Managing Diabetes in a Patient with Enduring Mental Health

Lavinia had suffered a relapse in her mental health and had been using illicit drugs and alcohol to combat the disturbing positive symptoms of her illness and had stopped taking any of her prescribed medications. The nursing assessment indicated that the first issue to deal with was her chaotic behaviour and once that was under control a series of therapeutic interventions could be put in place to aid her recovery. Initially her chaotic presentation and challenging behaviours (Beer et al, 2005; Xeniditis et al, 2001) made it difficult to engage with her with in a therapeutic way and she resisted staff’s attempts to help her. The decision was made to manage her using intramuscular injections (IM) of an anxiolytic that necessitated using physical restraint in order to administer the IM.

The first few days were not pleasant for Lavinia due to staff needing to restrain and inject her in order to manage her challenging behaviours but her chaotic behaviour did resolve over time and she became more accepting of staff interventions. Lavinia’s named nurse engaged with her and spent time ‘counselling’ her and a series of therapeutic interventions were agreed. Mental health nurses are specialists in caring for people with mental health problems and it has been identified that they have deficits in their knowledge of diabetes (Nash, 2009).

This was the case in caring for Lavinia at the time. Little emphasis was placed on the importance of managing her diabetes because staff were not aware of the implications of poor diabetes management. Discussion In the United Kingdom mental illness is by far the largest single source of burden of disease. There is no other illness or disease in the combined extent of persistence, prevalence and breadth that impacts on the person more (Friedli and Parsonage, 2007).

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There is an inextricable link between poor mental health and an increased risk of physical illness, increased health risk behaviour, deprivation, poor educational achievement, substance misuse (National Institute for Health and Clinical Excellence, (NICE) 2009). Managing mental illness carries the single largest cost to the National Health Service (NHS) coming in at ? 10. 4 billion (Department of Health, 2012). Schizophrenia is a psychotic disorder that can have a debilitating effect on many aspects of a person’s life including perceptions, thinking, language, emotions, social, behaviour.

The positive symptoms of schizophrenia can include hallucinations of any senses, delusions, disorganized thought processes, causing the person to lose contact with reality. Diabetes is a serious condition that can have a debilitating effect on the person. It can cause kidney failure, blindness, heart disease, stroke, psychosocial problems, if left untreated (NICE, 2008). The United Kingdom is facing a significant increase in the number of people diagnosed with diabetes. In the past 16 years the number of people diagnosed with diabetes has increased from 1. million to 2. 9 million cases and it is estimated that this figure will continue to increase as the number of older people and overweight/obese people increase (Diabetes in the UK, April 2012). Diabetes mellitus is a condition whereby the body is unable to properly use the glucose it produces because of either lack of or resistance to the hormone insulin. There are two main types of diabetes; type 1 & type 2. Insulin is needed to enable the glucose to pass from the blood and enter the cells of the body where it is stored.

Type 1 diabetes occurs when the body (pancreas) is unable to produce its own insulin (an autoimmune disease) and the person needs to have regular daily injections of insulin to counter this. Type 1 diabetes accounts for approximately 10% of all people with diabetes (Diabetes in the UK, April 2012). Type 2 diabetes mellitus is a condition whereby the body either does not produce sufficient insulin or that the person is insulin resistant. It can be treated with medication alone or medication and insulin.

Type 2 diabetes accounts for approximately 90% of all people with diabetes (Diabetes in the UK, April 2012). It is known that type 2 diabetes mellitus has an increased prevalence in people with schizophrenia compared to the the general population (Schoepf et al, 2011). Further, the treatment for schizophrenia is typically with antipsychotic medication and it is now clear that some antipsychotics elevate the risk of developing diabetes and weight gain (iatrogenic effect) though just why this happens is not fully understood (Dixon et al. 000). Lavinia suffers from schizophrenia, is obese, takes antipsychotics, and suffers from type 2 diabetes. Diabetes is potentially a life threatening condition. Blood glucose levels below 3. 5mmol/l are too low for the brain to function; this is hypoglycaemia. The signs of hypoglycaemia are similar to a person experiencing psychoses, e. g. aggression, disorientation, changed behaviour. It would have been imperative that nursing staff should have made it a priority that Lavinia’s blood glucose levels were monitored.

