Training dementia care professionals to help caregivers improve the management of behavioral and psychological symptoms of dementia using the DICE Approach: A pilot study

Most persons living with dementia (PLWD) exhibit behavioral or psychological symptoms of dementia (BPSD) over the course of the illness. The DICE Approach (DICE) is a framework that enables caregivers to identify, evaluate, and manage BPSD. This pilot pre-post test study examined the effects of DICE training on dementia care professionals' self-efficacy, knowledge, and attitudes regarding care of patients with BPSD. Participants underwent either in-person DICE training or, during the pandemic, online training. Case consultations were offered as additional learning opportunities in challenging situations. Of 134 participants in the trainings, 122 (91.0%) provided survey data for one or more instruments before and after training. Participants experienced significant improvement in knowledge and attitudes with respect to BPSD and improvement in self-efficacy with respect to helping caregivers respond to BPSD. Training dementia care professionals in DICE can improve their capacity to support caregivers in the management of BPSD.

Alcohol Use During Chemotherapy: A Pilot Study

INTRODUCTION

Alcohol use increases the risk for some cancers and can cause complications during treatment. The prevalence of alcohol use during chemotherapy has not been well documented in current literature. This pilot study aimed to examine self-reported alcohol use during chemotherapy among cancer survivors as a basis for future research and interventions.

METHODS

We surveyed Wisconsin cancer survivors (N=69) who participated in the ongoing population-based research study, Survey of the Health of Wisconsin (SHOW), on alcohol use during chemotherapy.

RESULTS

Of the cancer survivors who reported receiving chemotherapy, 30.4% (N=21) reported consuming alcohol while receiving chemotherapy, and 38.1% (N=8) of those who drank reported complications. Alcohol use during chemotherapy was higher among older adults (age 65+, rate ratio [RR], 1.9; 95% CI, 0.7-4.9), men (RR, 2.7; 95% CI, 1.3-5.4), former and current smokers (former: RR, 1.6; 95% CI, 0.7-3.8, current: RR, 2.5; 95% CI, 1.1-5.8), and those with non-alcohol-related cancers (RR, 2.0; 95% CI, 0.9-4.2.).

CONCLUSION

Alcohol use during chemotherapy is common and may increase the risk of complications. More research is needed to better understand this problem and to design effective interventions.

The Wisconsin Alzheimer's Institute Dementia Diagnostic Clinic Network: A community of practice to improve dementia care

BACKGROUND

The Wisconsin Alzheimer's Institute (WAI) Dementia Diagnostic Clinic Network is a community of practice formed in 1998 as a collaboration of community-based clinics from various healthcare systems throughout the state. Its purpose is to promote the use of evidence-based strategies to provide high quality care throughout Wisconsin for people with dementia. The purpose of this study is to describe the use of a community of practice to facilitate education of healthcare providers on best practices in dementia care, and the implementation of an interprofessional approach to diagnose and manage dementia and related disorders.

METHODS

Cross-sectional study of the members of the WAI's Dementia Diagnosis Clinic Network. Characteristics of clinics and healthcare teams, learners' participation in educational events and educational outcomes were collected from evaluation forms. Number and characteristics of patients seen in the memory clinics were collected from de-identified data forms submitted by members to a centralized location for data analysis.

RESULTS

The clinic network currently has 38 clinics affiliated with 26 different healthcare systems or independent medical groups in 21 of 72 Wisconsin counties. Most (56%) are based in primary care, 15% in psychiatry, and 29% in neurology. Between 2018 and 2021, we received data on 4710 patients; 92% were ≥65 years old, 60% were female, and 92% were white. Network members meet in-person twice a year to learn about innovations in the field of dementia care and to share best practices. Educational events associated with the network are shown to be relevant, useful, and improve knowledge and skills of participants.

CONCLUSION

Communities of practice provide added value via shared best practices and educational resources, continuing education of the health workforce, continuous quality improvement of clinical practices, and adoption of new diagnostic and management approaches in dementia care.

