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Teaching Nonvisual Diabetes Self-Care: Choosing Appropriate Tools and Techniques for Visually Impaired Individuals

Ann S. Williams, MSN, RN, CDE

Diabetes is the leading cause of new blindness among American adults between the ages of 20 and 74 years. (Throughout this article, the word "blindness" is used to indicate legal blindness, and the term "visual impairment" is used to indicate any loss of vision that affects a person’s ability to perform important tasks.) It is estimated that among people who have had diabetes for 15 years or more, 40% of those who take insulin and 5% of those who do not take insulin have proliferative retinopathy. An estimated total of 40,000 patients per year develop sight-threatening proliferative retinopathy.¹ Of these, 23,000 are estimated to become blind.²

Proliferative retinopathy is not the only cause of vision loss among people who have diabetes. An estimated 95,000 diabetes patients per year develop macular edema, and cataracts and glaucoma are also increased in people with diabetes.¹ In addition, many people with diabetes have some visual impairment but adequate functional vision much of the time. However, their vision fluctuates, and they become blind at times, such as when their blood glucose level is high. Further-more, people who have pre-existing blindness, such as from congenital blindness, retinitis pigmentosa, age-related macular degeneration, or other causes have the same chance of developing diabetes as anyone else in their age and ethnic groups. Therefore, there seems to be a substantial population in the United States of people who are living with both diabetes and blindness, although we do not have adequate recent estimates because "there is a need for national population-based data on the prevalence and incidence of loss of vision."^{1, p. 293}

The functional needs of people with diabetes and visual impairment have not been ignored. In the past 10 years, diabetes educators and diabetes equipment manufacturers have introduced many new tools and techniques for blind people. As a result, many visually impaired and blind people who have diabetes now perform all of their routine diabetes self-care tasks independently.

Still, copious private correspondence and phone calls received by this author in the position of Chair of the Visually Impaired Persons Specialty Practice Group of the American Association of Diabetes Educators indicate that many more visually impaired and blind people with diabetes are denied the opportunity to learn this set of necessary skills. Many practicing health-care professionals seem to be either unaware of the existence of blindness rehabilitation services and equipment³ or not familiar enough with nonvisual tools and techniques for diabetes care to recommend their use.

This article is an attempt to help close the information gap. It does not include comprehensive information about all of the current adaptive tools and techniques, since this information is available elsewhere.⁴ Rather, this article was written for health-care professionals who are unfamiliar with nonvisual diabetes self-care. It describes a process by which they can begin to choose appropriate adaptive tools and techniques for individuals with diabetes and visual impairment who ask to learn how to continue to care for themselves.

Referral to Blindness Rehabilitation
Before beginning to assess a patient’s abilities and to plan for teaching nonvisual diabetes self care, it is important to ensure that anyone who has severe visual impairment or blindness has had the opportunity to receive blindness rehabilitation services. This will enable visually impaired people to learn the concrete skills necessary for living as active and involved a life as they wish. It will also help them to adjust emotionally to the many losses that can accompany new visual impairment (e.g., loss of role in the family, loss of independent transportation, loss of visually pleasurable experiences, loss of body language communication). For an in-depth discussion of the losses that accompany vision loss and ways to address them, see Carroll’s Blindness: What It Is, What It Does, and How to Live With It.⁵ This text is available at most large public libraries.

Any health-care professional who works with visually impaired and blind people should learn what types of blindness rehabilitation services are available locally. (See accompanying article titled "Blindness Rehabilitation Services.") It is then a simple matter to refer people to any needed services they have not already received.

Nonvisual Diabetes Education:
Subject Areas
If blind people are to be fully equipped to provide diabetes self-care independently, they need to use nonvisual tools and techniques for all self-care tasks for which sighted people rely on vision. A careful assessment of patients’ functional low vision, nonvisual sensory limitations, and memory, as well as knowledge of the range of nonvisual choices available for each necessary task, will allow diabetes care professionals to carefully match tools and techniques to the needs and abilities of each patient.