Lavinia could have been experiencing a hypoglycaemic state when in fact nurses might have mistaken this for challenging behaviour. Lavinia’s blood glucose levels might have been above the recommended guidelines (>8mmol/l) which is hyperglycaemia and the nurses would need to have an understanding of the potential elevated blood glucose levels can have, e. g. damage to the micro and macro vascular system leading to blindness, increased risk of heart attack, increased risk of stroke, diabetic ketoacidosis.

Not having sufficient knowledge of diabetes while at the same time caring for someone with diabetes and not acting compromises the nurse’s professional obligations (Nursing and Midwifery Council, NMC, 2002) and the NMC or the courts would have no reluctance in pursuing this should it become an issue (Kane Gorny, 2009). Any nurse who cares for a person needs to be competent. Roach (1992) defines competence as, “the state of having the knowledge, judgment, skills, energy, experience and motivation required to respond dequately to the demands of one’s professional responsibilities”. The nurses caring for Lavinia would therefore be duty bound to refer her to a diabetes nurse/Dr. According to the NICE (2008) recommendations it is vital that people with diabetes receive an annual check up including; blood pressure; feet check; smoking status; urinary albumin test (or protein test to measure kidney function); serum creatinine test; retinopathy screen; cholesterol levels; weight and BMI measurements; HbA1c– blood glucose levels.

Lavinia may have had these checks carried out within the last 12 months but due to her chaotic lifestyle over the past few months her results might differ significantly thus during this admission it would be an opportune time to have these checks carried out. Hypertension can have devastating effects on the person whether they have diabetes or not, e. g. increased risk of stroke, cardiac disease, renal failure. Research by Diabetes UK (2012) found that little more than 50% of people with diabetes were meeting their blood pressure targets which they recommend should be 130/80.

The importance of good foot care in diabetes cannot be overstated. Poor foot care can lead to ulceration and ill health, gangrene and even amputation. Diabetes UK state that up to 80% of amputations annually in England are avoidable. The risks that smoking presents are well documented, e. g. heart disease, stroke, vascular complications, amputation. A person with diabetes is pre disposed to certain illnesses and should he/she decide to smoke then their health risk profile increases considerably by multiplying the potential deleterious effects.

Blood tests can identify potential or actual renal failure. Diabetes causes harm to the micro vascular system which includes the very tiny vessels in the retina of the eye. If this is not addressed it can lead to blindness and Diabetes UK recommend an annual eye screen. High cholesterol levels are serious whether the person has diabetes or not and can lead to heart disease, circulatory complications, stroke, fatty liver. Abnormal levels of cholesterol can cause insulin resistance.

Type 2 diabetes is one of the most serious consequences associated with being obese or overweight. Over the past 25 years the number of people in England who are classed as obese has doubled and it is anticipated by the year 2050 obesity will affect 60% of adult men, 50% of adult women, and 25% of children (Foresight, 2007). The blood glucose levels - HbA1c – is an indicator for risk of damage to blood vessels. NICE (2008) recommend an HBA1c level of between 6. 5% and 7. 5% would be the goal for people with diabetes.

For people with type 2 diabetes, effective blood glucose control can reduce the risk of diabetic eye disease by 25% and kidney damage by 33% (UK prospective Diabetes Study (UKPDS). It is clear that management of diabetes can be a challenging role and a multidisciplinary approach is needed to manage it as effectively as it can be managed. Multidisciplinary teamwork is important in any care giving role (Liberman et al, 2001). The most important person in the multidisciplinary team is Lavinia. She is the person who has the most control and needs to manage her diabetes on a daily basis.

For Lavinia there are two issues; managing schizophrenia and managing diabetes. Using a depot antipsychotic in preference to oral medication would help Lavinia because a nurse would administer it weekly thus reducing the risk of relapse. NICE guidelines (2009) advise that people with schizophrenia should be offered access to psychological therapies including cognitive behavioural therapy (CBT) and/or family therapy. If Lavinia did benefit from psychological interventions it might reduce her reliance on medication thus reducing side effects.

In order to manage her diabetes Lavinia should have access to a team of professionals including diabetic nurses; podiatry; Dr’s; ophthalmology; dietician; pharmacist; physiotherapist; counsellor. An assessment for management of diabetes should be holistic (Dunning, 2009 pgs. 36 - 49) and appropriate to a person’s lifestyle. For Lavinia this means sitting down with a specialist diabetic nurse and having a complete assessment of her lifestyle and her understanding of how it interacts with her diabetes. She needs to fully understand the importance of good glucose control and the consequences of poor control.

