of diabetes are at risk for developing several complications in the future including: blindness, Type 1 diabetes is usually diagnosed in children and young …
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Diabetes in Consumers with Mental illness
Introduction: Diabetes also known as Diabetes Mellitus is a disease in which individuals affected cannot regulate their blood sugar There are two different types of diabetes see below that often require different treatments Consumers affected by either of the two types of diabetes are at risk for developing several complications in the future including: blindness, kidney disease, heart disease, stroke, and amputations A diabetic consumer may also be more susceptible to infections, and may be prone to have delayed wound healing As a result, the care of the diabetic consumer by one person becomes an impossible task; it requires a team of health care professionals in order to deliver the best quality care The case manager plays an integral role in this team assuring the coordination of care Compared to the general population, consumers with mental illness have increased rates of developing diabetes and cardiovascular disease No one really knows why that is, but some experts think it may be related to the unhealthy lifestyles of mentally ill
consumers Such unhealthy lifestyles, along with poor medical follow-up, place consumers at an increased risk of experiencing complications from diabetes as well as death Because of this and other factors, life expectancy for these consumers is 57 years for men and 65 years for women, 20 percent shorter than the general population Some medications used recently in the treatment of mental illness also place consumers at an increased risk of developing diabetes The exact mechanism of this is not known but may be related to the weight gain associated with these medications Some consumers, however, have developed diabetes in the absence of weight gain It is important for the case manager to understand that not all consumers with diabetes will have been diagnosed and actually know that they have the disease The purpose of this monograph will be to familiarize the case manager with: 1 the definition of diabetes, 2 risk factors for diabetes, 3 common symptoms of diabetes and screening, 4 management of diabetes, 5 preventing complications of diabetes, 6 special considerations for consumers with mental illness 1 What is diabetes? Types of Diabetes: There are two types of diabetes Type 1
diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes In Type 1 diabetes, the body does not produce any insulin Insulin is a hormone that helps the body carry sugar from the blood into the cells Type 2 diabetes is the most common form of diabetes and typically develops in middle age In Type 2 diabetes, either the body does not produce enough insulin or the cells 1
are resistant to the insulin Most consumers that develop diabetes will develop it during adulthood and thus have Type 2 diabetes Causes of Diabetes No one really knows why some people develop diabetes and others do not It appears that diabetes may be caused by both genetic factors ie it tends to run in families and environmental factors The most important environmental factors associated with diabetes are diet and obesity Several studies have shown that individuals who have a strong family history of diabetes, do not develop diabetes themselves if they maintain a normal weight, proper diet and exercise In the case of the mentally ill consumer, certain medications may also be associated with the development of diabetes Point to Case Manager 1: Mentally ill consumers may
be at an increased risk for developing diabetes because of a combination of a family history of diabetes, obesity, poor diet that is high in fat, lack of exercise and some of the medicines they may be taking to treat mental illness 2 Risk Factors for Diabetes Consumers with mental illness are at an increased risk of developing diabetes, whether or not they are on the newer anti-psychotic medications known as atypical anti-psychotics The risk increases further if they are placed on such atypical anti-psychotic medications, or if any of the following risk factors are present: Weight gain, especially in the central abdominal region Family history first degree relative Ethnicity: African Americans, Hispanic Americans, Asian Americans and Native Americans Previous diagnosis of gestational diabetes diabetes during pregnancy Hyperlipidemia, a high density lipoprotein HDL level below 35 mg/dL, or a triglyceride level above 250 mg/dL are all associated with an increased risk for developing diabetes Point to Case Manager 2: Mentally ill consumers should be screened for other risk factors for developing diabetes If these exist, screening for diabetes should occur early and frequently ie every
