Transcript What is metabolic syndrome (Pathophys, sign symptoms)?

Guidelines for Integrated Care
(Psychiatric & Medical)
In the Community
Module I:
Diabetes and Glucose Monitoring
Objectives
 At the completion of Module I (Parts A and B),
participants will be able to:
 Appreciate the need for integrated care in the mental
health community to prevent premature deaths and
increased disability from Diabetes Mellitus (DM) types I
and II
 Basic knowledge of DM (abnormal amounts of sugar in the
blood)
 Know the risk factors associated with DM
Objectives
 Identify patients with mental illness who have DM/risk
factors
 Understand the concept of stages of change needed for
appropriate interventions including use of tools for selfcare, education and referral
 Help those who are at risk for/diagnosed with DM in
your caseload adequately communicate with their
healthcare team for optimal care
Key Concept: Circulatory System
Controlling Blood Sugar:
Balancing Act
Module I Part A:
Importance of Integrated
Care
Fact
 People with mental illness have a reduced life
expectancy
 They die at least 20 years younger than the general
population from treatable physical Illnesses (such as
DM)
Multi-State Study Mortality Data: Years of
Potential Life Lost
Year
1997
1998
1999
2000
AZ
MO
OK
32.2
31.8
26.3
27.3
26.8
27.9
25.1
25.1
26.3
RI
TX
UT
VA
(IP
only)
28.5
28.8
29.3
29.3
26.9
15.5
14.0
13.5
24.9
 Compared to the general population, persons with major mental illness
typically lose 25 to 30 years of normal life span
(Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available from:
URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm)
Ohio Named 10th Fattest State:
Persons with mental illness die even earlier in
Ohio
Severe Mental Illness (SMI)
Morbidity and Mortality
 Suicide and injury account for about 30-40% of excess
mortality
 60% of premature deaths in persons with schizophrenia
are due to preventable (and costly) medical conditions
with 20+ years of life lost
(URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm)
Physical Health Care
for People with SMI is Poor
 The CATIE (Clinical Antipsychotic Trials in Intervention
Effectiveness) study investigators found that at the
beginning of the study, participants had the following
medical conditions:
 88.0% had high cholesterol (dyslipidemia)
 62.4 % had high blood pressure (hypertension)
 30.2% had diabetes
 And they were not being treated!
(Nasrallah HA, et al. Schizophr Res. 2006;86:15-22)
Metabolic Syndrome
What is Metabolic Syndrome?
 Metabolic syndrome is a group of conditions/factors
that when present in an individual significantly increase
risks of heart disease and other acute and chronic
medical conditions, including DM
What is Metabolic Syndrome?
 Abdominal obesity: waist circumference >40 inches in men and
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

>35 inches in women
Abnormal amount of fats in the blood (dyslipidemia):
 High levels of LDL “bad” cholesterol that promotes build up of
“plaque” in the arteries
 Low levels of HDL “good” cholesterol that helps reduce the
build up of plaque
High blood pressure
Tendency to form blood clots (prothrombotic state)
Inability of the body to use insulin and blood sugar (blood
glucose) so blood glucose levels rise above normal  DM
National Cholesterol Education
Program: Diagnostic Criteria for
Metabolic Syndrome
 Three or more of the following:
• Waist Circumference:
 > 40 inches in men
 > 35 inches in women
• Triglyceride level>=150 mg/dl
• HDL “Good” Cholestero
 <40 mg/dl in men
 <50 mg/dl in women
• BP >=135/85
• Fasting (8-10 hours) blood glucose >=100 mg/dl
What is Glucose?
 A source of energy needed by the body for all of its
functions (digestion, movement, thinking, etc.)
 There is a range of blood glucose that is optimal for
these bodily functions:
 60-110 mg/dl
 Before meals less than 115 mg/dl
 Before bedtime less than 120 mg/dl
 Glucose level is controlled by insulin that is secreted by
the pancreas
Effects of Some
Psychotropic Medications
 Weight gain/obesity
 Insulin resistance by impacting insulin receptor or post-
receptor function  abnormally high blood sugars and
DM
 Abnormal amounts of fat in blood (dyslipidemia)
 Antipsychotic medications are associated with 2X the
risk of sudden cardiac death
(Correll.MD et al, “Cardiometabolic Risk of Second-Generation Antipsychotic
Medications During First-Time Use in Children and Adolescents”, JAMA, Oct., 2009)
(Ray et al, NEJM, Jan., 2009*)
Why is Diabetes
Mellitus (DM) so important?
