Week 9 - Diabetes and Mental Health (B) Flashcards
Outline what a mini mental state examination tests for, including the rough categories
Tests for impaired cognition, especially in relation to dementia or head injury
Shouldn’t be used to make a diagnosis, but can be used to indicate the presence of cognitive impairment
Rough categories - ‘CORRAL’:
- Copying / drawing
- Orientation
- Registration
- Recall
- Attention
- Language
Outline what the scores from a MMSE mean, including the maximum score possible
Maximum score possible = 30
25 to 30 = normal
21 to 24 = mild cognitive impairment
10 to 20 = moderate cognitive impairment
< 10 = severe impairment cognitive impairment
Outline what a GP assessment of cognition test is used for and roughly outline what the 2 halves entail
GPCOG was developed as a more practical tool as the MMSE was too difficult to use in general practice (takes 4 mins rather than 10)
Part 1 - ask patient about various details including the date, draw a clock face and recent news events
Part 2 - speak to relative / close friend (informant) about what patient is like compared to a few years ago
Outline the range of scores for GPCOG, including max score possible and what they mean (part 1 and part 2)
Part 1: max score possible = 9
9 = no significant cognitive impairment, no further testing
5 to 8 = proceed to Part 2, informant section
0 to 4 = cognitive impairment, conduct further investigations
Part 2: max score possible = 6
Count number of ‘no issues’
4-6 ‘no issues’ = no cognitive impairment
0-3 ‘no issues’ = cognitive impairment, conduct further investigations
List some factors that may increase someone’s risk of suicide (non-modifiable, medical-related, modifiable)
Non-modifiable:
- Male gender
- Family history of mental disorder / suicidal thoughts / suicide
Medical:
- Other mental health issues: severe depression / anxiety / personality disorder
- Recent discharge from psychiatric inpatient care
- Physical illness (especially recently diagnosed, chronic or painful)
Modifiable:
- History of previous suicide attempts / self-harm
- Alcohol / drug abuse
- Exposure to suicidal behaviour
- Access to resources / means
List some protective factors against suicide
- Social support e.g. friends / family
- Religious beliefs
- Responsibility of children (especially young children)
Outline the similarities and differences between suicide and self-harm
The key difference between self-harm and suicide is intent, despite having similar risk factors
Self-harm:
- Destructive behavior without any intention of suicide
- Usually used to cope with their feelings and stressors
- Coping strategy for preserving and enhancing life, not ending their life
Suicide:
- Intent to end their life due to ending their suffering
- Usually comes from a place of despair, hopelessness, and worthlessness
Outline some resources for patients experiencing suicidal ideation
NHS 111 (24 hours)
Samaritans (24 hours)
PAPYRUS (mainly during working hours)
Campaign Against Living Miserably or CALM (5pm-midnight)
Shout Crisis Text Line - can text “SHOUT”
Plus local charities / companies
List some risk factors associated with self-harm
- Pre-existing depression or anxiety
- Feelings of worthlessness / isolation
- History of trauma / abuse
- History of chronic stress
- Alcohol or substance abuse (or previous)
- High emotional perception and sensitivity
- Poor effective mechanisms for dealing with emotional stress
Outline the relationship between self-harm and suicide
- Presence of non-suicidal self-injury is a risk factor for suicidal thoughts and behaviors
Self-harm and suicide both indicate underlying distress, it is important to assess whether self-harming individuals are also suicidal
If so, provide the necessary treatment for individuals in both of these categories
Outline the management steps to be taken in someone presenting with self-harm
- Assess injury severity and provide necessary treatment
- Patient’s current emotional and mental state and level of distress
- Assess whether there is immediate concern about the person’s safety and ASSESS SUICIDE RISK
- Identify any safeguarding concerns
Management plan:
- CBT – starting asap
- Create a safety plan e.g. establish method, reduce risks if possible, identify barrier to treatment, identify coping strategies, establish protective factors
- Provide contact numbers for safety netting
Outline some reasons to refer a self-harm patient to a specialist mental health service for assessment
- Increase in frequency or degree of self-harm / suicidal intent
- Patient requests further support
- Concern from professional or from patient’s family/friends
List some complications of T1DM
- Macrovascular
- Microvascular
- Metabolic
- Psychological
- Other
Macrovascular complications
- MI
- Stroke
- Peripheral arterial disease
Microvascular complications
- Retinopathy
- Nephropathy
- Neuropathy
Metabolic complications
- DKA
- Episodes of hypoglycaemia
Psychological complications
- Anxiety
- Depression
- Eating disorders
- Behavioural disorders, relationship difficulties and risk-taking behaviour
Increased risk of developing other autoimmune conditions e.g. thyroid disease, coeliac disease, Addison’s disease, and pernicious anaemia.
