Assessment of the Established Diabetic

See also:
Dose Adjustment For Normal Eating and Exercise (DAFNE)
Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND).

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 health carer 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 diabetes and type 2 diabetes, which will need to be adapted, depending on an individual patient's type of diabetes.

• To educate the patient and enable them to monitor and manage their diabetes as well 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.
• Educate and reinforce healthy lifestyle advice.
• 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.

See also: Diabetic Audit

• Is the patient enrolled on practice and local diabetic register?
• Is the patient's Body Mass Index (BMI) recorded?
• Is the patient's smoking status recorded in the last 15 months (or once if lifelong non-smoker)?
• If the patient is a smoker, have they had smoking cessation advice offered in the last 15 months?
• Is the patient's HbA1c recorded in the last 15 months?
• Is the patient's HbA1c <7.4%? If not how can the situation be changed to achieve the target of 50% of patients below this figure?
• Is the patient's HbA1c <10%? If not how can the situation be changed to achieve the target of 85% of patients below this figure?
• Have they had diabetic eye screening and are they enrolled in a digital retinal photography programme?
• Is there a record of the patient's peripheral pulses in the last 15 months?
• Is there a record of the patient having had neuropathy testing in the last 15 months?
• Is there a record of the patient's blood pressure in the last 15 months? If the blood pressure is worse than 145/85, what is being done to reduce it and achieve the target of 55% of patients below this figure?
• Is there a record of microalbuminuria testing in the last 15 months?
• Is there a record of the patient's serum creatinine in the last 15 months?
• In patients with proteinuria or microalbuminuria, are they taking ACE inhibitors or A2 antagonists?
• Is there a record of the patient's total cholesterol in the last 15 months? If their total cholesterol is >5 mmol/l what measures are being taken to reduce it and achieve the target of 60% of patients with cholesterol ≤5 mmol/l?
• Has the patient been immunised against influenza and pneumococcus?
• Have they been, or do they need to be, enrolled into a foot-care programme?

The above provides a list of things to do - but it should be borne in mind that patients should be treated in a supportive way and as an individual. This will go some way in achieving full QoF/QMAS points and may mean that thresholds e.g. HBA1c may not necessarily help manage the individual patient.

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. This should be done in addition to the points in the checklist above:

• 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 as hypoglycaemia, diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic non-ketotic coma (HONK)?
• Has the patient had any treatment or hospital admissions for complications of their diabetes in the past year? For example, angina/myocardial infarction (MI), cerebrovascular accident (CVA)/transient ischaemic attack (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 glucose? When did they last calibrate their glucose monitoring equipment?
• Do they have their records of their blood 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.
• The above details can be filled into computer templates e.g. GMS templates or a modified version which automatically fills in Population manager/QMAS.

Examination

• Weight, height and BMI.
• Urinalysis for ketones, protein and nitrite (evidence of infection).
• Inspect injection sites of type 1 diabetics, looking for evidence of lipoatrophy and lipodystrophy/lipohypertrophy.
• 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.
• Palpate and record the peripheral pulses of the feet.
• 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.
• 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 neuropathy causing deformity and ulceration, or hypoperfusion due to peripheral vascular disease.

Blood results

• HbA1_c; or check when last done.
• Home capillary glucose monitoring results for type 1 diabetics. For type 2 diabetes blood testing is not more effective than urine testing and is only necessary in patients on insulin or who are taking sulphonylureas.
• Frequency and severity of hypoglycaemic episodes.
• Non-fasting lipid profile.
• U&Es and estimated glomerular filtration rate to look for diabetic nephropathy (in addition to urine results)

Medication review

• Current diabetic medication and doses – insulin (short- and long-acting), biguanides, sulphonylureas and thiazolidinediones. Review glitazone therapy if appropriate and consider changing rosiglitazone to pioglitazone or other treatment in light of concerns about cardiac ischaemia and heart failure.
• Current medication for other conditions, especially those designed to ameliorate cardiovascular risk such as diuretics, anti-hypertensives, ACE inhibitors, aspirin, beta-blockers etc.

Activity and education

• What is the patient's current level of physical activity and can this be improved if thought necessary? Are there any local physical activity programmes in which they could be enrolled?
• Has the patient received adequate diabetic education in their and your view? Would they like to receive more advice on self-management of their diabetes? Should they be enrolled into a local diabetes education delivery programme such as DAFNE (type 1 patients) or DESMOND (type 2 patients).

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.