Guidelines for Integrated Care (Psychiatric & Medical) In the Community

1. Guidelines for Integrated Care (Psychiatric & Medical) In the Community Module I: Diabetes and Glucose Monitoring

2. 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

3. 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 self-care, 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

4. Key Concept: Circulatory System

5. Controlling Blood Sugar: Balancing Act

6. Module I Part A: Importance of Integrated Care

7. 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)

8. Multi-State Study Mortality Data: Years of Potential Life Lost (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) Compared to the general population, persons with major mental illness typically lose 25 to 30 years of normal life span

9. Ohio Named 10th Fattest State: Persons with mental illness die even earlier in Ohio

10. 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)

11. 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)

12. Metabolic Syndrome

13. 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

14. What is Metabolic Syndrome? • Abdominal obesity: waist circumference >40 inches in men and >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

15. 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

16. 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

17. 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*)

18. 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

19. 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

20. 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

21. Risk Factors for Developing DM • Sedentary life style • Smoking • Nutritional intake • High BMI • Poverty • Genetic vulnerability

22. 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

23. DM: Racial Mis-representation

24. 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

25. 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

26. 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

27. Module I Part B: Implementing Guidelines for Diabetes within Community-Based Mental Health Services

28. Together we can make a difference!

29. 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

30. 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)

31. 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

32. 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

33. 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

34. 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?

35. 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?

36. 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?

37. 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?

38. 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

39. 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)

40. 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

41. 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

42. Early Signs of Hyperglycemia • Increased thirst/hunger • Headaches • Difficulty concentrating • Blurred vision • Frequent urination • Fatigue (weak, tired feeling) • Weight loss

43. 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

44. Urgent Hyperglycemia Conditions • Urgent signs: • Seizures • Hallucinations • Confusion • Disorientation • 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

45. 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

46. 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

47. Signs of Hypoglycemia • Hunger • Shakiness • Nervousness • Sweating • Dizziness or light-headedness

48. Signs of Hypoglycemia • CONFUSION and AGITATION/Combativeness • Difficulty speaking • Anxiety • Weakness • If severe/untreated: seizures, coma, and death

49. 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

50. Chronic uncontrolled DM Complications • Complications of Diabetes are found in all body systems: • Eyes • Peripheral nervous system • Blood vessels • Heart