Assessment Of The Established Diabetic

When, how and who?

Diabetic patients frequently attend their healthcare practitioners, either specifically for diabetes-related issues, for complications of their chronic illness, or for unrelated problems. They may see their GP, practice nurse, hospital diabetologist, diabetes specialist nurse, dietician and many others, from time to time. Each visit can be viewed as an opportunity to assess and improve the patient's understanding of their illness, and their ability to control the disease. After all, diabetic control is largely related to the effort put in to it by the sufferer, rather than the healthcare practitioner, although obviously a motivated and effective healthcarer gives a diabetic patient their best chance of achieving good diabetic control.

This is not to say that all the information contained in this article should be run through every time a diabetic patient crosses the threshold of the surgery or the hospital. It should be viewed as a fairly comprehensive list of all the assessments that may be needed, and from which the attentive practitioner can select those that are most relevant to this particular visit and that particular patient. If the patient attends a hospital- or primary care-based diabetic clinic for annual review, then it should cover the areas outlined in this article, in variable degrees of detail, depending on how relevant it is in individual cases. This article covers areas of assessment relevant to type 1 and type 2 diabetes, which will need to be adapted, depending on an individual patient's type of diabetes.

Aims of diabetic assessment

To educate the patient and enable them to monitor and manage their diabetes as best as possible.
To assess any problems in glycaemic control and address them to improve it.
To detect any complications of diabetes and treat them as appropriate.
To assess the patient's overall health and to treat any associated or coincidental illness, physical or mental.
To provide support and advice to the patient on how to cope with living with a chronic illness, and how they can best alter their lifestyle to maintain their health.

Administration, audit, data collection and GMS QMAS (Quality Management and Analysis System) points

History

There is much to cover if all the information below is to be discussed at the review. One way around this in terms of time constraints is to use a questionnaire that can be looked over by the doctor/nurse seeing the patient so that all the relevant areas are covered and there is time to focus on pertinent findings. This approach is also useful in terms of documenting within the clinical record that all the relevant areas were discussed.

How is the patient coping with self-care and self-management of their diabetes?
Does the patient consider that they eat a healthy diabetic diet and do they feel sufficiently informed about how to manage their diet and its relationship to their insulin regimen?
Have they received, or would they like to receive, any educational input to help them improve their understanding of their condition and its self-management? For example, DAFNE, DESMOND, dietetic input, exercise and activity programmes.
Has the patient had any hospital admissions in the past year for diabetic decompensations such ashypoglycaemia or DKA/HONK?
Has the patient had any treatment or hospital admissions for complications of their diabetes in the past year? For example, angina/MI, stroke/TIA, renal disease, diabetic retinopathy.
Has the patient had any symptoms of cardiovascular, cerebrovascular, renal, ophthalmological or neurological complications of diabetes?
Has the patient been otherwise well, or had any other illness of note over the last year for which they have consulted their GP or other healthcare services?
How is the patient coping with and complying with their diabetic medication regimen? Any problems with injection of insulin? Any problems with timing of insulin or oral medication? Do they miss injections or medication regularly?
Is the patient a smoker? If so, what help would they like to become a non-smoker and are they aware of the importance of stopping smoking?
Any problems with the equipment that they have to monitor their capillary or urine glucose? When did they last calibrate their glucose monitoring equipment?
Do they have their records of their blood or urine glucose monitoring?
How has their mood been? Any problems with, or treatment for, depression?
Is the patient pregnant? Are they planning on having any children? (relevant mainly for women in terms of pre-conceptual counselling and blood glucose control,¹ but there may be benefits from better blood glucose control for men before conception, although there is currently no evidence to back this up).
Has the patient had any problems with sexual function? Ask specifically about erectile dysfunction in men.

