Diabetes Mellitus and Quality of Life
World Small Animal Veterinary Association World Congress Proceedings, 2014
Stijn J.M. Niessen, DVM, PhD, DECVIM, PGCertVetEd, FHEA, MRCVS
Senior Lecturer Internal Medicine, Royal Veterinary College, University of London, London, UK; Research Associate, Newcastle Medical School, Newcastle, UK; Consultant, Veterinary Information Network, Davis, CA, USA

Whenever diabetes mellitus (DM) is diagnosed in a pet, the life of that pet changes significantly. However, the life of the owner of that pet also changes significantly. Instead of merely walking and/or cuddling their pet, owners suddenly have to inject their cat or dog and deny them the dinner left-overs they have been giving for 9 years. From a practical point of view, owners now also need to be at home twice daily at a fixed time for food and insulin. Going away on holiday now requires sorting out a place for their cat or dog that also manages to maintain the insulin and food regimen. And then there are the costs involved, especially in terms of blood glucose monitoring and possibly prescription food...Nevertheless, once treatment for DM has been initiated, clinicians often primarily focus on the biological side of things, i.e., control of blood glucose levels. Indeed, for many clinicians treatment success is often solely defined as obtaining "close to normal" serial blood glucose values and/or "normalising" fructosamine in conjunction with improvement in clinical signs (polyuria, polydipsia, polyphagia and weight loss). No wonder that recent data suggest that up to 30% of all diabetic pets have their treatment ceased within one year after diagnosis, which basically equates to elective euthanasia. This appalling fail rate will not just be due to lack of biological success.

In light of the above, when evaluating diabetic treatment success in dogs (and cats), we should probably also include paying a lot more attention to these earlier mentioned psychological and social effects of the impact of DM and its relatively complex daily treatment regimen, as well as the owner's perceptions of the disease and its management. Indeed, should an owner experience a particularly negative impact on his or her quality of life (QoL) or the QoL of their pet as a result of the DM, a decision to cease therapy may be the inevitable outcome regardless of the apparent clinical success.

In recent years novel research involving hundreds of veterinary practices and hundreds of diabetic pet owners has started to unravel the intricacies of the quality of life of the diabetic pet and the quality of life of the owner of such pet. We can now start to use this knowledge to our advantage to improve our short-term as well as long-term success rates when it comes to DM treatment. The table below shows all the areas in life that were identified to be impacted after a diagnosis of DM in a dog. These areas were identified by conducting hundreds of interviews with diabetic pet owners around the world. The order of the items indicates how important the items are thought to be for diabetic dog owners, with the top items being perceived to most negatively impacting QoL of a diabetic dog and his or her owner. The QoL impact score (final column) represents a simplification of a validated scientific measure that quantifies how severe the impact is perceived to be: the more negative the number, the more negative the impact and the bigger the need for the veterinary team to try to influence this area.

Item N°

Abbreviation

Item

QQL impact score

1

Worry

Do you worry about your pet's diabetes?

-6

2

Friends & family

Do you ever choose not to leave your pet to stay with friends or family because of the diabetes?

-6

3

Worry vision

Do you ever worry about your pet getting vision problems due to cataracts or did you worry about this prior to your pet suffering from such problems?

-6

4

Boarding kennels

Do you ever choose not to put your pet into boarding kennels because of the diabetes?

-5

5

Worry hypo

Do you ever feel worried about your pet suffering from an episode of low blood glucose?

-5

6

Social life

Do you ever find you need to fit your pet's diabetes into your social life (e.g., carrying needles, food, insulin, providing food on time)?

-5

7

Costs

Do your ever worry about how much money your pet's diabetes costs you and your family?

-4

8

Future care

Do you ever feel worried you will not be able to take care of your pet in the future because of the diabetes?

-4

9

Working life

Do you ever find you need to fit your pet's diabetes into your working life? (E.g., having to make special arrangements when you need to work late or need to start working earlier?)