year especially if they are on or about to start an atypical antipsychotic medication 3 Common Symptoms of Diabetes and Screening Some symptoms of diabetes include: Frequent urination also known as polyuria Excessive thirst also known as polydipsia Extreme hunger Unusual weight loss Increased fatigue Irritability Blurry vision
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Point to Case Manager 3: The symptoms of diabetes often go ignored because consumers, do not realize that some of these symptoms may signify a serious health problem As a result, screening for diabetes becomes very important A consumer has diabetes if: A random blood sugar greater/or equal to 200 mg/dL is detected, OR A fasting blood sugar greater/or equal to 126 mg/dL is detected, OR A 2-hour blood sugar greater/or equal to 200 mg/dL is detected after being administered 75 grams of oral sugar This is also known as a Glucose Tolerance Test or GTT A consumer has Impaired Glucose Tolerance impaired glucose tolerance can be thought of as pre-diabetes if: A 2-hour blood sugar greater/or equal to 140 mg/dL but less than 200 is detected after being administered 75 grams of oral sugar This is also known as a Glucose Tolerance Test or GTT, OR A fasting blood
sugar between the ranges of 110 to 125 Because of the fact that consumers with mental illness are at an increased risk for developing diabetes overall, the risk further increases if they are started on an atypical anti-psychotic medication and because of the fact that if they do develop diabetes, mentally ill consumers tend to have worse outcomes, it is recommended that every consumer: Have a risk assessment done inquiring about family history, ethnicity, diet and exercise Measure the body mass index BMI, blood pressure, and cholesterol panel Screen for diabetes with a fasting blood glucose early and frequently early for all consumers, regardless of age; frequently at least once a year 4 Management of Diabetes Diabetes can be managed successfully by eating well, exercising, and managing stress The principles of management include: Faithful monitoring of blood sugars, especially when ill such as when someone has an infection, or when stressed Glucose before meals should be between 80-120 mg/dL and two hours after meals between 100-140 mg/dL Check urine for ketones when blood sugar is 250 mg/dl or higher Ketones are breakdown products of the body and should never be present in the
urine If they are present in the urine, it signifies the fact that this persons blood sugars are going out of control and thus, the consumer should seek immediate medical attention It is important to pay attention to meal plan balance and timing Consumers should see a nutritionist at least initially Stress management Regular exercise program Medications when needed including insulin
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Hemoglobin A1c a blood test can determine the average amount of sugar the body has been exposed to over the past three months The results are measured in a percentage The usual lab reference range for a normal HgbA1c is from 44 - 64 percent A number over 8 percent indicates poorly controlled diabetes and is associated with an increased risk for diabetes complications Point to Case Manager 4: Every person with diabetes should have a hemoglobin A1c level also known as HgbA1c or glycosylated hemoglobin checked at least twice a year If this level is above eight percent, the consumer is NOT in satisfactory control Medications: The following is a list of medications commonly used to regulate blood glucose in diabetics Types of medications Drug family Sulfonylureas
Biguanides Thiazolidinedione
Alpha-glucosidase inhibitors Meglitinides DPP-4 Inhibitors Combination oral agents
Brand name Amaryl Diabeta Glucotrol XL Glynase Glucophage Avandia Actos Precose Glyset Prandin Starlix Januvia Glucovance Avandamet
Generic name Glimepiride Glyburide Glipizide Micronized Glyburide Metformin Rosiglitazone Pioglitazone Acarbose Miglitol Repaglinide Nateglinide Sitagliptin Glyburide Metformin Rosiglitazone Metformin
Type I diabetes can only be managed with insulin therapy Type II diabetes is often managed with the oral agents outlined above, but sometimes insulin must also be added to obtain maximum control Point to Case Manager 5: If consumers are started on a Thiazolidinedione, they need to have their liver function checked via a liver profile blood test frequently to assure that this medication is not causing any liver problems Point to Case Manager 6: If consumers are started on Glucophage Metformin, they need to have their kidney function checked blood creatinine level In consumers with kidney disease, this medication may stay in the body longer and subsequently accumulate to toxic levels
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Point to Case Manager 7: Consumers started on the Sulfonylureas need to be monitored