Using academic detailing to enhance the knowledge, skills and attitudes of clinicians caring for patients with behavioral and psychological symptoms of dementia

INTRODUCTION

Approximately 90% of persons with dementia experience behavioral and psychological symptoms of dementia (BPSD) over the course of their illness. Primary care clinicians often provide care as specialty geriatric-medicine or -psychiatry consultation may be difficult to obtain. Academic detailing (AD) is an evidence-based educational approach for engaging and persuading healthcare professionals to make changes in their practice (Avorn 2017). We sought to enhance the knowledge, skills and attitudes of providers' care of patients with BPSD using the AD model in primary care.

METHODS

We implemented AD in an urban clinic serving a largely Black community and a rural clinic serving a large, White community. Each AD visit included didactic content, case discussion, and consultation regarding patients with BPSD. Eleven visits over 18 months are planned for each site. Outcome measures include a 10-item multiple-choice assessment of knowledge and an adaptation of the General Practitioners Attitude and Confidence Scale for Dementia (GPACS-D) (Mason et al. 2019) at baseline before training, and 6 and 18 months, and Likert-scale measurement of acceptability at 6 and 18 months, all self-report.

RESULTS

We present interim data. Five urban and 14 rural providers completed baseline assessments. Providers were mostly White (95%) and Non-Hispanic (100%); 47% were female. Urban and rural providers had similar baseline BPSD knowledge (mean (SD) of correct answers, 5.4 (1.7) for rural, and 5.0 (2.6) for urban). The adapted GPACS-D, where higher score indicates more confidence, showed less confidence (mean score 11.4 versus 16.6, p=0.01) in urban versus rural providers. The overall attitudes score indicate there may be more confidence in treating BPSD at baseline among the slightly older rural providers as compared to their urban colleagues. Thus far, eight of 22 planned AD visits have been completed; 6-month assessments are forthcoming and will be presented.

DISCUSSION

Academic detailing may be a feasible and effective way of increasing self-reported knowledge and skills and improving self-reported attitude of primary care providers responsible for the care of patients with BPSD. The pilot data collected in this study will inform the design of a larger study to measure the impact of AD on patient outcomes.

Effectively training dementia care specialists and other dementia professionals on using the DICE ApproachTM with caregivers to improve the management of behavioral and psychological symptoms of dementia

INTRODUCTION

Most persons living with dementia will exhibit at least one behavioral or psychological symptom of dementia (BPSD) (Kales, et al., 2015). As brain pathology progresses, challenging behaviors can increase in frequency and severity, causing an increase in caregiver stress and burden. Furthermore, BPSD can result in unplanned hospitalizations and unnecessary use of psychotropic medications. Non-pharmacological management of BPSD should be the first line of treatment. The DICE (Describe, Investigate, Create, Evaluate) Approach^TM was developed by experts from the University of Michigan and John Hopkins University, to help caregivers learn how to identify and manage BPSD. This project describes a statewide implementation of the DICE approach with community-based dementia care providers.

METHODS

From September 2017 to April 2020, we held four DICE trainings (three in-person trainings, one web-based training) for Dementia Care Specialists (DCSs) and other dementia care professionals who work directly with family caregivers of people with dementia in Wisconsin. We assessed trainees' knowledge and attitudes from the Dementia Attitudes Scale (DAS) and the Knowledge about Memory Loss and Care test (KAML-C) at baseline of training, immediately after training, and six months after training. Consultations were provided to address challenging cases.

RESULTS

Participants (N=136) in both in-person and online DICE trainings experienced significant changes in knowledge, self-efficacy and attitudes from baseline to post-training (immediately after training) assessments (p<.01) (see Table 2 for details). Narrative feedback from trainees was generally very positive. Trainees used DICE with 165 caregivers who were primarily non-Hispanic white (92%) females (74.4%) from an urban location (68.1%), caring for their spouse (52.7%) (Table 1).

DISCUSSION

By using the DICE approach with caregivers of persons with dementia, Wisconsin's DCSs and other dementia professionals are uniquely positioned to help reduce risks associated with BPSD, including the use of psychotropic medications. Training satisfaction was high, knowledge about BPSD increased, and attitudes improved. The DICE trainings prepared trainees to implement this intervention with 165 family caregivers. A follow-up survey will explore the real-world application of DICE, including barriers to its use and modifications made in communities across the state.