Examination

Check height and weight and calculate BMI.
Carry out urinalysis for glucose, protein, blood, nitrite (infection) and microalbumin.
Inspect injection sites of type 1 diabetics, looking for evidence of lipoatrophy and lipodystrophy/lipohypertrophy.
Inspect eyes, looking for any evidence of xanthelasmata, cataract formation or ophthalmoplegia.
Check visual acuity, with distance vision glasses, if worn.
Carry out ophthalmoscopy, preferably with dilated eyes, unless this has already been done as part of the patient's diabetic ophthalmological screening and digital retinal photography programme.
Check pulse and blood pressure.
Listen for carotid bruits and to heart sounds/lung fields if there is any history consistent with cerebrovascular or cardiac illness.
Examine the legs for evidence of diabetic amyotrophy.
Check peripheral limb sensation using 128 Hz tuning fork, pinprick sensation with 'neurotips' and/or 10g nylon monofilament probe.²^,³
Check ankle and knee jerks using a tendon hammer.
Inspect footwear (for suitability) and the feet carefully for any evidence of peripheral neuropathycausing deformity and ulceration, or hypoperfusion due to peripheral vascular disease.
Palpate and record the peripheral pulses of the feet.

Investigations

Non-fasting lipid profile
HbA1_c
U&Es
Estimated creatinine clearance (using Cockcroft-Gault or modfication of diet in renal disease –MDRD – equations)⁴; measure actual creatinine clearance if previous evidence of renal impairment.

Assessing and addressing modifiable risk factors

Glycaemic control and how to improve it
Smoking status and how to stop smoking if needed
Dietary patterns and how to modify them (can help with improving glycaemic control)
Exercise and how to incorporate regular physical exertion into one's life
Lipid status and any lifestyle modifications or medication required to improve it
Blood pressure and how to improve its control with medication and lifestyle modification
Avoiding weight gain or losing weight (pertinent to both type 1 and type 2 patients).

Discussing results and agreeing a treatment plan with the patient

Ideally, where the annual diabetic review is carried out as a 'one-stop' service where the patient has had their blood tests in advance of the appointment, the meaning of the results should be discussed with the patient there and then.
Any change in management that is needed should be outlined and agreed and it should be clear to the patient what the 'medical' and what the 'self-managed' changes need to be.
Where blood results and other useful information that will determine management are not available until later, a useful practice is to send a copy of the clinic letter, that is sent to the GP, to the patient, discussing the results, what they mean, and what needs to change as a result of the annual review.
Where patients are seen exclusively in primary care, a further appointment should be offered to discuss what the ongoing treatment plan is and ensure that the patient is clear about it and knows how to proceed.
Arrange referrals to other practitioners as appropriate, e.g. ophthalmologist, dietician, footcare team, educational support.

Document references

McElvy SS, Miodovnik M, Rosenn B, et al; A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels. J Matern Fetal Med. 2000 Jan-Feb;9(1):14-20. [abstract]
Gin H, Perlemoine C, Rigalleau V; How to better systematize the diagnosis of neuropathy? Diabetes Metab. 2006 Sep;32(4):367-72. [abstract]
Tayside Diabetes Handbook. Screening and Mangement of Foot Complications.; Detailed evidence-based information on effective methods of sensation testing in the feet of diabetic patients.
Coresh J, Stevens LA; Kidney function estimating equations: where do we stand? Curr Opin Nephrol Hypertens. 2006 May;15(3):276-84. [abstract]

Internet and further reading

Diabetes UK; Website
Leeds Health Portal Website. Suggested schema for one-stop annual diabetic review.; Useful flow-chart for organising 'one-stop' annual diabetic review.
International Diabetes Federation. A Desktop Guide to Type 2 Diabetes.; Schema for diabetes-related consultations.
Type 2 diabetes: Prevention and management of foot problems, NICE Clinical Guideline (January 2004)
Diabetes - foot disease, Clinical Knowledge Summaries (2006)
Diabetes - hypertension, Clinical Knowledge Summaries (2006)
Diabetes - renal disease, Clinical Knowledge Summaries (2006)

Pathological - Disease Processes

Tuesday, March 17, 2009