 A common form of Metabolic Syndrome
 Ranked as the 7th leading cause of death in the US
 Estimated to affect 1 in 15 persons in the US
 Persons with mental illness have a greater incidence of
DM than the general population
Why is DM so Important?
 Untreated or mistreated DM can have severe
consequences in both the person’s mental and physical
conditions
 Mental Health clients have:
 60-70% chance of suffering from mild to severe nerve
damage
 65% chance of dying from heart disease or stroke
 increased chance of amputation, kidney failure and
adult blindness
Source: www.diabetes.org
What is DM?
 A chronic disease in which the body’s level of sugar
(glucose level in the blood) is not sufficiently regulated
 In Type I DM, the body’s pancreas is not able to produce
the needed level of insulin or any insulin at all resulting
in a build up of sugar (glucose) in the blood
 In type II DM, the body’s blood sugar (glucose) builds up
because the body’s cells are not able to utilize insulin to
metabolize its blood sugar
Risk Factors for Developing DM
 Sedentary life style
 Smoking
 Nutritional intake
 High BMI
 Poverty
 Genetic vulnerability
Risk Factors for Developing DM
 Side effects of medications (including some new-
generation anti-psychotics and anti-depressants)
 History of Abuse (physical abuse: 26%-54, unwanted
sexual touching:16%, forced sexual experience: 34%69%)
 Pregnancy
 Diagnosis of Schizophrenia or Bi-polar disorder
DM: Racial Mis-representation
Racial/Ethnic
Breakdown
Prevalence of
Diabetes in the
Community (%)
Racial/Ethnic
Composition in the US
(%)
Source:
Nat. Diabetes Assc.
US Census (2008)
Native American/Alaska
Native
16.5
0.7
African American
14.7
12
Hispanic/Latino
American
10.7
16
Caucasian American
9.8
66
Asian American/Pacific
Islander
7.5
3.7
Importance of ‘at-risk’ Clients
 Before people develop type II DM, they almost always have
"pre-diabetes” (blood glucose levels that are higher than
normal but not yet high enough to be diagnosed as diabetes)
 There are 57 million people in the United States who have
pre-diabetes.
 Recent research has shown that some long-term damage to
the body, especially the heart and circulatory system, may
already be occurring during pre-diabetes
How can DM be Prevented or Managed?
 Life style changes and self-monitoring:
 Sedentary life style  exercise regularly
 Smoking  decrease/stop smoking
 Nutritional intake  regulation of dietary intake
 High BMI  monitor weight and waist circumference
 Poverty  referrals, resources, benefits
How can DM be
Prevented or Managed?
 Life style changes and self-monitoring:
 Side effects of medications (some new-generation anti-
psychotics and anti-depressants)  switching
medications, lower doses
 Diagnosis of Schizophrenia or Bi-polar disorder  optimal
treatment
 Possibly testing blood sugar level 1-8x daily
 Taking oral glucose lowering medication or insulin
injections
Module I Part B:
Implementing Guidelines for
Diabetes within Community-Based
Mental Health Services
Together we can make a difference!