Reduced quality of life and life expectancy
Outline why the different microvascular and macrovascular complications occur
Macrovascular:
- Occurs due to chronic atherosclerosis, arteriosclerosis and inflammation
- Endothelial and smooth muscle dysfunction due to increased uptake of the glucose which doesn’t need insulin for this process (however glucose can’t actually reach the inside of the cell)
- Increased uptake of glucose leads to release of ROS, which causes inflammation and localised damage
- Dysfunctional endothelium allows LDLs into the cell and accelerates atherosclerosis
- Overall, leads to MI, stroke and peripheral arterial disease
Microvascular:
- Damaged caused by hypertension (from atherosclerosis and hyperglycaemia) causes blood vessel damage
- This reduces blood flow in small vessels in the eyes, kidneys and peripheral arteries leading to retinopathy, nephropathy and neuropathy
Outline how diabetes is diagnosed (including ranges)
Presence of one or more symptoms of diabetes:
- Polyuria
- Polydipsia
- Weight loss
Plus one of the following blood tests (need 2 if no symptoms, 1 week apart):
- Random plasma glucose concentration
(> 11.1 mmol/l)
- Fasting plasma glucose concentration
(> 7.0 mmol/l)
- Oral glucose tolerance test (OGTT) with 2 hour plasma glucose concentration > 11.1 mmol/l 2 hours after giving 75g glucose
List some symptoms in which patients with undiagnosed diabetes may present to GP
- Peeing a lot
- Excessive thirst
- Weight loss
Plus:
- Blurring of vision
- Frequent infections e.g. thrush
- Tiredness / lethargy / weakness
May also present acutely with symptoms of DKA:
- Reduced consciousness
- Abdominal pain
- Nausea and vomiting
- Pear drop breath
- Polydipsia / polyuria
Describe briefly what diabetes is, as if you were explaining it to a patient
Diabetes is a condition where the body is unable to regulate it’s own levels of sugar in the blood due to problems with insulin
Type 1 - can’t produce the insulin in the pancreas because it’s attacked by the body’s immune system
Type 2 - the cells of the body don’t respond to the insulin being produced
If left unmanaged, lots of complications can occur as a result of diabetes
Are there any screening programmes for T1DM and T2DM?
T1DM - no screening, based on presentation
T2DM - no screening, however NHS Diabetes Prevention Programme (DPP) identifies people with modifiable risk factors and non-diabetic hyperglycaemia (HbA1c 42 - 47 mmol/mol or 6 - 6.4%)
Outline the monitoring required for T1DM patients, including target HbA1c
Measure HbA1c levels at least:
- Every 3 months if < 18 yrs
- Every 3 to 6 months if adults
Target HbA1c = < 48 mmol/mol or < 6.5%
Requires regular monitoring of blood glucose (< 53 mmol/mol or < 7.0 %)
12 monthly:
- Thyroid function tests
- Diabetic eye screen (opticians)
- Urine ACR and eGFR
- Foot checks
- Review cardiovascular risk factors e.g. calculate BMI and BP
Outline the monitoring required for T2DM patients, including target HbA1c
Measure HbA1c levels at least:
- Every 3 to 6 months if things aren’t stable
- Every 6 months if stable
Target HbA1c = < 48 mmol/mol or < 6.5%, slightly less if on hypoglycemic risk medication