-4

10

Restrict your activities

Do you ever find the diabetes of your pet restricts or limits what you are doing or what you want to do, like going on holidays, away for weekends, away for the day/night, working?

-4

11

Worry DKA

Do you ever feel worried about your pet suffering from an episode of ketoacidosis?

-4

12

Pet's moods

Do you think the diabetes affects your pet's moods?

-4

13

Active day

Do you ever choose not to take your pet with you on an active day (e.g., walking longer distances, going to the beach, etc.) because of the diabetes?

-4

14

More control

Do you ever feel you want to take more control of the diabetes on your own, without the help from vets and other people?

-4

15

Pet unwell

Does your pet ever feel unwell, tired or in any other way negatively affected since treatment with insulin was started?

-3

16

Injections restrict life

Do you feel your life is restricted because of the daily insulin injections?

-3

17

Drinking

Does your pet still drink more than before the diagnosis?

-3

18

Urinate

Does your pet still urinate more than before the diagnosis?

-3

19

No treats

Do you ever feel you want to give your pet treats but you don't because of the diabetes?

-3

20

Hungry

Is your pet still hungrier than before the diagnosis?

-3

21

Weight loss

Is your pet still losing weight since treatment has begun?

-2

22

Injection worries

Do you ever worry about whether you have given the insulin correctly?

-2

23

Hypoglycemia

Does your pet ever show signs of a low blood sugar (e.g., wobbliness, collapse)?

-2

24

Injection pain

Does your pet ever react annoyed or in pain when injected?

-2

25

Resent inject

Do you resent having to give your pet insulin injections?

-1

26

Play less

Are you less inclined to play with your pet now that he/she has diabetes?

-1

27

Special bond

Do you feel you have a more special bond with your pet now that you are managing his/her diabetes?

+5

28

Play more

Are you more inclined to play with your pet now that he/she has diabetes?

+3

29

Extra things

Do you ever give your pet extra things, like snacks, treats, extra attention or extra walks because of the diabetes?

+3

The need for a change in our approach to the diabetic patient has been illustrated by the fact that a discrepancy exist between 81% of owners reporting a "good" QoL when simply asked "Is the QoL of you and your pet good despite the diabetes?" yet on the other hand the fact that 84% of those same owners nevertheless report a negative impact on QoL when asked about the specific aspects of life with a diabetic pet above.

Not all is bad though, since we, as clinicians, can use these data to our advantage. As an example, worry about the diabetic dog's vision appeared to exert a relatively marked negative influence on QoL (psychological score -6). How best to prevent cataract formation in diabetic dogs remains incompletely understood. Although optimal glycemic control and limited fluctuations in blood glucose concentrations might decrease its overall incidence, the diabetic complication still occurs in 80% of dogs within 470 days of DM diagnosis. Therefore informing owners better and preemptively about the success of currently available cataract treatment options, especially in terms of quality of life (e.g., phacoemulsification ± lens replacement) might aid at least in reducing the negative impact exerted by the worry surrounding this issue. We could also proactively offer owners to also teach people in their environment to give insulin injections to their diabetic pet, improving several areas on the list of negative impact, including 'friends & family,' 'boarding kennels,' 'social life' and 'working life.' And is it always necessary to give the insulin exactly every 12 hours in every single patient? In a particular pet-owner combination the social advantages can be great to deviate from this dogma, as long as the activity-profile of the insulin in that particular patient allows a variation in the timing (which it often does). If the duration of insulin action in that patient is 10 hours, surely, owners do not need to wait until 9 pm and postpone their 'going-out-for-dinner' plans and give the insulin at 7pm?