Diabetes education for sighted people includes teaching specific skills for which sighted people rely on vision in each of the following areas:⁶

• medication management
• blood glucose monitoring
• record keeping
• nutrition management
• foot care
• exercise

The teaching of cognitive material in other areas, such as relationships among nutrition, exercise, medication, and blood glucose levels, is often accompanied by printed material that requires vision to access.

Assessment: Functional Low
Vision, Nonvisual Sensory
Limitations, and Memory
Functional low vision. The numbers that describe visual acuity have limited usefulness in assessing whether a person needs to use nonvisual skills for diabetes self-care tasks. Certainly, a person who has no light perception or who has light perception only will need nonvisual skills. It is very likely that a person whose vision is measured at 20/200 or worse (legal blindness) will also need nonvisual skills, and it is quite likely, though not absolutely certain, that a person whose vision measures 20/100 or better will be able to perform many tasks visually, perhaps using magnification and appropriate lighting.

If a patient has a visual acuity measured between these numbers, however, the numbers themselves do not indicate whether the patient needs nonvisual techniques. Since the vision of people who have diabetes often fluctuates, a measurement of visual acuity that was taken in an ophthalmologist’s office in the middle of the day does not necessarily accurately predict functional visual abilities at the time that a person needs to perform diabetes self-care tasks.

Asking patients direct questions about visual function is a more reliable way to determine the need for nonvisual techniques. The most important question to ask is whether their vision fluctuates, and if so, what it is like at its worst. It is especially helpful to ask patients to describe their vision in terms of the limiting visual factors of the tasks themselves, i.e., whether they can see the lines on the insulin syringe using a syringe magnifier, whether they can see where to place a drop of blood for blood glucose monitoring, and whether they can see the display on a blood glucose meter.

Diabetes patients often have their worst vision either when they first arise in the morning or when their blood glucose level is high, and they often need to monitor blood glucose and administer insulin at such times. Therefore, patients with low vision need to know how to perform diabetes self-care tasks with their vision at its worst. This frequently means that these patients need to use nonvisual skills even when their measured visual acuity indicates substantial residual vision.

Nonvisual sensory limitations. If a patient needs to perform diabetes self-care tasks nonvisually, it is important to be aware of any nonvisual sensory limitations. Again, knowing about functional limitations is more important than knowing an objective measurement. Some of the nonvisual techniques require significant manual dexterity and sensation. Therefore, numbness or stiffness in the hands may limit a patient’s ability to use these techniques. If a person’s ability to use a particular adaptive tool depends on hearing a click, a beep, or a synthetic voice, then it is important to note whether the person can hear those sounds consistently and accurately. Finally, loss of the sense of smell can limit a person’s ability to receive certain nonvisual information.

Memory. It is also very important to be aware of a patient’s ability to retain new information. Learning any new procedures, including nonvisual techniques, can be extremely difficult for a person who has short-term memory loss. Once more, functional considerations are more important than objective measurements. If a patient was taught a particular skill and was able to perform it immediately after learning it, but has completely forgotten it a few days later, and if this is repeated two or three times, then it seems unlikely to be safe for that patient to try to do that task independently, with or without good eyesight.

It should be noted, however, that many people with some short-term memory loss can learn some new procedures with memory prompts and repetition. The closer the new procedure is to a procedure that is already familiar, the easier it is to learn. Using audiotaped instructions and involving family members or friends in helping the patient practice the procedure may also help.

Nonvisual Medication Management
Insulin drawing. Of the many nonvisual insulin measurement devices available, Table 1 lists those most commonly used. To learn about other currently available devices, readers are encouraged to consult other resources.^4,7

To choose the most appropriate device for a particular patient, one should consider:

1. The patient’s need for high or low dosing and for dosing flexibility.
2. The patient’s manual dexterity, manual sensation, and ability to hear a click.
3. The patient’s ability or the health insurer’s willingness to pay an increased ongoing expense.
4. The patient’s ability to learn a new procedure, which may be facilitated by the inclusion of audiotaped instructions.

In Table 1, information about all of these considerations is listed in the "Comments" section for each device.

