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Diabetes Watch

How Mental Health Can Affect Adherence In Patients With Diabetes

People with diabetes have a 25 percent lifetime risk of developing foot wounds.1,2 Annually, hundreds of billions of dollars go toward the treatment of diabetes-related diseases with up to $1 of every $3 spent linked directly to the care of diabetic foot ulcers.3,4 The enormity of that burden, in expenditures and time, translates clinically as we care for the diabetic population. The end goals, unequivocally, are to heal wounds and decrease recurrence.

There are instances, however, when clinicians encounter patients with severe concomitant disease states that inhibit healing. In this patient population, perhaps the subsequent natural progression of a wound to an amputation is regrettable but understandable. In other cases, individuals with the capacity to heal present with a confusing inability to do so. Many of these patients often demonstrate perplexing roadblocks to their own healing by showing minimal concern or decreased effort to help themselves through the healing process. These are the patients with whom we battle for adherence in terms of managing proper wound care regimens, maintaining healthy blood glucose and follow-up. The clinical management of patients in this scenario can prove to be taxing, may be a significant point of dissatisfaction as a practitioner and come with increased expenditures.

Common comorbidities of diabetes include micro- and macrovascular disease, nephropathy, retinopathy and neuropathy.  These comorbidities are well recognized and are often the subjects of lectures, research and educational curricula. There are, however, known psychological comorbidities of diabetes that are less often topics of discussion but may play an equally important role in the successful treatment of patients with diabetic foot wounds.  

Diabetes is a lifelong and life-altering disease state that requires frequent glucose monitoring, daily prescription dosing, increased visits to physicians and dietary restrictions. Not only does the disease prove to be physically demanding but the psychological effects of diabetes are far reaching and just as permeating. Accordingly, it is important to have a strong awareness of common mental health challenges that may complicate the treatment course of a non-healing, yet healable patient with diabetes. Knowing and considering these findings when creating a treatment plan may help decrease cost, improve clinical outcomes, augment patient satisfaction and promote clinician efficacy as a member of the patient’s diabetes care team.

Advising Patients On The Stress Of Diabetes
One forefront aspect of the psychology of diabetes, and wound care in particular, is acute patient stress. A recent study utilized wearable stress sensors during the duration of patients’ wound care visits, focusing on the evaluation of real time stress indicators.5 The study found patients to be in a state of elevated stress ranging from 20 to 80 percent of the timed duration of their podiatry office visit. Furthermore, the data indicates the greatest stress occurred during dressing changes.

Unfortunately, the stress does not stop after dressing changes. Researchers have demonstrated that the daily regimen of personal care for those with diabetes causes a significant stress reaction.6 A study of more than 200,000 adults found that patients with diabetes had a 20 percent greater incidence of anxiety than those without diabetes.7 Furthermore, increased levels of perceived stress correlate with less physical activity and increased body mass index (BMI).8 Similar studies have found that chronic stress leads to increased sedentary behaviour and further acute stresses nearly double the amount of time of inactivity.9 Authors have referred to this as a “self-reinforcing cycle of unhealthy behaviors.”

Stress is not always detrimental in the context of patient care. There are moments — when discussing progress, prognosis and treatment plans — when varying levels of stress help emphasize the importance of adherence. One should carefully consider the detrimental chronic stressors of diabetic wound care before presenting a treatment plan. An outline of short, mid- and long-term treatment goals can decrease the stress concerning treatment as well as paint a picture of the plan of care.  

During office visits, a clinician can make an effort to evaluate and attempt to minimize key factors that incite acute stress. Decreasing patient visualization of debridement, the complexity of dressings and attempting to decrease pain can all serve to reduce stress. Many facilities are using creative space arrangements, art and nature to provide stress relief for patients. Most importantly, physicians should maintain positivity. Patients progress at different levels. Physicians should support and encourage any method that increases a patient’s chance to heal.

When Patients With Diabetes Have Depression
Substantial research has indicated that there is a direct correlation with the diagnosis of diabetes and depression.10 Remarkably, up to 28 percent of women and 18 percent of men with diabetes, and approximately one out of three patients of either gender with uncontrolled diabetes satisfy the criteria for clinical depression.10 Even in individuals without clinical depression, the distress associated with the management of the disease is significant.7,11

The increased incidence of diabetes combined with the decreasing age of onset underscore the importance of understanding the effects of diabetes on the psychological health of younger patient populations. New findings suggest that young adults with diabetes suffer a greater incidence and impact of depression while managing their disease in comparison to older adults.7

One can easily extrapolate the effects of depression on a patient’s attention to physical health and how that may transfer to the phases of wound care. Although in one study, self-care — including foot checks, blood glucose monitoring and diet regimen — was low for all patients with diabetes, those with depression demonstrated a marked decrease in self-care efforts.12 In fact, authors found that the frequency of smoking, fat intake and sedentary activity also increased in this same population. Considering a causal relationship between the two is less important than the knowledge that diabetes and depression coincide with alarmingly detrimental effects.     