The top ten negative items for diabetic cats and their owners is shown below:

  

Diabetic cats and owners

QoL impact score

1

'Boarding kennels'

-5

2

'More control'

-4

3

'Friends & family'

-4

4

'Worry'

-4

5

'Worry hypo'

-4

6

'Social life'

-3

7

'Costs'

-3

8

'Working life'

-3

9

'Pet's moods'

-3

10

'Restrict your activities'

-3

A remarkable difference with dogs is the prominent position of "more control," which features high on the diabetic cat owner list, yet only occupies the 14th place on the list of negative impact areas of diabetic dog owners. This might represent a genuine difference in attitudes and desires between dog and cat owners, or the fact that more recently changes in treatment philosophies and protocols have occurred predominantly in the field of feline DM. Indeed, compared to the situation in canine diabetes mellitus, in recent years owner involvement in blood glucose measurement and achievement of diabetic remission in cats might have been more explicitly promoted by veterinary and non-veterinary sources and might have led to a higher proportion of diabetic cat owners desiring and indeed assuming more control over the management of their pet's diabetes mellitus. It is therefore our duty as the veterinary team to identify this need of a diabetic pet owner and find solutions for it, which might include the initiation of home blood glucose monitoring.

Interestingly, nine of the 10 items in the feline and all 10 of the canine top 10 negative impacts were mostly associated with the owner's QoL rather than with the pet's QoL, emphasising once again we should pay attention to this side of the story. Interestingly, in both the diabetic dog and cat population items specifically related to injecting insulin did not feature in the top 15 most negatively impacting items. In fact the first item of this nature for diabetic dogs documented the restriction exerted by insulin injections on the owner's life rather than the actual injecting itself, while items such as "injection worries," "injection pain" and "resent injections" featured even lower on the list.

In both the diabetic dog and the diabetic cat population a discrepancy seems to be present between the perceived high impact of worrying about hypoglycemia ('worry hypo': -5/-4) and the perceived lower impact of hypoglycemia actually occurring ('hypo': -2). It is understandable that owners are concerned about the possible occurrence and consequences of overdosing and hypoglycemia. Additionally, 40% of diabetic dog owners reported hypoglycemic episodes to possibly have been reported to occur at least occasionally in diabetic dogs. A similarly high prevalence has been found in a diabetic cat study (35%). The veterinary team should therefore probably intensify any efforts to decrease the frequency of such episodes occurring, as well as promote owners' confidence in recognizing hypoglycemia and adequately managing it. Home blood glucose monitoring might also help with this, although it would be wise to ensure this extra responsibility is not perceived to be a detrimental burden by a specific diabetic pet-owner combination.

Finally, a recent study, using the DIAQoL-pet, a QoL-tool for diabetic pets and their owners, based on the questions above, could not document that home blood glucose monitoring was consistently associated with an overall decrease in hypoglycaemia-associated anxiety of diabetic cat owners. This consolidates the logical concept that the "average diabetic pet owner" does not exist and that a careful consultation of each individual pet-owner combination about the specifics of DM management is indicated, rather than implementing a practice-wide standard protocol which is imposed on every single case. Using a standardised approach of questioning, possibly by using the tool based on the specific questions above, will help this process to individualise diabetic pet care in your practice. The whole veterinary team, and in particular, the veterinary nurse could play an extremely essential role in this process and it seems only logical to have nurses be involved in the ongoing QoL assessment of this important patient group, as well as their owners.

References

1.  Niessen SJ, Powney S, Guitian J, Niessen AP, Pion PD, Shaw JA, Church DB. Evaluation of a quality-of-life tool for cats with diabetes mellitus. J Vet Intern Med. 2010;24(5):1098–1105.

2.  Niessen SJ, Powney S, Guitian J, Niessen AP, Pion PD, Shaw JA, Church DB. Evaluation of a quality-of-life tool for dogs with diabetes mellitus. J Vet Intern Med. 2012;26(4):953–961.

  

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Stijn J.M. Niessen, DVM, PhD, DECVIM, PGCertVetEd, FHEA, MRCVS
Royal Veterinary College
University of London
London, UK


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