Quality measures in dementia care across a network of memory clinics: An implementation study

BACKGROUND

In 2015 the American Academy of Neurology and American Psychiatric Association updated the Dementia Management Measurement Set from 2009. Out of the nine measures proposed, four have been included by the Centers for Medicare and Medicaid Services (CMS) in their Merit-Based Incentive Payment System, which is used to determine payment adjustments in pay-for-reporting program. In 2018, the Wisconsin Alzheimer's Institute (WAI) developed a process to track the performance of these measures across the WAI Dementia Diagnostic Clinic Network, which consists of 44 statewide clinics across 24 healthcare systems.

METHOD

In September 2018, WAI launched the following implementation strategies to improve adoption of the quality measures: audit and feedback, new de-identified forms, and development of a codebook with definitions and examples on how to fill the new forms. Clinics submit de-identified forms containing demographics, diagnosis and process measures that are used to calculate performance on the quality measures. Descriptive analyses were performed, and performance was calculated according to criteria set by CMS.

RESULT

Over 24 months, 23 clinics have submitted information on 3,247 patients. Early adopters demonstrated a high performance on the measures, but as more clinics participate, the distribution has shown regression to the mean (Table 1). When comparing clinic performance between Oct 2019 - Oct 2020 with CMS benchmarks for 2020, the percentage of clinics performing above the CMS average were: 68% for measure #2; 91% for measure #3; 48% for measure #4; and 86% for measure #5 (Figure). Variations in performances have been attributed to unique characteristics of each clinic, for example, some do not follow-up individuals and only provide recommendations to primary care providers; this lowers their metrics in measures that require management of behaviors or conditions.

CONCLUSION

Implementation of the quality measures across the WAI network has been facilitated by the use of clinical care models that promote interdisciplinary care. Further research is required to explore additional mechanisms that increase participation of clinics, and to develop new data collection methods that can explore the impact of these measures on health outcomes.

Training professional caregivers to screen for report of cognitive changes in persons with intellectual disability

Introduction

By age 60, 60% of adults with Down syndrome (DS) have dementia. Detecting dementia in persons with intellectual disability (ID) can be challenging because their underlying cognitive impairment can confound presentation of dementia symptoms and because adults with ID may have difficulty reporting symptoms. The National Task Group Early Detection Screen for Dementia (NTG‐EDSD) was developed to aid detection of report of cognitive impairment in adults with ID. We implemented an educational curriculum using the NTG‐EDSD and evaluated the impact of the intervention on professional caregivers’ self‐assessed capacity to identify persons with ID and dementia.

Methods

We held five in‐person training sessions for professional caregivers of persons with ID, partnering with various managed care organizations and social services agencies. We assessed knowledge and attitudes at baseline; immediately after training; and 1 week, 1 month, and 6 months after training.

Results

A total of 154 direct care workers, case managers, health‐care providers, and other social services staff attended the trainings. Satisfaction with the NTG‐EDSD training was high; 94% of attendees agreed or strongly agreed that they could use the NTG‐EDSD with their clients. After training, attendees reported a marked increase in confidence in their ability to track various health circumstances and detect functional decline in their clients, although some gains were not sustained over time. As a result of the training, one managed care organization made the NTG‐EDSD a standard part of its assessment of adults with DS starting at age 40.

Discussion

Social services and health‐care professionals can learn to document signs of cognitive decline in adults with ID using the NTG‐EDSD. Attendees were highly satisfied with the training, experienced an increase in confidence in their care of persons with ID, and found the NTG‐ EDSD feasible to use. Because not all gains were sustained over time, booster trainings may be necessary.

Effects of the COVID‐19 pandemic on healthcare and community‐based service use for people living with dementia: Perspectives from dementia care professionals

Background

Dementia care and healthcare delivery systems have changed substantially as a result of the COVID‐19 pandemic (Wang et al., 2020). Experts have identified a number of barriers to health care access for people living with dementia (PLWD) during the pandemic, including difficulty implementing telemedicine practices, discontinuation of home care services, increased caregiver burden and financial hardship (Brown et al., 2020; Greenberg et al., 2020). Assessment of dementia care providers’ perceptions of the change in use of healthcare and community‐based services by PLWD is needed to identify gaps and to improve care for this vulnerable population during the COVID‐19 pandemic.

Methods

We designed an online survey asking about changes to PLWD and caregiver use of 14 healthcare and community‐based services during the COVID‐19 pandemic and about 15 factors that may have contributed to these changes. The survey was distributed to a network of dementia care professionals across the state of Wisconsin between August 28^th and October 9^th, 2020.

