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Transition Management of the Adolescent with Diabetes Mellitus

MARK A SPERLINGUNIVERSITY OF PITTSBURGH,

CHILDRENS HOSPITAL of PITTSBURGHDIVISION OF ENDOCRINOLOGY


1.AdolescenceRapid Physical Growth – Hormones Turbulent Emotional Adjustments

Independence IndestructibilityImmortalityRisk Taking Behavior

Sexual MaturationSexual Activity Pregnancy


2. Hormonal Adaptations in Adolescents

GLUCOSE AND INSULIN RESPONSES TO OGTT IN PRE-AND PUBERTAL SUBJECTS

PRE-PUBERTAL GLUCOSE DOSE 1.75 g/Kg 55g/M2

( N=9) (N=8)

Fasting Blood 82.0±3.1 75.6±4.1Glucose (mg/dL) Peak Blood 151.6±8.5 143.3±7.5 Glucose (mg/dL)

Area Glucosemg/dL x 4hr 409.5±16.3 421.1±17.0

Area Insulin 118.5±17.3** 115.4±16.5§µU/ml x4hr

PUBERTAL GLUCOSE DOSE 1.75 g/Kg 55g/M2 (N=10) (N=9)

84.3±3.0 83.2±3.7

152.2±7.9

148.8±11.5

432.7±17.9

429.1±22.9

299.1±77.6** 365.4±114.8§

INSULIN RESPONSE TO STANDARD HYPERGLYCEMIC CLAMP

CHANGE IN PLASMA BCAA DURING HYPERGLYCEMIC CLAMP


3. Microvasular Complications of Diabetes During Adolescence

MicroalbuminuriaRetinopathy Neuropathy-Gastroparesis


4. Emotional Adjustments

Patton GC –Lancet 2007;369:1130-39-adapted from Gluckman P et al Trends Endocrinol Metab 206;17:7-12

Pubertal transitions in health-

Management Issues in Adolescents with Diabetes

a). Provider Requirements

▪ Understand diabetes management and normal adolescent development

▪ Consistent care provided by a single physician or team

▪ Enjoy working with adolescents ▪ Confidence in diabetes management

skills ▪ Willing to compromise on aspects of

diabetes care


b). Clinical Factors

▪Flexible appointment times▪Convenient clinic location and facilities▪Staff sensitivity toward patient-parent

interactions

▪Consistent use of appointment reminders


c). Patient Factors

▪Good staff understanding of patient-parent conflicts and patient interests

▪Clearly written, easily understood instructions


d). Regimen Factors

▪A simple regimen ▪Emphasis that monitoring benefits the

patient▪Well-documented negotiations and parent

understanding of management goals ▪Short-term compromise for long-term

success

Specific Management Issues in Adolescents with Diabetes

a). Insulin

▪ Three daily injections ▪ Total daily dose 1 – 1.5 U/KG/D▪ Intermediate: Short acting insulin 2:1 to

3:1

▪ Insulin pumps


b). Monitoring

▪ Unrealistic demands and expectations may lead to misrepresentation

▪ Glycosylated hemoglobin tests may uncover falsified home records

Recommendation: Carefully confront the patient.

Emphasizing importance of accurate records


c). Nutrition

▪Meal plan tailored to patient with help of dietitian

▪Regulate increased caloric needs (100-200 calories/day for each year > 12 years)

▪Be aware of body image concerns


d). Alcohol and drugs

▪ Use may express rebellion or peer pressure

▪ Increased danger of hypoglycemia

Treatment: Consider referral for counseling


e). Recurrent Ketoacidosis

▪ Associated with poor adherence and psychosocial adjustment

Treatment: Prompt referral for counseling


f).Sex and Marriage

▪Well-controlled diabetes before conception

▪ Ready access to birth control information

Recommendation: Both partners attend clinic and diabetes education sessions.