for hypoglycemia low blood glucose Out of all the medications in the table above, only the Sulfonylureas can cause hypoglycemia Consumers with impaired glucose tolerance pre-diabetes usually do not require any medications In these consumers a diet should be prescribed, along with exercise and they should be followed very closely for the possibility of developing diabetes in the future It is important to note that managing blood sugars with either diet/exercise, medications or insulin, is only one part of managing diabetes An equally important part of managing this disease involves screening and if possible preventing complications of the disease from occurring The next section focuses on this 5 Preventing complications of diabetes Diabetes can be associated with both short-term and long-term complications Short-term complications: A condition known as diabetic ketoacidosis, or DKA is a lifethreatening complication most often associated with Type 1 diabetes; however, it is also occurring more frequently in consumers with Type 2 diabetes, which is the most common form seen in the mentally ill population This is of significant concern since the 6-10 percent of DKA consumers may die if
it is not identified and treated early The mortality rate of DKA may be even higher in mental illness since these consumers may not be as vigilant as the general public in seeking medical treatment for illness DKA occurs when a persons blood sugar goes up very high usually above 500, but at times can go as high as over 1000 As a result of these high blood sugars, acids build up in the consumers blood and the condition known as DKA occurs The main causes of DKA include underlying or concomitant infection 40 percent, most often are urinary tract infections or pneumonia, missed insulin treatments 25 percent, and newly diagnosed, previously unknown diabetes 15 percent DKA occurs when there is a state of insulin deficiency aggravated by elevated intermediary blood sugars, dehydration, and acid-producing elements in the blood Consumers who may be developing DKA will complain of fatigue, malaise, thirst, and frequent urination Depending on the length of symptoms the consumer may be able to report weight loss As the consumer becomes increasingly ill they may begin to vomit and complain of abdominal pain and have a fruity smelling breath often mistaken for alcohol use If you suspect that a
consumer may be developing DKA, urgent treatment is required The 
treatment goals of the consumer with DKA are as follows: 1 improve the dehydration with intra-venous fluids, 2 decrease the serum sugar emergent inpatient insulin treatment, 3 reverse the acidic state in the consumers blood, 4 correct electrolyte losses and imbalances, and 5 find and treat the underlying causes Point to Case Manager 8: Any mentally ill consumer suspected of having DKA should be immediately referred to EMERGENT medical attention Other short-term complications include the fact that diabetics are more susceptible to infections and if injured take longer to heal when compared to the general population
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Point to Case Manager 9: Every diabetic consumer should be offered the pneumonia vaccine every six years and the flu vaccine every year because of the fact that they are more susceptible to these infections Long-term complications: The long-term health problems that occur in diabetes are caused by injury to both large and small blood vessels Over time micro-vascular small blood vessel disease damages the kidneys, peripheral nerves and retina vision This can also lead to erectile dysfunction impotence and
gastroparesis constipation, bowel obstruction Macro-vascular large blood vessels disease increases the risk of hypertension, stroke and heart attacks seen in consumers with Type 2 diabetes See Cardiovascular disease monograph for more information Screening for kidney disease: Every consumer diagnosed with diabetes should have a blood creatinine test and a urine micro-albumin test done once a year The blood creatinine test measures kidney function, but by the time an abnormality is picked up by this blood test, a significant amount of the kidneys may already be damaged For this reason, a urine micro-albumin test is required This urine test is able to detect early damage to the kidneys from diabetes Anyone who has positive micro-albumin in the urine should be started on Ace-inhibitor medications Such medications have been shown to slow down the progression of kidney disease in the diabetic Screening for peripheral nerve damage: Diabetes is one of the leading causes of leg/foot amputations, partly because of peripheral nerve damage resulting in decreased sensation to the legs and feet As a result, these consumers are more prone to injure their legs and feet and not feel anything Any