Only requires regular monitoring of blood glucose if on insulin treatment
12 monthly:
- Diabetic eye screen (opticians)
- Foot checks
- Urine ACR / eGFR
- Review cardiovascular risk factors e.g. blood pressure
- Bloods for lipid profile
Outline the role of structured education programme ‘DESMOND’ in diabetes
DESMOND = Diabetes Education and Self Management for Ongoing and Newly Diagnosed
- Run a range of group-based and online programmes
- Support for self-management for people who are at risk of developing or currently diagnosed with type 2 diabetes
Outline the role of structured education programme ‘DAFNE’ in diabetes
DAFNE = Dose Adjustment For Normal Eating
- Help adults with type 1 diabetes lead as normal a life as possible, whilst also maintaining blood glucose levels within healthy targets
- Aims to reduce the risk of long-term diabetes complications
Outline the main mechanism of action of Biguanides e.g. Metformin
Inhibits hepatic glucose production
- Stops new glucose from being produced
- Stops breakdown of glycogen
Outline the main mechanism of action of Sulfonylureas e.g. Gliclazide
Inhibits K+ channels in the pancreas
- Causes the pancreas to make more insulin
- However, requires working pancreas *
Outline the main mechanism of action of Thiazolidinediones e.g. Pioglitazone
Activates PPAR-gamma
- Increases peripheral sensitivity to insulin (in muscle and fat tissues)
Outline the main mechanism of action of SGLT-2 inhibitors e.g. Dapagliflozin
Inhibits SGLT-2 transporters in kidneys
- More glucose is lost into the urine
Outline the main mechanism of action of DPP-4 inhibitors e.g. Sitagliptin
Inhibits breakdown of DPP4 enzyme in blood
- So less GLP-1 broken down
- More GLP-1, means less glucose produced by the liver, more insulin production
Outline the main mechanism of action of incretin mimetics (tides) e.g. Exenatide or Liraglutide
Analogue of GLP-1
- So effectively more GLP-1
- More GLP-1, means less glucose produced by the liver, more insulin production
List some contraindications and cautions for use of Biguanides e.g. Metformin
Contraindications:
- Metabolic acidosis e.g. ketoacidosis
Cautions:
- eGFR < 30
List some side effects for use of Biguanides e.g. Metformin
- GI disturbance e.g. abdominal pain, nausea, bloating, and diarrhoea
- Lactic acidosis
- Skin rash
- B12 deficiency
- Loss of appetite
- Metallic taste
- Hypoglycaemia (uncommon but more likely if taken with sulfonylurea or alcohol)
- Hepatitis
List some contraindications and cautions for use of Sulfonylureas e.g. Gliclazide
Contraindications:
- Metabolic acidosis e.g. ketoacidosis
Cautions:
- G6PD deficiency
- Elderly
- Obese
List some side effects for use of Sulfonylureas e.g. Gliclazide
- Hypoglycaemia
- Nausea
- Skin rash
List some contraindications and cautions for use of Thiazolidinediones (glitazones) e.g. Pioglitazone
Contraindications:
- Metabolic acidosis e.g. ketoacidosis
- Heart failure
- Previous / active bladder cancer
Cautions:
- Use alongside insulin (risk of heart failure)
- Elderly
List some side effects for use of Thiazolidinediones (glitazones) e.g. Pioglitazone
Hypoglycaemia!