Result

A total of 102 individuals completed the survey. Most respondents worked in the Wisconsin Department of Health Services dementia care specialist system, were employed by Aging and Disability Resource Centers (53.5%), identified as female, White race and worked in rural settings. Services most frequently reported as no longer in use included senior center programs, adult day programs, and companion/friendly visitor services, while meal delivery was reported as having increased use by PLWD. Factors identified most frequently as barriers to service use included changes in access to caregiver support/respite services, access to natural supports, compassion fatigue/caregiver burnout and both knowledge of and access to technology/virtual tools.

Conclusion

The results highlight the increased demand for certain services like meal delivery and the need to find alternatives to in‐person enrichment/recreational and caregiver respite opportunities such as senior center and adult day programs that are being used less. Access to and knowledge of technology and increased stress on caregivers and support systems were identified as some of the more frequent barriers to service use, thus allocating resources towards these areas may be particularly impactful towards improving service use for PLWD during the COVID‐19 pandemic.

A Comparison of Self- and Proxy-Reported Subjective Sleep Durations With Objective Actigraphy Measurements in a Survey of Wisconsin Children 6-17 Years of Age

Children's sleep quality and duration are important to overall development, health, and wellbeing. However, measuring children's sleep is challenging, especially in situations where objective assessment is impractical. This study aimed to assess age and proxy effects in comparing subjective sleep duration with objective measures, in a community-based sample of Wisconsin children (aged 6-17 years), recruited from 2014-2017. The sample participants had a mean age of 11.4 (standard deviation, 3.3) years and 52% of them were male. We used linear mixed effects models to test for age effects in proxy- and self-report groups separately, and a quasiexperimental regression discontinuity approach to compare subjective sleep duration with objective actigraphy estimates across proxy- and self-report groups. We found evidence of systematic overestimation of sleep duration when using subjective measurements but did not find evidence of age effects in either group. Based on these analyses, we found evidence of differential overestimation by proxy- or self-report condition. Proxy reporters overestimated sleep duration by 2.3 hours (95% confidence interval: 2.2, 2.4), compared with 1.0 hour (95% confidence interval: 0.7, 1.2) for self-reporters. These findings suggest that proxy- versus self-reporting conditions are an important consideration when designing a study, and that it might be beneficial to reduce the age at which children self-report.

Prescribed Opioid Use in Wisconsin 2008-2016: Findings From the Survey of the Health of Wisconsin

BACKGROUND

The opioid epidemic is a national crisis. The objectives of this report were to describe prescription opioid use in Wisconsin from 2008 through 2016 using unique populationrepresentative data and to assess which demographic, health, and behavioral health characteristics were related to past 30-day prescribed opioid use.

METHODS

Data were obtained from the Survey of the Health of Wisconsin (SHOW), a statewide representative sample of 4,487 adults. Prescription medication use was ascertained via in-person interviews that included an inventory of all prescription medications used by the respondent in the past 30 days. The data were weighted to represent the adult population of Wisconsin, aged 21 to 74. Chi-square, logistic regression, and descriptive statistics were used to analyze data.

RESULTS

From 2008 to 2016, 6.4% (95% CI, 5.5-7.3) of adults age 21 years or older reported using a prescribed opioid in the past 30 days. Hydrocodone was the most prescribed opioid class followed by oxycodone. People 50 years of age and older, self-identified black or Hispanic, urban dwellers, those with a high school education or less, and those having incomes below 200% of the federal poverty level (FPL) reported significantly higher rates of prescribed opioid use relative to others. Participants reporting physician-diagnosed drug or alcohol abuse, current smokers, and those currently suffering from depression also reported significantly higher use.

CONCLUSION

These data from 2008-2016 demonstrate concerning levels of prescription opioid use and provide data on which population groups may be most vulnerable. While policies and clinical practice have changed since 2016, ongoing evaluation of prescribing practices, including consideration of behavioral health issues when prescribing opioids, is called for.

1015. Antibiotic use and indications in a community sample of adults in Wisconsin

Background

There is significant inappropriate and overuse of antibiotics in the United States. We describe patterns of self-reported actual use of antibiotics and indications in Wisconsin adults.