consumer with diabetes should have at least an annual foot exam to determine both sensory perception and circulation to the legs and feet If there is damage to the nerves and/or circulation to the legs and feet, diabetics should be instructed on proper foot care Screening for diabetic retinopathy: Diabetes is the leading cause of blindness in this country Because there are no symptoms or loss of vision until there is significant damage already present, yearly diabetic eye exams are necessary to detect early damage microscopic hemorrhages or changes to the eye Damage to the retina can be prevented with good blood sugar management Screening for macro-vascular disease: To prevent macro-vascular complications from occurring in the diabetic consumer, the most important thing to do is to screen for high blood pressure and elevated lipids cholesterol Ninety-seven percent of the people with diabetes have abnormal cholesterol levels Therefore, fasting lipid levels should be included as part of annual blood evaluations The standard of treatment is to maintain the low-density lipoproteins LDL levels below 100 in every diabetic Recent evidence now suggests that all diabetics should be started
on cholesterolreducing medications regardless of their cholesterol levels in order to decrease the risk of developing heart disease Finally, tight control of blood pressure is also essential in the diabetic Elevated blood pressure places a diabetic at risk for developing both macro-vascular and micro-vascular disease
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6 Special considerations for consumers with mental illness There are a growing number of reports suggesting an association of treatment with some atypical antipsychotic medications and weight gain, new onset of Type 2 diabetes, exacerbation of existing diabetes, and in rare instances death The onset or exacerbation of diabetes with these agents can occur even in those consumers who were not obese Examination of all the available data consistently show that consumers treated with clozapine or olanzapine have an increased risk for diabetes compared to consumers treated with other atypical anti-psychotics The risk associated with risperidone and quetiapine was less clear For aripiprazole and ziprasidone there does not appear to be increased risk Point to Case Manager 10: A mentally ill consumer being started on clozapine or olanzapine needs to be carefully monitored
for the onset of diabetes, exacerbation of existing diabetes, or the onset of DKA This can occur even in those consumers who do not experience weight gain and are not obese The risk associated with risperidone and quetiapine is less clear In healthy, non-diabetic consumers, the following assessments should be performed before starting treatment with an atypical anti-psychotic medication: Height and weight Body mass index BMI Waist circumference Fasting plasma glucose and lipid levels The frequency with which laboratory measures are repeated will vary considerably based on clinical history but should be repeated at least once a year Obtaining baseline values of the relevant physical and laboratory parameters including blood pressure, weight, height, BMI, waist circumference, fasting serum lipids total, LDL, and HDL cholesterol along with triglycerides, and a fasting plasma glucose level is critical prior to initiating anti-psychotic medications During the initiation of anti-psychotic treatment, consumers should have these values monitored regularly, although frequency must be dictated by the individual consumers level of risk For example, an obese mental illness consumer with a
family history of diabetes who has gained 30 pounds on his current anti-psychotic medication demands more intensive monitoring than a slender consumer with no family history of diabetes who is not gaining weight during anti-psychotic treatment In general, assessments should be made more frequently during the initial titration phase of treatment Nevertheless, all mentally ill consumers treated with anti-psychotic medication should have a yearly assessment of fasting lipids and glucose The Consensus Development Conference recommends monitoring of weight every 4 weeks for the first 3 months and then quarterly thereafter Blood pressure and fasting glucose should be measured after 3 months and then annually Fasting lipids are recommended to be measured after 3 months and then every 5 years Similarly, vital signs, weight, and waist circumference should be measured at every visit, as these are simple measures to monitor that have a high yield of alerting clinicians to adverse metabolic side effects of anti-psychotic medications Point to Case Manager 11: The risk of diabetes is managed effectively by 1 Consideration of metabolic risks when starting atypical anti-psychotics, 2 Consumer,