Trans-disciplinary approach
 Management of co-occurring conditions needs to be
team based
 The team includes the client and family members
(where appropriate or possible)
 Implementation of the guidelines discussed below to be
coordinated between disciplines and specialties
 Guidelines preferably provided/coordinated in one
location of care, if possible
Role of Mental Health Professionals
 Monitor and Assess (integrated treatment begins with the
clinicians awareness) for risk factors/current DM
 Initial assessment questions/observations of client
 Medical records
 Current medications
 Monitor and Assess for DM related risk factors of certain
psychotropic medications
 Weight gain:
•
•
•
•
•
•
•
•
Zyprexa (olanzapine),
Clozaril (clozapine),
Seroquel (quetiapine),
Risperdal (risperidone),
Depakote (valproic acid),
Lithium (lithobid),
Elavil (amitriptyline),
Remeron (mirtazipine)
Role of Mental Health Professionals
 Monitor and Assess signs and symptoms of DM
 Educate on DM and blood sugar monitoring
 Encourage individuals to take more responsibility for
their own health
Role of Mental Health Professionals
 Remind yourself and your clients that small steps can yield
big results
 Listen attentively to your clients and assist them in
developing their own healthy living plans
 Develop and Implement a healthy living plan: diet, exercise,
smoking, alcohol, self-help groups, supportive relationships,
medication management
 Refer to primary care providers, specialists (podiatry,
endocrinology, nutrition, etc.), home health, and
support/education groups
 Coordinate care between supports systems named above as
well as with family and friends
Stages of Change
 Pre-contemplation: Not yet acknowledging that there is a
problem behavior that needs to be changed
 Contemplation: Acknowledging that there is a problem but
not yet ready or sure of wanting to make a change
 Preparation/Determination: Getting ready to change
 Action/Willpower: Changing behavior
 Maintenance: Maintaining the behavior change
Initial Questions and Observations
 For clients without a current diagnosis of DM but are at
increased risk:
 Is this person obese?
 Is there a family history of DM?
 What is the client’s ethnicity?
 Is there a family history of physical/sexual abuse?
Initial Questions and Observations
 For clients without a current diagnosis of DM but are at
increased risk:
 Is their diet heavy in fats and salt?
 Does the client have high blood pressure?
 Does the client have a sedentary lifestyle?
 Is the client on medications with known side effect of
weight gain?
 Diagnosis of Schizophrenia, Bi-Polar Disorder, or
Depression?
Initial Questions and Observations

For clients with a current diagnosis of DM:
 What do you know about your diagnosis?
 Do you know the signs and symptoms of low and high
blood sugar?
 Do you see a PCP about the sugar in your blood?
 Describe what you do to help control your diabetes each
day?
Initial Questions and Observations

For clients with a current diagnosis of DM:
 Who tests your blood sugar?
 If you test your own blood sugar, do you:
 Do you have a glucose meter?
 Do you have test strips?
 Do you keep a record of your blood sugar is and the time you
tested it?
 Do you understand what you need to do if your blood sugar is
high or low?
Common DM Related Tests
 Three different tests the healthcare provider can use to
determine whether a person is pre-diabetic:
 The A1C test
 The fasting plasma glucose test (FPG)  abnormal
blood glucose level indicates impaired fasting glucose
(IFG)
 Oral glucose tolerance test (OGTT)  abnormal blood
glucose level indicates impaired glucose tolerance
(IGT)
 IFG and IGT are both also known as pre-diabetes
What Type I DM signs/
symptoms to observe for?
 Symptoms of Type I DM:
 Unusual thirst
 Extreme hunger
 Unusual weight loss
 Extreme fatigue and irritability
 Fruity breath (ketones)
What Type II DM signs/
symptoms to observe for?
 Symptoms of Type II DM:
 Any of the type I symptoms
 Frequent infections
 Blurred vision
 Cuts/bruises that are slow to heal
 Tingling/numbness in the hands/feet
 Recurring skin, gum, or bladder infections
* Often people with type II DM have no symptoms
High Blood Sugar (Hyperglycemia)
 Skipping or forgetting insulin or oral glucose-lowering
medicine
 Eating too much carbohydrates
 Eating too much food and having too may calories
 Infection
 Illness
 Increased stress
 Decreased activity or exercising less than usual
 Overly strenuous physical activity
Early Signs of Hyperglycemia
 Increased thirst/hunger
 Headaches
 Difficulty concentrating
 Blurred vision
 Frequent urination
 Fatigue (weak, tired feeling)
 Weight loss
Prolonged Signs of Hyperglycemia
 Skin infection
 Slow healing cuts or sores
 Decreased field of vision
 Nerve damage causing painful, cold, or insensitive feet
 Loss of hair in lower extremities
 Erectile dysfunction
 Stomach or intestinal problems such as vomiting,
diarrhea, or constipation
Urgent Hyperglycemia Conditions
 Urgent signs:
 Seizures
 Hallucinations
 Confusion
 Disorientation
 Coma
 Two specific types of hyperglycemic conditions:
1.