Methods

The Survey of the Health of Wisconsin (SHOW) is an annual health study of a wide range of health determinants and outcomes among a population-based sample of residents with targeted recruitment of underrepresented minorities. In 2016, SHOW initiated WARRIOR (Winning the War on Antibiotic Resistance), an ancillary study that assessed actual antibiotic use and indications among adults. Antibiotics were grouped by pharmacologic class, and indications were grouped into clinical categories. Descriptive statistics and logistic regression were used to examine factors associated with antibiotic use.

Results

Overall, 756 adults [435 female and 321 male; mean (SD) age=54.2 (16.5)] were recruited, and 256 (33.5%) reported antibiotic use in the past year. Females (OR=1.87, 95% CI: 1.29, 2.70), people with current comorbidities or history of certain health conditions (OR=2.04, 95% CI: 1.23, 3.39), and people with a mental health or developmental condition (OR=1.93, 95% CI: 1.33, 281) were statistically significantly more likely to report antibiotic use. BMI (kg/m2) was slightly higher among antibiotic users (31.2) than nonusers (29.8; P = 0.064). Diabetes, heavy drinking, and smoking history were not correlated with antibiotic use.

Top antibiotic classes used were penicillins (31%), macrolides (12%), first-generation cephalosporins (9%), tetracyclines (8%), quinolones (7%), and nitroimidazoles (3%). Top indications reported were upper respiratory infection (URI; 32.3%), dental condition or procedure (21.0%), surgery (12.6%), lower respiratory infection (11%), urinary tract, bladder, or kidney infection (7%), skin or soft-tissue infection (6%), and insect bite or insect-borne infection (6%).

Conclusion

Antibiotic use varies among Wisconsin adults, and certain groups are more likely to have used antibiotics in the last year. The top two reported indications for antibiotics were categories with known high rates of inappropriate (e.g., URI) and prophylactic (i.e., dental) prescribing. Further studies are needed to determine specific opportunities to reduce antibiotic use in Wisconsin.

Disclosures

All authors: No reported disclosures.

The trajectory of IGF-1 across age and duration of type 1 diabetes

BACKGROUND

Individuals with type 1 diabetes may have low IGF-1, related to insulinopenia and insulin resistance. There are few longitudinal studies of IGF-1 levels to establish its pattern in type 1 diabetes with duration and age, and to examine whether IGF-1 tracks within individuals over time. We examine age and duration trends, and the relationship of IGF-1 to gender, glycaemic control, insulin level and other factors.

METHODS

Participants in the Wisconsin Diabetes Registry Study, an incident cohort study of type 1 diabetes diagnosed May 1987-April 1992, were followed for up to 18 years with IGF-1 samples up to age 45 for women and age 37 for men.

RESULTS

IGF-1 is lower with type 1 diabetes than in normative samples. Although, the pattern across age resembles that in normative samples with a peak in adolescence and slow decline after age 20, the adolescent peak is delayed for women with type 1 diabetes. There was low to moderate tracking of IGF-1 within an individual. Higher insulin dose was associated with higher IGF-1 as was puberty, and female gender. Adjusted for these factors, IGF-1 declined rapidly across early diabetes duration. Lower HbA1c was most strongly related to higher IGF-1 at Tanner stages 1 and 2.

CONCLUSIONS

IGF-1 is low in type 1 diabetes, with a delayed adolescent peak in women and is especially influenced by glycaemic control in early and pre-adolescence. High variability within an individual is likely a challenge in investigating associations between IGF-1 and long-term outcomes, and may explain contradictory findings.

Managing type 1 diabetes: trends and outcomes over 20 years in the Wisconsin Diabetes Registry cohort

CONTEXT

The Wisconsin Diabetes Registry Study is a Wisconsin cohort of patients with type 1 diabetes, who were diagnosed in 1987-1992 and actively followed. The study provides patients and health care professionals with better prognostic information and helps identify aspects of diabetes management that need improvement.

OBJECTIVE

To describe diabetes management and acute and chronic complications from the time of diagnosis.

DESIGN AND SETTING

All incident cases diagnosed at age <30 in 28 counties were eligible and 590 enrolled. A baseline interview, blood sample kits, biannual/annual questionnaires and study examinations at 4, 7, 9, 14, and 20 years duration were administered.

