We must ensure sensory loss is not a barrier to good diabetes care

We all need to communicate with other people. Communicating our needs, wishes and feelings is vital, not only to maintain our quality of life, but also to preserve our sense of identity and to highlight what is important to us. We tend to think of communication as talking, but, in fact, it consists of much more than that. A large proportion of our communication is non-verbal, including gestures, facial expressions and touch. In health care, it is well recognised that non-verbal communication is on the whole more important to consider, especially when we have to care for a person who has an impairment related to the ability to use “normal” language skills.

Just over 12 months ago, NHS England published the NHS Five-year Forward View document, which set out the challenges we face and encouraged us to “radically upgrade” our health services in prevention and public health (NHS England, 2014).

We have to consider the importance of sensory impairments when assessing our patients, when providing education sessions and when supporting people to have the best diabetes outcomes. Without appropriate support we run the risk of not having the knowledge or skills to achieve this “radical upgrade”.

Sensory loss
As diabetes practitioners we are all too aware of the long-term complication of sight loss; however, do we ever consider the other main senses: hearing, taste, touch and smell. Many people we come into contact within in our diabetes service may have difficulties with one or more of their senses, which will impact on their quality of life and the ability to get from the most from their consultations.

Sight
There are just over 84 000 registered blind and partially sighted people of working age in the UK (RNIB, 2014). However, according to the government’s Labour Force Survey, around 185 000 people of working age in the UK have a self-reported “seeing difficulty” (Hewett and Keil, 2014). This includes people with sight loss that is not eligible for registration, but which is still of sufficient severity to affect their everyday lives. It also includes those who do not consider themselves as disabled.

We are all aware diabetes is the leading cause of sight loss among the working-age population in the UK (Liew, 2014). This is partly attributable to the increasing incidence of the disease and its causal link with sight loss. Within 20 years of diagnosis nearly all people with type 1 and almost two thirds of people with type 2 diabetes have some degree of retinopathy (Scalon, 2008)

The risk of developing retinopathy and other diabetic eye diseases is significantly reduced if diabetes is properly managed and people attend regular screening programmes to detect early signs of eye disease (Diabetes UK, 2015a).

Hearing
I have been fortunate to have worked alongside a specialist team specialising in deaf people with mental health issues for the past six years. Seeing the work they do, I have come to recognise there are many barriers to communication and how this impacts some individuals’ understanding of their diabetes. British Sign Language (BSL) is a very visual language; therefore, having a true and accurate explanation and educational session can be difficult for both patient and healthcare professional if the professional does not have the necessary skills.

Within our clinics we often do not have access to specialist qualified signers; therefore, we risk poor communication and difficulties in receiving and giving the correct information in order to have a truly valuable consultation that allows the individual to take control of their condition.

Diabetes UK has worked with Action on Hearing Loss (formerly RNID) to produce information in BSL for the people with diabetes in the deaf community and have produced videos, Understanding diabetes and Diabetes and the body, to support understanding.

Diabetes UK reviewed research undertaken in Austria in 2002 that showed that at least 14% of deaf people have diabetes. People with diabetes who are deaf are more at risk of facing health inequalities in accessing care and are less likely to find accessible information to help better manage their diabetes (Diabetes UK, 2015b).

We should all be working hard collaboratively to reach people who are deaf and have diabetes with appropriate information in an appropriate format to meets their needs.

Taste and smell
The taste of food is detected by taste buds located on top of the tongue. There are five basic tastes: sweet, bitter, sour, salty and savoury. Smell, like taste, is deemed to be a chemical sense. There are hundreds of olfactory receptors or sensory cells in our nasal passage, each of which will bind itself to a different molecular smell feature.

Although not directly a complication of diabetes, we are aware having diabetes can cause lots of taste and smell disturbances due to increased risk of oral candidiasis (thrush) or infections, which lead to taste changes. Frequently, guilt and anxiety can have an impact on the enjoyment of food, which can lead to related depression and anxiety around food choices.

Touch
Neuropathy is the long-term complication that affects the nerves, sense of touch and the ability to feel appropriately. We understand neuropathy can cause significant side effects; however, as diabetes professionals we have to recognise the importance of a cuddle with a loved one or a hand-shake and that these can be impacted by diabetes. Nerves carry messages between the brain and every part of our bodies, making it possible to see, hear, feel and move. Nerves also carry signals that we are not aware of to parts of the body such as the heart, altering the rate it beats at, and the lungs, so we can breathe. Therefore, damage to the nerves can cause problems in numerous parts of the body.

Sensory neuropathy affects the nerves that carry messages of touch, temperature, pain and other sensations from the skin, bones and muscles to the brain. It mainly affects the nerves in the feet and the legs, but people can also develop this type of neuropathy in their arms and hands making touch uncomfortable (Said, 2014).

Motor neuropathy affects the nerves that control movement. Damage to these nerves can lead to weakness and wasting of the muscles that receive messages from the affected nerves.

The loss of autonomic nerve pathways have a major impact on sexual function and erectile dysfunction. We cannot underestimate the emotional impact this could have on the individual.

The challenges
Diabetes professionals can easily list the long-term complications of diabetes without much prompting or thought. However, the sensory loss discussed has a much deeper implication than just another long-term complication.

As our diabetes population ages, we also need to consider the sensory impairment that comes with dementia. People with dementia may have difficulties with accurate or successful language. The inability to communicate pain, discomfort, illness or the side-effects of medication can be quite a challenge. It may be difficult to make sure glasses have the correct subscription to see, their hearing aid is working properly to hear, or that their dentures fit well so they can enjoy their food (Alzheimer’s Society, 2013).

Sensory loss is often a hidden issue. People with these impairments may not recognise them themselves, or it can be thought of as an inevitable part of ageing. However, we must consider these issues during our consultations.

Difficulties with communication can be upsetting and frustrating for the person with diabetes and for those around them, but there are lots of ways to help make sure that you communicate with each other effectively.

The Five Year Forward View includes a national Type 2 Diabetes Prevention Programme (NHS England, 2014). As part of this, a user involvement group will be established in order to ensure the programme takes into account the views of those at risk of type 2 diabetes. Hopefully this expert group will include people with sensory impairment and these particular needs will not be forgotten as they develop these preventive diabetes programmes.