Ketoacidosis: primarily type I DM, dangerously high
levels of ketone acids in the blood
2.
Hyperglycemic Hyperosmolar Nonketotic Syndrome
(HHNS): primarily type II DM, usually brought on by
illness or infection
Urgent Hyperglycemia Conditions
 Urgent signs:
 Seizures
 Hallucinations
 Confusion, Disorientation, and Coma
 Two specific types of hyperglycemic conditions:
 Ketoacidosis: primarily type I DM, dangerously high levels
of ketone acids in the blood
 Hyperglycemic Hyperosmolar Nonketotic Syndrome
(HHNS): primarily type II DM, usually brought on by illness
or infection
Low Blood Sugar (Hypoglycemia)
 Blood glucose below normal levels
 Can happen suddenly
 Usually mild
 Can be treated quickly and easily by eating or drinking a
small amount of glucose-rich food:
 Sugary candy
 Banana
 Peanut butter
 Crackers
Signs of Hypoglycemia
 Hunger
 Shakiness
 Nervousness
 Sweating
 Dizziness or light-headedness
Signs of Hypoglycemia
 CONFUSION and AGITATION/Combativeness
 Difficulty speaking
 Anxiety
 Weakness
 If severe/untreated: seizures, coma, and death
Hypoglycemia During Sleep
 Signs include:
 Crying out or having nightmares
 Finding pajamas or sheets damp from perspiration
 Feeling tired, irritable, or confused after waking up
Chronic uncontrolled DM Complications
 Complications of Diabetes are found in all body systems:
 Eyes
 Peripheral nervous system
 Blood vessels
 Heart
Eyes
 Persons with diabetes are at risk for eye diseases that
can lead to blindness
 Blurred vision can be a safety issue
 Regular check-up are needed at least once a year—
check when reviewing care plan
Peripheral Nerve Pain
 DM nerve pain has been described by some patients as
constant or that it comes and goes
 Everyday things (bed sheets, socks) may cause pain
 Words clients used to describe this pain:
 Aching
 Burning
 Numbness
 Shooting Pain
 Stabbing
 Throbbing
 Tingling
Blood Vessels: Skin and Circulation
 DM impairs the ability of the body to heal – feet are
especially affected
 Encourage the client to perform skin assessment
 Inspect between the toes, bottom of the feet, and the heels
for:
 Broken skin
 Sores
 Blisters
 Areas of increased warmth or redness
 Changes in calluses
 If your client presents with these conditions, please inform
your medical staff before infection takes hold
 Podiatrist referral/linkage for toe nail cutting/foot care
Kidneys and Heart
 Changes in blood pressure may indicate kidney damage
 Refer to appropriate health care provider for routine lab
tests/treatment
 Heart attacks/failure are the major cause of death for
persons with DM
What can I eat if I have diabetes?
 Eat lots of vegetables and fruit
 Eat non-starchy vegetables such as spinach, carrots, broccoli
or green beans with meals
 Choose whole grain foods over processed grain products.
 Try brown rice with stir-fry or whole wheat spaghetti with
pasta sauce
 Avoid foods high in fat (e.g. foods fried in oil or fat)
 Choose liquid oils for cooking instead of solid fats (high in
saturated and trans fats)
What can I eat if I have diabetes?
 Include dried beans (like kidney or pinto beans) and
lentils
 Include fish in your meals 2-3 times a week
 Choose lean meats like cuts of beef and pork that end in
"loin" such as pork loin and sirloin
 Remove the skin from chicken and turkey.
 Choose non-fat dairy products such as skim milk, non-
fat yogurt and non-fat cheese
 If you're trying to lose weight, watch your portion sizes
Exercise
 Anything that gets you moving, such as walking,
dancing, or working in the yard
 Increases muscle/bone strength, flexibility, and
endurance needed for daily activities
 Helps the client feel and look better
 Lowers blood glucose, blood pressure, and cholesterol
 Reduces risk for heart disease and stroke
 For optimal weight loss regimen, a combination of
physical activity and wise food choices can help reach
and maintain target weight
Glucose Meters
 Things to know about glucose meters:
 Meters are vital to keeping track of day-to-day blood
glucose levels
 They're accurate, but improper use or faulty materials can
cause incorrect readings
 Many kinds of meters are available
 Meters are relatively inexpensive—however test strips are
expensive
Glucose Meters
 Experts testing meters in the lab setting found them accurate
and precise. But meter mistakes most often come from the
person doing the blood checks.