MAIN OUTCOME MEASURES

Diabetes management indicators, general health, and acute and chronic complications.

RESULTS

Glycemic control was poor in adolescence, but improved with age. A high percentage of individuals do not meet treatment standards for blood pressure and lipid profile. Self-reported health deteriorated with age, and body mass index was similar to that of the general US population. Chronic complications were present at 15-20 years, but tended to be relatively mild.

CONCLUSION

There is room for improvement in diabetes management, especially in meeting goals for blood pressure and lipid profile. Nonetheless, individuals with type 1 diabetes can be offered a more optimistic prognosis than in the past.

Poor glycemic control is associated with low BMD detected in premenopausal women with type 1 diabetes

SUMMARY

The etiology of bone fragility in individuals with type 1 diabetes is unknown. This study demonstrated that bone turnover favors resorption and that poor glycemic control is associated with low bone mineral density (BMD) and low bone turnover, in premenopausal women with type 1 diabetes. The results could inform future interventions.

INTRODUCTION

Low BMD and fracture may be complications of type 1 diabetes. We sought to determine the roles of bone turnover and glycemic control in the etiology of low BMD.

METHODS

Premenopausal women from the Wisconsin Diabetes Registry Study and matched controls were compared (n = 75 pairs). Heel and forearm BMD were measured, and hip and spine BMD were measured in a subset. Markers of bone formation (osteocalcin) and resorption (NTx), and glycemic control (HbA1c) were determined.

RESULTS

Age ranged from 18 to 50 years with a mean of 28, and 97% were Non-Hispanic white. Among women with diabetes, mean disease duration was 16 years and current HbA1c was 8%. Compared to controls, women with diabetes had a high prevalence of previous fracture (37% vs. 24%) and low BMD for age (heel or forearm: 49% vs. 31%), low heel and forearm BMD, and low osteocalcin levels. Levels of NTx were similar, suggesting uncoupled turnover favoring resorption. Poor glycemic control was associated with low BMD at all bone sites except the spine, and with low osteocalcin and NTx levels.

CONCLUSIONS

Optimal glycemic control may prevent low BMD and altered bone turnover in type 1 diabetes, and decrease fracture risk.

Increases in central aortic impedance precede alterations in arterial stiffness measures in type 1 diabetes

OBJECTIVE

Increased pulse pressure has been associated with increased cardiovascular risk in individuals with diabetes. Changes in central aortic properties can increase central pulse pressure and may adversely affect microvascular perfusion and cardiac performance. This study was performed to define early changes in central arterial properties in a group of young individuals with type 1 diabetes.

RESEARCH AND DESIGN METHODS

Seventeen individuals with type 1 diabetes and their nondiabetic control subjects who were participating in the Cardio-Diab Study had arterial stiffness and pulsatile hemodynamics measured with calibrated tonometry and pulsed Doppler. Aortic characteristic impedance (Z(c)) was calculated from the ratio of change in carotid pressure and aortic flow in early systole. Pulse wave velocity (PWV) was assessed from tonometry and body surface measurements.

RESULTS

Duration of type 1 diabetes was 15.3 +/- 0.7 (mean +/- SD) years. In type 1 diabetic subjects, central pulse pressure was elevated (45 +/- 11 vs. 36 +/- 10 mmHg in control subjects, P = 0.02), as was peripheral pulse pressure (54 +/- 13 vs. 43 +/- 10 mmHg, P = 0.002). Z(c) was elevated in type 1 diabetes (179 +/- 57 vs. 136 +/- 42 dynes x s/cm5 in control subjects, P = 0.004), whereas PWV was not different (5.9 +/- 0.9 vs. 5.9 +/- 0.7 m/s in type 1 diabetic vs. control subjects, respectively; NS). There was a moderate correlation between Z(c) and urinary albumin excretion (coefficient 0.39, P = 0.02).

CONCLUSIONS

Z(c) appears to be increased early in type 1 diabetes, before elevation of PWV and is associated with higher pulse pressure, which may contribute to renal microvascular damage in diabetes.