g). Parental supervision: Evolving independence

▪Gradual increase in adolescent responsibilities for care

▪ Inability to take responsibility may lead to poor control

▪Link driving privileges to reasonable control and adherence

▪Wear Medical identification necklace or bracelet


f). Sports

▪ Safe participation possible with appropriate adjustment of diabetes regimen

▪Physician reassurance of school officials often needed

SummarySummary

Accepting the critical role of continued parental Accepting the critical role of continued parental involvement and yet promoting independent, involvement and yet promoting independent, responsible self-management appropriate to the responsible self-management appropriate to the level of maturity and understandinglevel of maturity and understanding

Understanding that knowledge about diabetes in Understanding that knowledge about diabetes in adolescence is predictive of better self-care and adolescence is predictive of better self-care and (metabolic) control but the association is modest(metabolic) control but the association is modest

Discussing emotional and peer group conflictsDiscussing emotional and peer group conflicts Teaching problem solving strategies for dealing Teaching problem solving strategies for dealing

with dietary indiscretions, illness, hypoglycemia, with dietary indiscretions, illness, hypoglycemia, sports, smoking, alcohol, drugs and sexual health sports, smoking, alcohol, drugs and sexual health

(continued)(continued)

SummarySummary

Negotiating targets, goals and priorities Negotiating targets, goals and priorities and ensuring that the tasks taken on by and ensuring that the tasks taken on by the adolescent are understood, accepted the adolescent are understood, accepted and achievableand achievable

Understanding that omission of insulin is Understanding that omission of insulin is not uncommon. The opportunity should be not uncommon. The opportunity should be grasped for non-judgemental discussion grasped for non-judgemental discussion about thisabout this

Developing strategies to manage transition Developing strategies to manage transition to adult servicesto adult services

What do Adolescents Seek in Transition to Adult Care Court J Outpatient –based transition

services for youth Pediatrician 1991;18:15-56.

100 adolescents-mean 20.5yr (17-27)-left RCH clinic1-5 yr prior-

70% response rate to non validated questionnaire

Ideal age for transition-17-20 yrs(53%);up to 25 yr (35%)

Prioritized privacy, promptness, confidentiality, trust & informality-”care giver you like and get to know”

What do Adolescents Seek in Transition to Adult Care(2)

Eiser et al 1993-clinic for <25yr olds-patients indicated helpful if clinic could have been visited before transfer of care-seek co-ordination between pediatric and adult care giver

Pediatricians emphasize “school progress & family relations” vs.”exercise and blood glucose control” by Physicians

What do Adolescents Seek in Transition to Adult Care(3)

Pacaud et al 1996 –postal quest. For 135 patients-50% expressed difficulty with transition due to delay, loss of regular F/U.Concerns at insecurity,less information, less interest, more efficient blood sampling.

Summary:Paucity of Data

Principles of Successful Transition Gradual preparation of youth and family Choice of “ideal time” for transfer may

vary e.g choice of college vs work force Introduce concept of transition in mid –

late puberty to allow sufficient time for concept of eventuality of Tx.

Personality, independence, physical and emotional maturity rather than age alone must be the determining criteria.

Principles of Successful Transition(2) Continuum of environment (large

group/academic center) Good working relationship between

involved care givers. CONSIDER CREATING

ADOLESCENT/YOUNG ADULT CLINIC PROVIDE INFORMATION ON

EMERGENCY/TELEPHONE ADVICE ENCOURAGE INDEPENDENCE/AUTONOMY

AND RE-INFORCE CONTROL VS. COMPLICATIONS

OUTCOMES NEGATIVE IMPACT OF DM ON QUALITY OF

LIFE,DISEASE RELATED-CONCERNS AND LIFE SATISFACTION MAY NOT CHANGE WITH AGE,OR GENDER.

RELATIVELY FEW COMPLICATIONS ARE NOTED IN EARLY ADULTHOOD.

INTENSIVE TREATMENT DOES NOT SIGNIFICANTLY CHANGE THESE PATTERNS-DEPRESSED TEENS ARE MORE LIKELY TO BECOME DEPRESSED ADULTS.

INSABELLA G ET AL Transition to young adulthood in youth with T1 DM on intensive treatment-Pediatric Diabetes –in press

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