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Addressing cognitive impact of hyperglycemia on diabetes self-management
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Hyperglycemia causes many physical issues, particularly if blood glucose is high for extended periods, but both short and long periods of elevated blood glucose levels can cause drastic cognitive issues that often go unattended too. This cognitive impairment can trigger poor diabetes management and destabilize emotions, leading to depressive symptoms, poor judgment and impaired decision-making while causing psychological problems and relationship issues.
While patients deal with blood glucose levels differently, it is helpful to think of them according to two types: “managed” and “fear driven.” Although cognitive impairment affects both groups, how they respond is different.
The managed group includes patients who appear to self-manage their diabetes well and tend to have HbA1c levels in target range. These patients usually get a pat on the back at office visits. However, they may have several hyperglycemic episodes throughout the week, and may be overlooked when it comes to blood glucose stability and emotional distress.
The fear-driven group includes patients who may self-manage their diabetes but who choose to or unknowingly keep blood glucose levels above 200 mg/dL out of conscious or unconscious fear of hypoglycemia. Management of this group is more complicated considering that cognitive impairment does not let up. This group tends to receive a lot of negative attention from friends, family members and health care providers. They may feel helpless not having the tools to improve their glycemic control.
Daily impact
Patients in the managed category may already be aware of the impact of hyperglycemia. Motivation decreases as glucose levels increase. Patients may avoid glucose testing and taking bolus insulin for meals, and may even ignore pump alarms. Management needs go unattended during periods of elevated glucose.
For example, a patient is going to a movie premiere that night, talks your ear off about it, and says “I’ve been waiting all year for this premiere!” At the next appointment, he reports a period of hyperglycemia after his last visit. Feeling depressed and unmotivated, and unaware of the emotional impact of his blood glucose level, he skipped the movie. Unfortunately, when his blood glucose returned to normal, he blamed himself for missing the premiere.
During hyperglycemia, patients also have poor memory retention and recall. When blood glucose levels are high, patients may forget what a health care provider — or anyone — asked them to do. Whether they agree to change their basal rate or pick up diapers from the store, hyperglycemia can cause them to forget. The impact on relationships can cause miscommunication and unnecessary arguments.
Hyperglycemia also affects judgment and triggers defense mechanisms that protect people from difficult emotions and thoughts. Conscience fades away the more blood glucose increases.
Compared with the managed group, those in the fear-driven group have similar cognitive issues, with one major difference: The impairments are constant. Low levels of motivation, poor memory retention and recall, poor judgment, increased impulsivity and emotional instability can reduce clarity of thought, causing poor reality testing. Unrelenting cognitive impairments make these patients vulnerable to addiction, and they may struggle to maintain relationships.
These patients often fear diabetes complications and hypoglycemia. They feel guilty about not adequately managing their disease. Their cognitive impairment prevents retention of new information, including self-management issues. Unaware of the cognitive impairments, they see no way out, and their providers may feel the same way.
Strategies to help
Treating the fear-driven group is challenging. Management advice likely will have little effect. Due to their cognitive impairments, these patients may appear not to care about their diabetes. Most people in this group do want help, but lack the motivation and cognitive resources to implement it.
Helping this group requires a team approach — shared information among their health care providers, good case management and keeping patients informed. Collaborating with family members and friends can help patients make and keep appointments with referred health professionals.
As long as cognitive impairments remain, these patients may not improve. However, there are resources, and these patients should be referred to a psychotherapist, a psychiatrist and a certified diabetes educator.
A psychotherapist is needed to help patients break out of the hyperglycemia-impairment-hyperglycemia cycle. The therapist helps patients process fears around hypoglycemia or other emotional issues preventing healthy diabetes self-management.
Psychopharmacology is often needed, and a psychiatrist can prescribe antidepressants to help reduce cognitive impairments that prevent appropriate self-management. All patients should be evaluated for psychiatric issues, as these issues can have a devastating impact on a patient’s ability to manage. For those in this category, other underlying psychiatric issues may be masked by hyperglycemia.
Finally, a certified diabetes educator is needed to help patients with self-management education, providing new management techniques and tools.
Long-term hyperglycemia can produce a phantom symptomatic hypoglycemic response in patients. Although these phantom symptoms of low blood glucose occur at higher blood glucose levels and are no cause for alarm, this phenomenon can be scary for someone who has been consciously or unconsciously avoiding hypoglycemia for many years.
The managed patient group needs attention, as well. Even when diabetes appears to be under control, it often is not.
Even if these patients report no management issues or emotional concerns, it is important to them that a health care provider understands how complicated it is to live with diabetes. The goal is to create a safe, nonjudgmental environment for patients to share.
When an issue requires more time, a health care provider should schedule a follow-up appointment and, if needed, make the proper referrals. The follow-up shows caring and concern while building trust.
Hyperglycemia action plan
One useful tool is a plan of action that utilizes a patient’s support network when blood glucose levels are greater than 200 mg/dL. This plan should be location-specific and provide information to the patient’s support group on how to best support that patient — what they need to do when hyperglycemia occurs and until it subsidies.
For example, I helped a client of mine, Bob, create his action plan. Before his last hyperglycemic episode, he informed his wife about his plan, which called for her to be available but not too attentive.
When Bob noticed that his blood glucose had risen to 250 mg/dL, he told his wife. She asked whether he needed her to do anything. Bob appreciated the comment but said no. His wife let him know she was willing to help and would be in the other room.
Bob noticed that he felt helpless but acknowledged the situation and followed his plan to work on a simple task or to watch a funny movie. Since Bob had meant to organize his computer desktop for several months, he began that task, and 2 hours later when his blood glucose level had improved, he informed his wife.
Before devising his action plan, Bob would inevitably end up getting frustrated, fight with his wife and feel embarrassed and guilty. Instead, after this incident, he felt happy and accomplished.
Each plan is situation-specific and requires problem-solving skills. Devising an appropriate plan is a team effort; you can always refer when struggling to help a patient.
Keep in mind that most patients have unreasonable expectations and may have been let down by the medical community. Many patients think health care providers are interested only in the numbers, or they expect their providers to fix everything. It is important for them to understand the provider’s role and know what other resources are available. Building trust by listening to patients and including them in the decision-making process is critical to their success.
- References:
- McCrimmon RJ, et al. Lancet. 2012;doi:10.1016/S0140-6736(12)60360-2.
- Northam EA, et al. Diabetes Care. 2001;24:1541-1546.
- Sommerfield AJ, et al. Diabetes Care. 2004;27:2335-2340.
- For more information:
- Eliot LeBow, LCSW, CDE, is a diabetes-focused psychotherapist, presenter, author and founder of DiabeticTalks and Diabetes-Focused Psychotherapy. His private practice is in New York City and is also available via Skype. LeBow, who has been living with type 1 diabetes since 1977, treats the many diverse cognitive, behavioral and emotional needs of people living with diabetes. He can be reached at eliot.lebow@gmail.com. He reports no relevant financial disclosures.