She might already have experienced hypoglycaemic attacks but been unaware of what they were/are, i. e. could be confused with positive effects of schizophrenia. As a starting point it would be appropriate to ensure she knows how to test her blood glucose levels, which is one of the NICE (2008) guidelines, and how to interpret the result. She needs to be aware of the relationship between food intake, physical activity and medication understanding how managing these can help her maintain appropriate blood glucose levels. Diet is known as the cornerstone of management in type 2 diabetes.

An appropriate diet will help control blood glucose levels, maintain an appropriate weight/body mass index, and prevention of complications. Lavinia is obese which is possibly due to the combination of antipsychotic medications she takes for schizophrenia and her lifestyle. An assessment by a dietician or specialist diabetic nurse into her eating habits would help to identify any areas she would benefit from by making changes to her diet. The ‘Eatwell Plate’ (Department of Health, 2011) offers a model for healthy eating in the United Kingdom (see appendix 2).

It gives good visual, easy to understand, guidance on the balance/proportion and types of food that contribute to a healthy diet. Lavinia would benefit from an assessment with the physiotherapists to determine her level of fitness and areas that could be worked on in order to improve her fitness with a view to losing weight. Exercise can reduce the risk of major illnesses e. g. heart disease, stroke, diabetes and cancer by up to 50% (National Health Service, 2012). However, the benefits of exercise on glycaemic control and body mass in type 2 diabetes is not clear (Boule’ et al, 2001).

The potentially damaging effects that diabetes can have on a person are well known and documented (e. g. UK prospective Diabetes Study, 1977 thru 1997 (UKPDS). The damaging effects of poor blood glucose control are not always immediately observable and consequently people with diabetes do not always fully appreciate the importance of controlling their blood glucose levels (see Mail Online, 2010). The reality of diabetes care is self management and effective self management delays the onset of complications. Lavinia needs to understand how the lifestyle choices she makes, e. . level and frequency of physical activity, what and when she eats, managing her mental health, are all major factors in controlling her diabetes. Because the damaging consequences of not managing diabetes are not immediately obvious the impetus to manage it is not always paramount (Diabetes UK, 2012). It might be enough that Lavinia understands these factors and therefore takes action to manage her condition. If not, she would need support to help her change her behaviour/lifestyle in order to manage her diabetes. There are several models of behavioural change, e. g. ealth belief model (Becker, 1974); theory of reasoned action (Fishbein and Atzen, 1975); social learning theory (Bandura, 1977). Motivational interviewing (MI) (Rollnick and Miller, 1995) is a model that is used to bring about behavioural change and has been shown to be effective in bringing about change in a range of healthcare settings including diabetes care, e. g. VanWormer et al (2004); Clark and Hampson (2001); Kim et al (2004). The aim of MI is to bring about discrepancy in the persons beliefs and thoughts by bringing about a state of cognitive dissonance, i. e. he difference between where the person is currently and where they want to be in future and setting small goals to achieve. Thus, Lavinia has full knowledge of the damaging effects diabetes can have and in future she would like to get married and have children. To have children she needs to be as ‘healthy’ as she can be and therefore she will be self motivated to resolve the dissonance she experiences. Used in combination with Prochaska and DiClemente’s model, stages of change (1983) and Egan’s (1998) skilled helper model of problem management could work to good effect for Lavinia in bringing about a change.

Conclusion The link between poor mental health and poorer outcomes for physical illness, increased health risk behaviour, deprivation, educational achievement, substance misuse is well known (NICE, 2009). Diabetes is potentially a life threatening condition; Lavinia has schizophrenia and diabetes. Her poor mental health could be supporting the deleterious effects of her diabetes. Not having sufficient knowledge of diabetes while at the same time caring for someone with diabetes and not addressing it compromises the nurse’s professional obligations (NMC, 2002).

Lavinia needs support from both the mental health and diabetes services. She needs to have a good understanding of the interplay between the diabetes and mental health. She needs to have insight into potential relapse signatures to her mental health so that she can get help as early as possible. A diabetes counsellor could help Lavinia make lifestyle changes by engaging her in a course of motivational interviews (Rollnick and Miller, 1995) in combination with Prochaska and DiClemente’s model, stages of change (1984) and Egan’s (1998) skilled helper model of problem management.

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