite of diabetic coma, occurring when there is too much insulin in the blood. It may result from injecting too much insulin or from an unusual amount of exercise that burns up glucose normally available. Individuals may feel weak, hungry and nervous. They patient may perspire although the skin is cold to the touch. Confusion and personality changes may occur. If not treated the patient may become unconscious and brain damage and eventually death may occur.
Complications from diabetes can affect a number of body systems and result in major disability. Vascular changes can contribute to myocardial infarction or cerebrovascular accident. Circulation problems can result in peripheral vascular insufficiency so that even minor injuries are prone to become so severely infected that amputation becomes necessary. Deprivation of blood supply to the kidney can result in kidney failures. There can also be changes in the nervous system and changes in the peripheral nerves that result in loss of sensation and pain sensations.
In Type 2 diabetes lifestyle changes can be of great value and the psychologist’s knowledge of motivation and adherence can be of great help. The key to self-regulation in diabetes is testing blood sugar each day and for optimal effect more than once a day. Self-testing is rare in Long Term Care but it remains important that the patient be engaged and keeps track of levels even if the nurse does the testing.
One service that the Primary Care Psychologist should provide is Motivational Interviewing to promote (e.g. especially for Type I). Behavioral strategies aimed at enhancing motivation and self-regulation have been shown of great value. Also, hypoglycemia can be very frightening and many patients remain hyperglycemic as an avoidance strategy. The psychologist’s knowledge of fear and the management of fear can be of value.
Stress coping and affective regulation are important in management of diabetes. Depression has been shown to lead to failure of adherence to the medical regimen. Improved ability to manage stress has been shown to enhance the management of the disease. A well designed personalized program for better management of stress can result in:
- Improved psychological well-being
- Improved blood glucose control and thus reduced risk of complication
- Reduced insulin regulation
- Fewer emergency episodes.