For many people, more than one device may be appropriate. Keeping in mind that people who have new vision loss often acutely feel their loss of choices and loss of independence, diabetes care professionals should offer any choices that are available. When more than one device could meet a particular need, patients should have an opportunity to hold and try each possible device and choose the one that they like best.

For all of the devices that use a standard syringe and insulin vial, the following precautions are necessary to ensure accurate insulin measurement:

1. The syringe must be placed correctly in the device. Sometimes this is not as obvious tactilely as it is visually. The patient needs to know how to check for correct syringe placement. Gen-erally, an incorrectly placed syringe does not fit snugly in a device and will move around when the plunger is pushed back and forth.

2. When drawing insulin, the syringe should point vertically. Some blind people have difficulty sensing vertical positioning nonvisually. Holding the device against a vertical surface, such as a wall or refrigerator, or placing the elbows on a horizontal surface, such as a table, can help.

3. Patients who need to mix insulins need a method for distinguishing the fast-acting insulin from the slower-acting insulin. One commonly used method is to wrap a rubber band around the fast-acting insulin. A blind person living alone can request that the pharmacist do this.

4. To exhaust any air bubbles when drawing insulin, the plunger should be pulled down and pushed back completely three times before measuring the insulin. If the patient is drawing a mixed dose, this is done only with the first insulin.

5. To avoid accidentally drawing air, the patient needs a way to know when to replace a near-empty vial of insulin. In general, a blind person should not draw the last 50 units from any insulin vial. Therefore, there are 950 usable units of insulin in each vial. By dividing the total daily dose into 950 units, one can calculate how many days a person should use a particular vial. Patients can then count out the number of syringes needed for that number of days and keep them in a separate location. When the syringes have all been used, it is time to start a new vial of insulin. If a patient is using two types of insulin, usually the rapid-acting insulin is used in smaller doses. It may simplify matters to use the above technique for the insulin used in larger doses, and to replace the insulin used in smaller doses on the first of each month, or at some other easily-remembered time.

It is worth noting that, as of this writing, Medicare does not provide coverage for devices that enable a visually impaired person to draw insulin independently. Some private insurance companies do provide such coverage.

Other medication identification. Most blind people who take a small number of medications can recognize their pills tactilely by shape and size. However, people who take two or more pills that are similar in shape and size, or those who take many medications, need to find another system for recognizing their pills.

Several tactile identification systems are possible. One of the simplest is to keep different medications in different sizes and shapes of vials. Many pharmacies, if requested to do so, are willing to consistently package particular medications in particular sizes of vials. Another possibility is to make tactile labels for medication bottles using file folder labels and dimensional fabric paint (available in crafts stores). When patients bring home new medications, the pills can then be transferred to the marked vials. A third possibility is to store different medications in different locations in the home.

Many people, both sighted and blind, find that it is easier to sort and remember multiple medications by using weekly pill boxes. Pill boxes with one bin for each day of the week are widely available in pharmacies. For people who take pills several times each day, pill boxes with four bins for each day, for a total of 28 bins per week, are also available. These may be more difficult to locate. Two suppliers are: Apothecary Products (800-328-2742) and Maxi Aids (800-522-6294).

Blood Glucose Monitoring
Of the blood glucose monitoring systems currently available in the United States for nonvisual use, only the One Touch Profile offers a system that has both a simple, no-wipe procedure and an easy-to-use, reliable method for placing a blood drop on the strip. Since these attributes provide significant advantages for most blind users, other available systems are not discussed here. To learn about other currently available systems, readers are encouraged to consult other resources.^4,7

At the time of this writing, three companies make plug-in synthetic voice adapters for the One Touch Profile. They are: The Lighthouse (800-829-0500), LS&S (800-468-4789), and Science Products for the Blind (800-888-7400). A fourth company, Myna Corporation (508-768-9000), expects to release a synthetic voice for the One Touch Profile in the near future.

All of these voice attachments plug into the computer portal on the side of a standard One Touch Profile, are simple to use, and have clear voices that announce all the messages that appear on the visual meter display. They all can function using either batteries or an AC adapter. They are similar in price, ranging from $200 to $250 when purchased from the manufacturer, and all are covered by Medicare for people who use insulin under code #EO609. The only major functional difference is that the speech of the Lighthouse voice is somewhat slower, which may be better for someone who has hearing problems.