Self-rated health among young people with type 1 diabetes in relation to risk factors in a longitudinal study

Care for type 1 diabetes mellitus should both alleviate the physical complications of the disease and improve overall quality of life. The Wisconsin Diabetes Registry, comprising a population-based cohort that is followed longitudinally from diagnosis of type 1 diabetes, provided the authors with a unique opportunity to examine quality of life in children, adolescents, and young adults with type 1 diabetes and its relation to both sociodemographic and clinical risk factors. The authors analyzed data from 1987-2002 with a mean of 10.2 years' duration of diabetes (n = 569). They used ordinal-scaled self-rated global health as a measure of quality of life. In this paper, they propose a random-effects model for drawing inferences on individuals regarding the relation of longitudinally measured quality of life to multiple risk factors. Results showed that male gender, higher parental socioeconomic level, younger age at diabetes diagnosis, shorter diabetes duration, no hospitalization in the preceding 6 months, lower glycosylated hemoglobin level, and questionnaire responses by a person other than the subject were independently associated with better reported health. The authors found that individuals varied in their reported health even after adjustment for all identified risk factors. This could imply either that there is variability in perception even with the same health status or that there are independent unmeasured risk factors for poor health in persons with type 1 diabetes.

Risk factors for frequent and severe hypoglycemia in type 1 diabetes

OBJECTIVE

To determine the risk of frequent and severe hypoglycemia and the associated demographic and clinical risk factors.

RESEARCH DESIGN AND METHODS

Demographic and diabetes self-management factors were measured in 415 subjects followed prospectively for 4-6.5 years of type 1 diabetes duration as participants in a population-based incident cohort. Blood samples were collected up to three times yearly to test glycosylated hemoglobin (GHb) levels. Reports of frequent (2-4 times/week) and severe (lost consciousness) hypoglycemia as well as other diabetes self-management data were collected by questionnaires.

RESULTS

Frequent hypoglycemia was common (33 and 35% of participants reported this on the 4- and 6.5-year questionnaires, respectively), whereas severe hypoglycemia occurred much less often. Better glycemic control (odds ratio [OR] 1.3 per 2% decrease in GHb, 95% CI 1.1-1.5) and more frequent self-monitored blood glucose (1.5 per blood glucose check, 1.3-1.7) were independently related to frequent hypoglycemia. The association of frequent hypoglycemia with intensive insulin therapy increased with age. Better glycemic control (1.5 per 2% decrease in GHb, 1.2-2.0) and older age were related to severe hypoglycemic reactions. No sociodemographic factors other than age increased the risk of hypoglycemia.

CONCLUSIONS

Frequent hypoglycemia was common in a population representing the full range of glycemic control in the community. Intensive insulin management and blood glucose monitoring independently predicted frequent but not severe hypoglycemia. This information may be useful for updating patients such that minor changes in diabetes management might decrease the daily burden of this condition while maintaining intensive insulin therapy.

Risk factors for hospitalization in a cohort with type 1 diabetes. Wisconsin Diabetes Registry

The authors investigate the postonset hospitalization rate and risk factors during 1987-1994 in Wisconsin, in a population-based, incidence cohort followed from diagnosis of Type 1 diabetes mellitus at ages 0-29 (n = 577). The overall rate was 8.9 +/- 0.60 (standard error) per 100 person-years of diabetes, whereof 5.7 was due to hyperglycemia, 1.9 to hypoglycemia, and 1.3 to other and undetermined causes. Major risk factors for hospitalization were longitudinally measured glycosylated hemoglobin level (rate ratio = 1.5 per 2% increase, 95% confidence interval 1.4-1.7), black/other race (rate ratio = 1.9, 95% confidence interval 1.0-3.6), diagnosis in a non-university-based setting (rate ratio = 1.9, 95% confidence interval 1.2-3.2), female sex (rate ratio = 1.5, 95% confidence interval 1.0-2.4 at age 11), age in males (rate ratio = 0.6, 95% confidence interval 0.4-0.8 per 5-year increase), and public or no insurance up to 18 months postdiagnosis (rate ratio = 2.2, 95% confidence interval 1.1-4.4). For individuals less than 18 years, "black/other race" was replaced in the model by "having other than two biologic parents in the home" (rate ratio = 2.0, 95% confidence interval 1.1-3.5). Hence, hospitalization is common in children, adolescents, and young adults with diabetes, primarily for problems with glycemic control.