In a fast-paced clinical setting, it may seem that evaluating a patient for depression is more cost than benefit. However, do not underestimate the extent that depression may be harmful to patient and physician success. There are multiple validated rapid assessment questionnaires available to help physicians quickly and accurately screen patients in or out of clinical depression. Patients may complete the questionnaire discreetly while waiting for the doctor to screen them, calculate their own score and be ready to discuss the outcome in a very brief conversation during the patient interview. This open dialogue allows physicians to provide references to colleagues or treatment centers that may help facilitate further medical care for patients who meet depression criteria.

Current Insights On Diabetes And Cognitive Decline
Most wound care may seem relatively simple to medical staff. We routinely apply therapy, bandages and boots without a second thought. When patients return with evidence of weightbearing, improper use of offloading devices or a week’s worth of damage due to an erroneous dressing, we may find it easy to apathetically attribute it to a patient’s lack of attention or blatant non-adherence. Not only may these patients be suffering from the neglect resulting from depression or anxiety, but emerging studies suggest that decreased adherence may be related to cognitive change associated with diabetes.  

Although the pathophysiology is not well understood, Bangen and colleagues indicated that patients with diabetes may have an early decline in cognition.14 Studies have directly linked impaired glucose tolerance in people with diabetes to decreased verbal understanding, long-term memory scores, mini-mental status exams and multiple forms of dementia in comparison to non-diabetic counterparts.15-18 These changes may be evident in the clinician’s office as a consistently decreased ability to understand and apply the information provided by medical staff.14 In some cases, despite apparently understanding and “agreeing to the plan” while in the office, there may be significant difficulty in processing information for performing tasks upon returning home.

In the past decade, we have seen an eruption of products addressing cognitive decline while advancing the ease of self-care and independence of the rapidly increasing elderly population, colloquially known as the “Silver Tsunami.” Weekday pill boxes are now divided into morning, noon and night. Prescription packages have fill-in calendars for physicians to outline dosing regimens in exact detail. Daily tasks are outlined on conspicuously colored and prominent to-do lists, and all varieties of necklaces, wrist bands, key chains and satchels are readily available to facilitate organization.

With the increased understanding that all patients with diabetes may have difficulty in self care, perhaps there is need for a similar diabetic foot wound care industry revolution. Small steps of simplification may go a long way. Ideas such as providing simple instruction lists for dressing changes, outlining a weekly schedule including the next office visit, and emergency bandage instructions are simple ways to decrease the loss of information between one office visit to the next. In understanding the alteration in cognition that some patients are facing, it may be necessary to re-evaluate one’s threshold for ordering home healthcare. Perhaps repeat offenders in non-adherence or dressing failure may be optimal candidates for the careful eye and experienced hand of home healthcare providers.  

In Conclusion
Stress, depression and cognitive change are merely a few of the confounding factors of patient non-adherence, seeming self-neglect and lack of progress. As physicians, we have the task of evaluating the physical and mental status of our patients when creating a plan of care. Increased knowledge of the rising incidence of stress, depression and decreased cognition may alter the treatment course on a patient-to-patient basis.

Physicians can help reduce stress by:
• providing a short, mid- and long-term plan of care;
• evaluating pain, the visualization of wound debridement and dressing complexity while the patient is in the office; and
• remaining positive during the progress and lulls of diabetic foot care.
Physicians may help patients with unrecognized or undiagnosed depression by utilizing simple in-office self-rating scales. Patients who meet that criteria may get referrals to the appropriate medical specialist to help them treat and cope with depression.
Physicians may help those with failing cognition by:
• providing easy to understand printed or written dressing instructions;
• providing dressing and office visit calendars;
• re-evaluating patients with persistent non-adherence or dressing failure for candidacy for home healthcare.

Finally, physicians should consider the inclusion of all available family, friends and support groups for patient care. Research has shown that when others participate in a patient’s care, it not only has a positive psychological impact on the patient but the individual(s) involved as well.19

An understanding of how mental health can affect patients with diabetes combined with specially chosen alterations in care that address an impairment to healing may prove to decrease cost, increase adherence, augment healing and deepen the satisfaction of all involved in a patient’s care.

Dr. Hatch is a first-year resident within the Tucson Medical Center/Midwestern University residency program.

Dr. Armstrong the Director of the Southern Arizona Limb Salvage Alliance and a Professor of Surgery at the University of Arizona Medical Center in Tucson, Ariz.


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Diabetes Watch
David C. Hatch, Jr., DPM, and David G. Armstrong, DPM, MD, PhD
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