Diabetes Mellitus

Chronic Complication Screening

Chronic complications of diabetes may be associated with increased risk for impairment, severe hypoglycemia and inability to safely perform essential job functions, and warrant further assessment. Chronic complications of diabetes for which screening should be performed include:

Diabetic Retinopathy and Macular Edema – Diabetic retinopathy is a leading cause of new-onset blindness and visual loss.9 (p 729) A complete eye exam by a qualified ophthalmologist or optometrist, including a dilated retinal exam should occur at time of diagnosis of type 2 diabetes and after 5 years of type 1 diabetes. Follow-up eye exams should be done every other year for those without retinopathy, and annually or more frequently for those with retinopathy or macular edema, as recommended by a qualified eye professional.2 (p s44-45), 10

LEOa with the following conditions should be advised that vigorous physical intensity could lead to complications (see Appendix A):

• Proliferative diabetic retinopathy
• More than moderate non-proliferative diabetic retinopathy
• Clinically significant diabetic macular edema

LEOs with diabetic retinopathy or macular edema need further assessment by their treating physician for the following:

• Exercise stress testing to at least 12 METs
• The treatment has been reviewed and, if indicated, adjustments made
• Criteria found in the Eye and Vision chapter are met
• Screening for other chronic complications of diabetes

Diabetic Neuropathy – Severe autonomic and/or peripheral diabetic neuropathy can impair the LEOs safe and effective performance of essential job functions and may require restrictions. Testing for diabetic neuropathy includes the following, with special attention to the feet 8 (p 604-606), 11:

• Motor examination (muscle strength and gait testing)
• Vibratory testing with a 128 Hz tuning fork (most sensitive in eliciting diabetic neuropathy)
• Sensation testing with 10 gram Semmes-Weinstein monofilament
• Deep tendon reflexes
• Position sense testing
• Orthostatic blood pressure and pulse testing. 12

The LEO with diabetic neuropathy should be evaluated to ensure that they can perform their essential job functions. The following conditions should be considered:

• Physical activity or performance that is limited due to pain, weakness or numbness
• Ataxia
• Reduced balance
• Reduced or loss of proprioception, which may result in the inability to control the foot pedals of vehicle, reduced balance, clumsiness or a history of falls
• Contact-induced discomfort or pain
• Foot ulceration or infection that affects wearing of footwear or ambulation
• Orthostatic hypotension, especially if symptomatic or if requiring treatment.

Cardiovascular Disease
Cardiovascular disease is a major cause of morbidity, mortality, and health care costs for patients with diabetes. 13 (p e82) The following assessment is recommended:

• LEOs with No Known Cardiac Diseasej, 8 (p 586), 13 (p e50-103), 14, 15, 16, 17
  LEOs, both those with and without diabetes, should be assessed for risk of cardiovascular disease according to the Cardiovascular Disease Chapter, section on coronary artery disease.
  
• LEOs with Cardiac Symptoms
  LEOs with typical or atypical cardiac symptoms should be referred for further evaluation. 18 (p S67)
  
• LEOs with an Abnormal Electrocardiogram
  LEOs with an abnormal electrocardiogram should be referred for further evaluation. 18 (p S67)
  
• LEOs with Known Cardiac Disease
  LEOs with known cardiac disease should be referred for further evaluation (see Cardiovascular Disease chapter) and screened for other chronic complications of diabetes.

Diabetic Nephropathy
Diabetes is the leading cause of end-stage renal disease. Increased albuminuria and decreased GFR are each independently and additively associated with an increase in all-cause and cardiovascular disease mortality, and most of the excess cardiovascular disease of diabetes is accounted for by the population with diabetic kidney disease. 19 (p 2865), 20

LEOs with diabetes should provide the following information to the police physician annually:

• Serum Creatinine
• eGFR (estimated Glomerular Filtration Rate)
• Urinary albumin excretionl

eGFR levels <45 ml/min or albuminuria of ≥30 mg/g creatinine (moderate to severe loss of kidney function) may suggest changes that can impair the LEOs safe and effective performance of essential job functions and may require restrictions. This level of renal impairment is associated with a significantly greater risk of cardiovascular disease, anemia, malaise, and greater risk for hypoglycemia, especially in those treated with some sulfonylureas or insulin. 2 (p S42-44), 19 (p 2869), 21, 22 (p 91), 23, 24

LEOs with diabetes and with an eGFR level of <45 ml/min or with albuminuria of ≥30 mg/g creatinine need further assessment by the LEO’s treating physician for the following:

• Confirmation of urinary albumin excretion
• Complete blood count
• Exercise stress testing to at least 12 METs
• Nephrologist evaluation—most important—with protection of renal status addressed
• The treatment has been reviewed and, if indicated, adjustments made
• Screening for other chronic complications of diabetes