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Blood Glucose Awareness Training

Blood Glucose Awareness Training. An Introduction to the Research and Use of Neuroglycopenic Cues John Zrebiec, MSW, CDE Joslin Diabetes Center. BGAT-What is it?. Recognition, prediction & prevention of extreme blood glucose Active & personalized learning experiences

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Blood Glucose Awareness Training

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  1. Blood Glucose Awareness Training An Introduction to the Research and Use of Neuroglycopenic Cues John Zrebiec, MSW, CDE Joslin Diabetes Center

  2. BGAT-What is it? • Recognition, prediction & prevention of extreme blood glucose • Active & personalized learning experiences • Usually group format

  3. Who Is BGAT For? Adults Taking Insulin • Frequent hypoglycemic episodes • Hypoglycemic unaware • Too afraid or lack a fear of hypoglycemia • Frequent motor vehicle accidents or violations • Family conflict due to BG • Trouble at work due to BG • Attempting intensive insulin therapy • Pursuing pregnancy

  4. BGAT History • NIH funded research for past 25 years • 15 US and international studies • Translated into 5 languages • Hypoglycemia, Anticipation, Treatment and Training (HAATT) • www.healthsystem.virginia.edu/bmc/ bgathome • BGAT for Parents

  5. Reduction of Risk for Severe Hypoglycemia through Psychobehavioral Intervention Linda Gonder Frederick, PhD, Daniel Cox, Phd, Boris Kovatchev, PhD, William Clark, MD and John Zrebiec, MSW • University of Virginia, Charlottesville • Joslin Diabetes Center, Boston

  6. Effects of BG on Cognitive Function in School-Aged Children with T1DM: A Field Study Linda Gonder-Frederick PhD, John Zrebiec MSW,* Andrea Bauchowitz PhD, Daniel Cox PhD, Lee Ritterband PhD, Jarim Lee BA,* Boris Kovatchev PhD, and William Clarke MD University of Virginia and *Joslin Diabetes Center, Harvard Medical School Research supported by NIH R01DK60039 and Abbott Diabetes Care, Inc.

  7. Within-Subject Results • Question: How many children show a clinically significant deterioration in performance with mild hypoglycemia? • Clinically significant defined as: Performance on the math task more than one SD poorer on > 50% of trials during mild hypoglycemia as compared to euglycemia. • Result: 17% of children

  8. BG Detection in School-Aged Children with T1DM and their Parents Linda Gonder-Frederick, Ph.D. John Zrebiec, M.A.* Daniel Cox, Ph.D. Boris Kovatchev, Ph.D. Lee Ritterband, Ph.D. William Clarke, M.D. University of Virginia *Joslin Diabetes Center at Harvard University Research supported by NIH R01 DK 060039 and Abbott Diabetes Care, Inc.

  9. EGA ResultsBG < 70 mg/dl (4.0 mmol/L) (n = 263)

  10. EGA ResultsBG < 50 mg/dl (3.0 mmol/L) (n = 65)

  11. EGA ResultsBG > 250 mg/dl (14 mmol/L) (n = 705)

  12. Conclusions • School-aged children with T1DM and their parents show poor ability to recognize hypo- and hyperglycemia. • Failure to detect extreme BG levels occurs as often or more often than accurate detection. • Children and Parents are far more likely than adults to mistake low BG for high, and vice versa.

  13. BGAT Patient Benefits • Improves detection of extreme BG • Reduces occurrence of extreme BGs • Preserves Counter-Regulatory Response during intensive insulin treatment • Reduces sequeli of extreme BG 1. DKA 2. Severe hypoglycemia 3. Motor vehicle accidents & violations

  14. BGAT PATIENT BENEFITS Average Accuracy Before 45% After 75% Most Accurate: Trained in Internal and External Cues

  15. BGAT Patient Benefits Improves driving decisions 81% choose not to drive when low Million miles driven: 7 accidents BGAT 29 accidents non-diabetic Swerve first, then slow down