The limiting factor in the use of an audio-adapted One Touch meter is the ability to place an adequately large drop of blood in the right place on the strip. Two techniques can help to accomplish this easily: using either raised marks on the strip holder or the Sure Drop. These are described below.

For people who have good sensation in their fingers, one can place raised marks on the strip holder of the One Touch meter. Using dimensional fabric paint, one places a raised bump to the right and the left of the test spot on an inserted strip. For people with low vision, it helps to use a bright, contrasting color such as yellow or white and also to outline the strip insertion opening (see Figure 1). A visually impaired person can then use these raised marks to place the blood drop accurately by lancing the rounded tip of the finger (not the pad, but the rounded area just distal from the fingernail), turning the meter so the strip is perpendicular to the direction of the extended finger, placing the pad of the fingertip on the raised mark, and tipping the finger forward (see Figure 2). The person should be instructed not to press down, but rather to place the blood drop lightly. Also, Braille readers should avoid lancing the finger they use for reading.

People who have decreased sensation in their fingers will find it easier to use the Sure Drop (available from Science Products for the Blind, 800-888-7400). This device fits snugly over the top of the meter with a frame extending behind the display area to hold it firmly in place. It has a bridge over the strip holder area across which the user draws a lanced finger, depositing a drop of blood. When a large enough drop has accumulated, it falls into place on the strip.

Blind meter users will not be able to see whether their blood testing equipment has become soiled. Therefore, they should be taught to clean any area that has been in contact with blood after each use. Since the One Touch test area and the Sure Drop can both be damaged by alcohol and harsh detergents, the strip holder and the Sure Drop should both be cleaned with mild soap and water only.

Figure 1. Placement locations of dimensional fabric paint on a One Touch test strip holder.

Figure 2. Placement of blood drop on target area of One Touch test strip, using raised areas of dimensional fabric paint for tactile clues

Record Keeping
Methods for recording and retrieving information are usually taught in blindness rehabilitation. Most people who have low vision can keep records using thick, dark markers on paper that is either white (for high contrast) or light yellow (for decreased glare). Many people are helped by magnifiers with appropriate lighting, or closed circuit televisions, which project a greatly magnified image from a tray onto a screen. People who have little or no usable vision may use Braille if they have adequate sensation in their fingers, or they may find it more convenient either to keep records on audiotape or to use an audio-adapted computer.

Nutrition Management
Nutritional principles (such as macro-nutrient and micronutrient needs) are, of course, the same for blind and sighted people. However, food measurement is usually accomplished by sighted people using visual techniques. Therefore, it is helpful for a newly blinded person to learn nonvisual methods of food measurement.

Nonvisual food measurement is usually taught in blindness rehabilitation. Volume measurement is done using a set of plastic, nested measuring cups, which are widely available. For people who need greater precision, such as those on dialysis, a food scale that has a synthetic voice may be useful (available from Lighthouse, 800-829-0500).

Since few people, sighted or blind, actually measure their food most of the time, and it is exceptionally easy for people who cannot see to gradually increase the size of their portion "guesstimates," it can be helpful to discuss some everyday methods of managing to control portion size. Obtaining and using cups, glasses, and bowls that are the correct size for commonly used portions (such as a 4-ounce juice glass or a 1 1/2-cup cereal bowl) can help people to avoid overly large estimates of portion size. It is also helpful for people to measure how much the serving spoons and ladles they use at home actually hold. Finally, in order to stop an indefinite gradual increase of portion sizes, many people find it useful to set aside one day per month as a "measuring day," on which they measure everything they eat or drink.

Foot Care
Daily visual foot examination is routinely recommended to sighted people who have diabetes.⁶ Visually impaired people with diabetes, many of whom already have both macrovascular and microvascular damage, have a high risk of foot infection.⁸ Those who have numbness from neuropathy or from any other cause have an especially high risk of amputation, since they lack both visual and tactile means of detecting foot problems early. Therefore, diabetes care professionals should ensure that all visually impaired patients have learned basic principles of foot hygiene, and should re-teach any areas their patients have forgotten or never learned. In addition, all visually impaired diabetes patients need to learn nonvisual methods of foot inspection or to recognize any need for assistance in this area and arrange for it.