- Water retention
- Numbness
- Chest infections
- Skin rashes
- Worsening of osteoporosis and bone fractures
List some contraindications and cautions for use of SGLT-2 inhibitors (gliflozins) e.g. Dapagliflozin or Empagliflozin
Contraindications:
- Metabolic acidosis e.g. ketoacidosis
Cautions:
- Hypotension
- Elderly
List some side effects for use of SGLT-2 inhibitors (gliflozins) e.g. Dapagliflozin or Empagliflozin
- Hypoglycaemia / DKA
- Thrush / UTIs
- Polydipsia / polyuria
- Postural hypotension
- Constipation
State a caution for use of DPP4 inhibitors (gliptins) e.g. Sitagliptin
Previous pancreatitis
List some side effects for use of DPP4 inhibitors (gliptins) e.g. Sitagliptin
- Gastrointestinal disturbances e.g. constipation or diarrhoea, N&V
- Acute pancreatitis (uncommon but severe)
- Skin rash
- Headache
- Dizziness
- Tremor
- Muscle aches, joint pain and swelling
List some contraindications and cautions for use of incretin mimetics (tides) e.g. Exenatide and Liraglutide
Contraindications:
- Metabolic acidosis e.g. ketoacidosis
- Severe GI disease
Cautions:
- Pancreatitis
- Elderly
- Low BMI - may cause loss > 1.5 kg weekly
List some side effects for use of incretin mimetics (tides) e.g. Exenatide and Liraglutide
- Gastrointestinal disturbances e.g. constipation or diarrhoea, N&V, GI discomfort
- Inflammation at injection site
- Decreased appetite
- Headache
- Skin reactions
- Weakness
Outline the different classes of diabetes drugs that can be used in the management of diabetes
1st line = Biguanides e.g. Metformin
2nd line = Sulfonylureas e.g. Gliclazide
Other options:
- Thiazolidinediones (glitazones) e.g. Pioglitazone
- SGLT-2 inhibitors (gliflozins) e.g. Dapagliflozin
- DPP-4 inhibitors (gliptins) e.g. Sitagliptin
- Incretin mimetics (tides) e.g. Exenatide
Outline how you go about managing someone with non-diabetic hyperglycaemia (pre-diabetes)
- Refer to the national NHS diabetes prevention programme (for lifestyle changes)
- Yearly blood tests to monitor HbA1c
Outline the general conservative management steps for T1DM
- Ensure care plan is in place
- Offer a structured education programme e.g. DAFNE programme
- Ensure they are set up with contacts to the diabetes specialist team (including how to contact and how often)
- Provide information on diabetes support groups
- Manage lifestyle issues, such as diet, exercise, and alcohol intake
- Monitor for complications regularly
Outline what is covered in an individual care plan for T1DM
Medical assessment:
- Review potentially confounding diseases and drugs
- Investigate vascular risk factors, such as hypertension
- Check substance use or other factors
Individual factors:
- Understand patient preferences on nutrition and physical activity
- Assess emotional state to determine the appropriate pace of education
Outline the medical management steps for T1DM
- Introduce insulin management
- Advise regular blood monitoring up to 10 times per day (or continuous with libre device)
- Continue to monitor for diabetic complications
Outline the advice/support for lifestyle factors in type 1 diabetes for:
- Alcohol
- Smoking
- Diet
- Exercise
Alcohol:
- Avoid drinking on an empty stomach
- Warn about similarity of being drunk and hypoglycaemia
Smoking:
- Advise against smoking / promote smoking cessation
Diet:
- Should have healthy diet to manage CVS risk
- Offer carbohydrate-counting training
- Can refer to the specialist diabetes team
Exercise:
- Warn about risk of hypoglycaemia
- Regular exercise to manage CVS risk
Outline the general management steps for T2DM (non-pharmacological)
- Ensure care plan is in place
- Offer a structured education programme e.g. DESMOND programme
- Ensure they are set up with contacts to the diabetes specialist team (including how to contact and how often)
- Provide information on diabetes support groups
- Manage lifestyle issues, such as diet, exercise, and alcohol intake
- Offer immunization against influenza and pneumococcal
- Advise about entitlement to free NHS prescriptions
- Monitor for complications regularly
Outline the medical management steps for T2DM
1st line - Metformin (monitor renal function)
- Consider additional drug therapy
- Assess the person’s cardiovascular status
- Regularly monitor for complications and HbA1c
2nd line - Sulphonylureas e.g. Gliclazide
3rd line - add additional oral hypoglycaemics
Outline the advice/support for lifestyle factors in type 2 diabetes for:
- Alcohol
- Smoking
- Diet
- Exercise
Alcohol:
- Avoid drinking on an empty stomach
- Alcohol and some drugs may increase the hypoglycaemic effects of some drugs e.g. Gliclazide
Smoking:
- Advise against smoking / promote smoking cessation
Diet:
- Should have healthy diet to manage CVS risk
- Advise to aim for weight loss if possible
Exercise:
- Regular exercise to manage CVS risk
- Minimize time spent being sedentary
State the 5 stages of grief
Denial
Anger
Bargaining
Depression
Acceptance