  16. BGAT Patient Benefits • Psychological benefits • Improves knowledge about diabetes • Reduces fear of hypoglycemia • Reduces depression • Reduces family conflict • Improves quality of life

  17. Benefits for Physicians and Diabetes Educators • Saves professional time dealing with hypoglycemia prevention • Reduces emergency telephone calls • Reduces time spent with anxious family members • Improves BG control • Educates patients about how to recognize and treat extreme BG

  18. Risk Factors Associated with Hypoglycemia Male Long Duration of Diabetes History of Severe Hypoglycemia History of Recurrent Mild Hypoglycemia Going to sleep with BG <100

  19. Most Common Causes of Hypoglycemia 1. Taking Too Much Insulin 2. Delaying Eating 3. Delaying Treating

  20. Most Common Symptoms of Hypoglycemia Trembling Pounding Heart Difficulty Concentrating Uncoordination Only 50% report these symptoms 50% report non-specific symptoms Only 50% actually recognize symptoms

  21. Research Findings • 50% lows occur while asleep • Average episode of nocturnal hypoglycemia lasts 86 minutes • 50% higher risk for next 24 hours • 25% higher risk for next 48 hours • Autonomic symptoms are significantly depressed for next 72 hours

  22. NeuroglycopeniaThinking & Performance Cues • BG primary fuel of brain • Brain sputters with low fuel • Neuroglycopenia disrupts thinking and coordination

  23. Things To Look For • Informal performance cues • fine motor • gross motor • Formal performance cues • fine motor • gross motor

  24. Common Informal Mental Performance Cues • Following directions • Doing simple arithmetic • Making change • Following conversations • Thinking of the correct word • Having difficulty reading • Having difficulty concentrating

  25. Informal Gross Motor Performance Cues • Walking quickly and turning • Walking • Climbing stairs • Standing up • Bending over at your waist • Dancing

  26. Informal Fine Motor Performance Cues • Writing a check or addressing an envelope • Hammering a nail or turning a screw • Unlocking a door • Typing • Tying a knot, shoelace, or tie

  27. Formal Performance Cues • Doing a tongue twister • Mental subtraction by 3’s • Thinking of words that begin with a certain letter of the alphabet • Flipping a dime

  28. Other Common Neuroglycopenic Symptoms • Fuzzy thinking • Slight confusion • Trouble talking • Uncoordinated • Dizzy or lightheaded • Unusual fatigue or sleepiness • Visual problems • Feeling “heavy” in arms or legs

  29. Hypoglycemia and Driving • Mid 50’s disrupts driving • Accidents 3x more common among T1DM • For every accident there are 5 episodes of severe hypoglycemia • Judgment to drive is poor

  30. Driving Performance Cues • Difficulty steering in a straight line • Driving slower than usual to compensate for bad driving • Difficulty finding your way • Running stop signs or red lights • Tailgating • Stopping too soon before a stop line or a parked car • Other drivers honking at you

  31. Best Driving Cues • Trembling • Incoordination • Blurred vision

  32. Rules of the Road • If you think you might be low, CHECK BG before starting the car • If you are low while driving, STOP immediately • TREAT immediately • WAIT to continue driving until BG rises

  33. Good News about Driving • BGAT improves judgement when not to drive • Judgement to drive significantly correlates with crash record • BGAT reduces crashes and motor vehicle violations

  34. Daily Diary

  35. Daily Diary sample

  36. BG Diary / Summary Sheet Low BG / High BG

  37. BG Diary / Summary Sheet Analysis • Find every actual low BG • List each individual and different cue • List BG values occurring with each cue • Find the average Example Symptom / Average BG Irritable 53+66+64+61+49= 293 / 5 = 58

  38. BG Diary / Summary Sheet Analysis 5.List the frequency of each cue 6. Find consistency: divide frequency by total number of low BG entries Example Symptom / Avg BG / Frequency / Consistency Irritable 58 10 10/20 = 50%

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