Nonvisual foot inspection. For people who have good sensation in their hands, a systematic tactile inspection of the foot can enable them to detect many foot problems independently. Using the fingers and thumbs, such patients should begin with the large toe and inspect all the toes, feeling all surfaces and between the toes, then bring the fingers around the outside edge of the foot, to the ankle and heel, then feel inside the arch, the top of the foot, and the bottom of the foot. The fingers are especially sensitive to changes in texture and surface, so they will feel such changes as blisters, small cuts, corns, calluses, or areas of swelling.

After inspecting the foot with the fingers, patients should also check the surface of the foot with the back of their hand. The sensors on the back of the hand are more sensitive to temperature changes, so this inspection will enable patients to feel any areas of unusual warmth, which would appear red visually, and may signal an irritation or infection.

Patients should also be advised to notice any unusual smell of the feet. Although feet often have an unpleasant odor, they should not have a foul odor. A foul odor may be a sign of an infection and may be noticed before any other sign of infection is evident.

Sighted foot care assistance. Because of the high risk associated with any cut on a diabetic foot, visually impaired people should not cut their own toenails. If they wish to shorten their toenails independently, it is much safer to use an emery board. If the toenails need to be cut, it is best to arrange for a podiatrist to do it. This has the added advantage of assuring regular professional screening of the feet.

Visually impaired people whose hands and feet are numb cannot adequately inspect their feet independently. They should be encouraged to arrange for a family member or friend to perform this needed task daily.

Exercise
Exercise plays an important role in health maintenance and glycemic control for all people with diabetes, including visually impaired people. Although a person who has active diabetic retinopathy or other diabetes complications will probably need to restrict activities, visual impairment itself does not preclude any form of exercise for which nonvisual safety adaptations can be devised.

Retinopathy precautions. Anyone who has diabetic retinopathy and remaining vision should avoid activities that increase the risk of retinal bleeding. Such activities include: anything that increases the blood pressure, such as lifting heavy objects, isometrics, and some weight-resistance exercises; bending the head forward below the level of the heart, such as some calisthenics or yoga exercises; performing the Valsalva maneuver, such as with sit-ups or leg-lifts; and any activity accompanied by severe atmospheric pressure changes, such as mountain climbing or deep-sea diving.

It should be noted that people who have no usable vision need not observe these precautions, since they have no need to avoid vision loss.

Nonvisual exercise adaptations. People are much more likely to continue doing exercise they enjoy. There-fore, visually impaired people should be encouraged to find adaptations for forms of exercise they enjoyed when they were sighted. Basic skills for moving about safely in the world are taught in blindness rehabilitation by Orientation and Mobility Instructors. These professionals can be an invaluable resource to blind people who want to find or create adaptations for favorite activities.

Some common examples of exercise that is easily adapted for blind people include: walking with a white cane, guide dog, or sighted companion; swimming in a pool with lane markers; tandem bicycle riding, canoeing, and golfing with sighted friends; and use of exercise equipment, such as a treadmill, stationary bicycle, or ski machine.

The author is also personally acquainted with blind people who engage in very challenging forms of exercise, such as rock climbing, horseback riding, cross-country skiing, adapted forms of basketball and baseball, and skydiving. It seems that the sky is truly the only limit.

Diabetes Education Materials
in Accessible Format
Locating a wide variety of up-to-date diabetes education materials produced in a format accessible to blind people is a challenge. Many available materials were produced before the release of the results of the Diabetes Control and Complications Trial and do not reflect current diabetes education practice. Following is a list of available resources.

• Cleveland Sight Center, Taping Service (216-791-8118)
Has available on audiotape a basic, simplified diabetes education pamphlet series and a pamphlet about carbohydrate counting produced by the Diabetes Association of Greater Cleveland. Also has many diabetes books on audiotape, though not many are recent.

