Transitioning Care of Young Adults

Complications: DKA and Neuropathy

Anne Peters, MD, CDEAnne Peters, MD, CDEProfessor, USC Keck School of MedicineProfessor, USC Keck School of MedicineDirector, USC Clinical Diabetes ProgramsDirector, USC Clinical Diabetes Programs

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DKA Rates in Adolescents in DCCTDKA Rates in Adolescents in DCCT

In DCCT, DKA rates = 4.7/100 patient years In DCCT, DKA rates = 4.7/100 patient years (control), 2.8/100 patient years (intensive (control), 2.8/100 patient years (intensive group). NS between 2 groups.group). NS between 2 groups.

J Pediatrics 125:177, 2004

Rates of DKA at Diagnosis Fall with Increasing Age

Presence of Diabetic Ketoacidosis at Diagnosis of Diabetes Mellitus in Youth: The Search for Diabetes in Youth Study. Pediatrics

2008;121;e1258-e1266

• The prevalence of DKA at diagnosis was 25.5%. The prevalence was 37.3% in children aged 0 – 4 years and fell to 14.7% in those 15 – 19 years.

Basic Information

Diabetes Care 27 (Suppl 1):S94, 2004

Age Separation for Treatment Guidelines

Adult patients defined as >20 years of Adult patients defined as >20 years of age; pediatric <20 years.age; pediatric <20 years.

Main difference in treatment of DKA are Main difference in treatment of DKA are in terms of fluid resuscitation—concern in terms of fluid resuscitation—concern over cerebral edema in those <20 years over cerebral edema in those <20 years old.old.

Age Distribution of Cerebral Edema and DKA

J Ped 141:793, 2002

15-16 17

DKA Treatment: Kids

DKA Treatment: Adults

Precipitating Factors for DKA—ETOH?

HNKS in Young Adults

HNKS in Young Adults

Transition Care Program Reduces DKA Admission Rates by 30%

Measurable Neuropathy Present in Children and Adolescents with DM

Rates of Neuropathy in Australian Adolescents Over 10 Years: Cross-sectional Analysis

Diabetes Care 28:1974–1980, 2005

related to height/BMI increases N=250-300, age ~14.6

1990-94 1995-2002

Heart Rate/BP variation

Thermal/vibration

DCCT: Benefit of Tight Control on Neuropathy in Adolescents (13-17 yrs)

J Pediatrics 125:177, 1994

N = 195, clinical sxs neuropathy 6 cont/3 int

Eating Disorders and Painful Neuropathy

What Parents Say

Changes in Parental Involvement with DM Care for High School Age Children

“Before I used to be more careful and tell her and be on her case about diabetes…so her doctor advised me not to be that way and that it would be better to leave her more independent…now I am not as focused on what her food is…”

“Yes it has changed. When he was younger, he was more conscientious and more responsible. Now that he’s older he’s become more irresponsible. I told him he was going backwards like the crabs.”

What Parents Say

Issues with Providers

“My daughter when we go to the nutrition class she will carb count for the first few days then she forgets because she comes home and she’s so hungry and she wants to eat everything…The doctor told me that she could eat anything she wants as long as she gives herself the right amount of insulin. Then the nutritionist says eat small portions so it can be confusing.”

“My daughter was embarrassed of having a ball of fat right here and she hid it with her hair. It’s her fault she didn’t mention it to the doctor. Visit after after she didn’t mention it. So I asked her when are you going to take responsibility…finally I asked for her…she has to take responsibility and learn how to ask.”

What Parents Say

Leaving Pediatric Care

“They are going to finish pediatrics. That’s not the problem. The problem is that they are going to continue to study and will not be working so how are they going to afford their medical costs? To me this topic is very important…”

“That the transition will be from your part so that they won’t stop going to school so that they can work to pay for the medications. That is my biggest fear. And then they will not have a future.”

What Providers Say

Participants•Phone survey•Seventeen providers from 6 academic centers in LA County (LAC+USC, CHLA, White Memorial, Harbor UCLA, Miller Long Beach Children’s Hospital, Mattel Children’s UCLA Hospital)• 41% MD’s, 35% RN’s, remainder SW, NP, PA, LVN.

Data•Age at which transition discussion starts: 15-17•When does change occur? 18-21

What Providers Say

Challenges•Greatest challenge is insurance coverage•Next is lack of adult endocrine providers

Resources•82% reported discussing fears/concerns with patients before transfer•65% provide patient education and support tools•29% completed formal consultation and discharge letter to adult provider

What Providers Say

What Would Help•Develop and maintain an updated list of adult providers•A tool to assess readiness to change/knowledge level•Group meetings/peer education and mentoring programs•“Young adult” clinic•Guidelines for transition—a checklist to follow to be sure patient makes the transition safely•Letter from adult providers for pts—what to bring/what to expect from first visit

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