 For good results you need to do each step correctly.
 Other things that can cause a meter to give a poor reading:
 Dirty meter
 Meter or strip that's not at room temperature
 Outdated test strip
 Meter not calibrated (set up for) the current box of test strips
 Blood drop that is too small
 Client should ask their health care team to check their skills
at least once a year
Supports and Referrals
Interventions focused on prevention and information/activities:
 The internet: local groups, message boards, education, statistics,
podcasts, self-assessment of risk factors
 www.cdc.gov/diabetes
 American Diabetes Association: www.diabetes.org
 CDC BMI chart:
http://www.cdc.gov/healthyweight/assessing/bmi/
 Referral/Linkage with RN, PCP, Specialty Providers (podiatrist,
endocrinologist, ophthalmologist, dentist, nutritionist, etc.), local
diabetes groups, Home health
CASE STUDIES
Case Study 1
 James is a 45 year old African American male with a
diagnosis of schizophrenia. He has stopped taking his
medication since he was laid off six months ago. He
currently has no insurance and has not applied for SSI
or SSDI. He is 5’9” and 196lbs. He noted some weight
gain (15 pounds) over the past few months from
inactivity.
 Recently, at a health fair, he had his blood sugar checked
and he was told it was 187. His blood pressure was
140/92. He was told to follow up with a primary health
care provider, but he states he isn’t sure where to go
because of his lack of health insurance.
Case Study 1
 What are some of the risk factors James has for
diabetes?
 How might a case manager follow-up with the
psychiatric health care provider?
 What other types of linkages/resources would be
helpful for James?
 What kind of education could you do with James?
 Where would you document this information?
Case Study 2
 Mary Beth is a 37 year old Caucasian female who has a
diagnosis of schizoaffective disorder. She has been
taking Geodon, Depakote, and Prozac. Through her
medical health care provider, she is prescribed
Glucophage (metformin), an oral medication to control
her diabetes.
 Her primary healthcare provider has her checking her
blood sugar at least once a day. Lately it has been in the
low 200s. She states she has been under a lot of stress
lately since her son was incarcerated and hasn’t been
sticking to her dietary plan. She also notices she has put
on a few pounds.
Case Study 2
 What are important assessment questions for Mary Beth?
 What are some symptoms of high blood sugar that you could look for in
Mary Beth?
 What are some of the risk factors that predispose Mary Beth for
diabetes?
 What are some of the medications to watch out for that have a higher
risk of leading to weight gain and diabetes?
 How might a case manager follow-up with the psychiatric health care
provider and primary care provider?
 If Mary Beth was having trouble using her blood glucose machine, who
should she see to learn how to use it correctly?
Case Study 3
 Larry is a 48 year old Chinese American with a psychiatric diagnosis of
paranoid schizophrenia. He was recently diagnosed with end stage
renal disease as a complication of his diabetes. Larry’s blood glucose
readings ranged between 60 to 300 depending on when it is taken. His
registered nurse, Susan, goes to Larry’s apartment to assess his
psychiatric and medical condition and to administer his medications
everyday.
 When Andy, Larry’s case manager visited him, Larry appeared very
anxious. He was pacing in his apartment and appeared irritable. Larry
has a frown on his face and was cursing under his breath. He began to
use profane language and asked if his plane reservations have been
made and if his clothes were packed. Larry’s skin appeared sweaty and
clammy, he was belligerent, and he slurred his speech more than he
usual. After a few minutes of pacing his apartment, he threw his
television remote control at his window and yelled at Andy, telling him
to “get the f@#k out of my house!!!” Andy was confused as he felt that
they had always had a positive working relationship.
Case Study 3
 What should Andy do at that moment?
 What are some possible explanations for Larry’s
behavior?
 When Andy returns to his agency, what should he
communicate to his treatment team?
 Whose expertise should he seek to formulate a
treatment plan?
 What should be the team’s action steps in response to
Larry’s outburst?
Questions?
Evaluation.
Please take a moment to give me
feedback!
Thanks!!