• Hadley School for the Blind. You, Your Eyes, and Your Diabetes. (800-323-4238)
A course in basic diabetes education, available on audiotape and in large print. Open to visually impaired and blind people, their immediate family members, and the people who work with them.

• National Federation of the Blind, Diabetes Action Network. The Voice of the Diabetic. (573-875-8911)
A quarterly newsletter published in print or on audiocassette (recorded at 15/16 IPS for the blind; i.e., requires special equipment for playback). Contains articles about living with diabetes, personal stories by people who live with diabetes and its complications, and information about equipment for blind and visually impaired people. It is free.

• National Federation of the Blind, Materials Center (410-659-9314)
Has American Diabetes Association Exchange Lists on audiotape and in Braille. Also has "Resource List of Aids and Appliances" on audiotape and in large print and Braille.

• The National Library Service for the Blind and Physically Handicapped of the Library of Congress (Talking Books)
This service is available to everyone in the United States whose ability to read print is impaired. It can be accessed through any local public library. Talking Books has a number of diabetes books available on audiotape. Expect delays if a book must be ordered from another area of the country.

• Prana Publications, The Diabetic Reader. (800-735-7726)
Contains ordering information for many diabetes education audiotapes, often tapes of talks by well-known professionals. Also carries an audiotaped edition of Betty Brackenridge’s New Nutritional Guidelines for a New Day in Diabetes Care.

Conclusion
Although the loss of vision is a life change of major proportions, it does not need to signal the end of independence and participation in meaningful activities. Diabetes care professionals can facilitate adjustment for people who have both diabetes and visual impairment by making appropriate referrals to blindness rehabilitation services and teaching carefully chosen independent diabetes self-care skills.

References

¹Klein R, Klein BEK: Vision disorders in diabetes. In Diabetes in America. 2nd ed. Washington DC, US Government Printing Office (DHHS publ. no. NIH 95-1468), 1995, p. 293-338.

²Eastman R: Cost-effectiveness of detecting and treating diabetic retinopathy. Diabetes Spectrum 9:182-83, 1996.

³Bernbaum M, Albert SG: Referring patients with diabetes and vision loss for rehabilitation. Diabetes Care 19:175-77, 1996.

⁴Cleary ME (Ed.): Diabetes and Visual Impairment: An Educator’s Resource Guide. Chicago, American Association of Diabetes Educators, 1994.

⁵Carroll TJ: Blindness: What It Is, What It Does, and How to Live With It. Boston, Mass., Little Brown & Co., 1961.

⁶Brink S, Siminerio L, Hinnen-Hentzen D, Deeb LC, Daly AS, Anderson BJ, Agrin RJ: Diabetes Education Goals. Alexandria, Va., American Diabetes Association, 1995.

⁷Buyer’s guide to diabetes supplies. Diabetes Forecast 49(10):54-55, 1996.

⁸Reiber GE, Boyko EJ, Smith DG: Lower extremity foot ulcers and amputations in diabetes. In Diabetes in America. 2nd ed. Washington DC, US Government Printing Office (DHHS publ. no. NIH 95-1468), 1995, p. 409-27.

Resources for More Information

The Adaptive Monitor: an informal quarterly newsletter for professionals who work with people who have both diabetes and visual impairment. Published by Cleveland Sight Center, Cleveland OH (216-791-8118). A free sample copy will be sent upon request.

Diabetes and Visual Impairment: An Educator’s Resource Guide: a comprehensive text covering in detail all aspects of helping people with diabetes and visual impairment to learn the skills necessary for independent self-care. Available from the American Association of Diabetes Educators (800-338-3633).

Voice of the Diabetic: for a description, see the preceding list of diabetes education materials. Although its intended audience is people who live with diabetes, this newsletter does contain information valuable for diabetes professionals. It is free upon request.

Ann S. Williams, MSN, RN, CDE, is a diabetes educator in Cleveland, Ohio. She is chair of the Visually Impaired Persons Practice Group of the American Association of Diabetes Educators.

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Last updated: 6/16/97
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