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family, and care giver education, 3 Baseline screening, 4 Regular monitoring, 5 Referral to specialized services when appropriate When treatment-emergent weight gain, elevations in cholesterol profile, and/or diabetes are observed, switching to another agent that is not associated with significant weight gain or diabetes should be considered For certain situations clinical benefits may outweigh risks, as is the case with clozapine improvement in treatment refractory consumers outweighs risk of metabolic side effects These consumers should also be referred to diabetes selfmanagement education programs as well as a specialist for further medical consultation Finally, case managers and clinicians need to be aware of the signs and symptoms of acute metabolic deterioration eg, DKA Confusion, abdominal pain, nausea, frequent urination and thirst can be indicative of life threatening complications and these symptoms should prompt emergent evaluation and treatment In addition, mentally ill consumers suffer from impaired insight, lack of resources ie, access to medical care, lower medication and treatment adherence, and more psychosocial stress, all of which can compound medical problems
For these reasons, the case manager must at times be proactive in terms of assessing the consumer for any of the above noted symptoms
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The following summarizes the main points discussed in this monograph: 1 The following risk factors place a mentally ill consumer at increased risk of developing diabetes: obesity, sedentary lifestyle, family history, ethnicity, elevated blood pressure, abnormal lipid profile, gestational diabetes diabetes during pregnancy 2 Certain atypical anti-psychotic medications have been associated with diabetes, these have included: clozapine and olanzapine This can occur even in those consumers who do not experience weight gain and are not obese The risk associated with risperidone and quetiapine is less clear 3 Common symptoms of diabetes include: frequent urination also known as polyuria, excessive thirst also known as polydipsia, extreme hunger, unusual weight loss, increased fatigue, irritability, blurry vision 4 A consumer has diabetes if: a random blood sugar greater/or equal to 200 mg/dL is detected, OR a fasting blood sugar greater/or equal to 126 mg/dL is detected, OR a 2-hour blood sugar greater/or equal to 200 mg/dL is detected after being
administered 75 grams of oral sugar This is also known as a Glucose Tolerance Test or GTT 5 Every mentally ill consumer should have a hemoglobin A1c level checked at least twice a year If this level is above eight percent, the consumer is NOT in optimal control 6 If consumers are started on a Thiazolidinedione, they need to have their liver function checked frequently to assure that this medication is not causing any liver problems 7 If consumers are started on Glucophage Metformin, they need to have their kidney function checked blood creatinine level In consumers with kidney disease, this medication may stay in the body longer and subsequently accumulate to toxic levels 8 Consumers started on the Sulfonylureas need to be monitored for hypoglycemia low blood glucose 9 Symptoms of DKA include: fatigue, malaise, thirst, and frequent urination, vomit, abdominal pain and a fruity smelling breath or breath that smells like alcohol Any mentally ill consumer suspected of having DKA should be immediately referred to EMERGENT medical attention 10 Every diabetic consumer should be offered the pneumonia vaccine every six years and the flu vaccine every year because of the fact that they are
more susceptible to these infections
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11 A urine micro-albumin test is required every year This urine test is able to detect early damage to the kidneys from diabetes Anyone who has positive micro-albumin in the urine should be started on Ace-inhibitor medications Such medications have been shown to slow done the progression of kidney disease in the diabetic 12 Any consumer with diabetes should have at least an annual foot exam to determine both sensory perception and circulation to the legs and feet If there is damage to the nerves and/or circulation to the legs and feet, diabetics should be instructed on proper foot care 13 Yearly diabetic eye exams are necessary to detect early damage microscopic hemorrhages or changes to the eye 14 The standard of treatment is to maintain the Low-Density Lipoproteins LDL levels below 100 in every diabetic Recent evidence now suggests that all diabetics should be started on cholesterol-reducing medications regardless of their cholesterol levels in order to decrease the risk of developing heart disease 15 Tight control of blood pressure is also essential in the diabetic Elevated blood pressure places a diabetic at risk for developing both
macro-vascular and microvascular disease
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Source:libertymedical.com
