- Patients with diabetes are often stigmatised and healthcare workers can feel frustrated managing them
- Some antipsychotics can increase the risk of diabetes – especially clozapine and olanzapine, but also quetiapine and risperidone
- Very rarely patients can deliberately over or under-treat with insulin and mislead the clinical team
Refusal of treatment for DKA
- Document capacity assessment (see below)
- See if they will accept a modified DKA protocol – negotiate! This may involve slower correction, less invasive tests, alternative insulin administration ie subcutaneous
- Understand what the barriers and fears are
- Check their mental health record and whether there are any individualised care plans
- Consider involving liaison psychiatry (psychiatry review often useful during same admission as they may not attend future appointments)
- If they regain capacity (before they are fully treated for DKA) – and decline further treatment, then treatment must stop
- Involve their family if around
- If no capacity – treat in their best interests
- The capacity assessment
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- Can be difficult (involve liaison psychiatry if unsure)
- If malnourished and omitting insulin to lose weight, their judgment may be clouded and they may not be able to weigh up all information
- Capacity can fluctuate
- Management of diabetes is not a single decision, it involves multiple frequent decisions (that together form a kind of macro decision) regarding insulin, diet, monitoring, hospital attendance etc
- Occasionally patients who are unable to manage their diabetes due to a mental disorder are moved to care homes with DOLS in place
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Recurrent DKA in type 1 DM
- Causes
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- Disordered eating (diabulimia)
- Insulin-omission due to self-neglect / diabetes distress / personality disorders
- Substance misuse
- Vulnerability – learning disability, dementia, mental illness (safeguarding issues)
- Poor diabetes education
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- All-cause mortality post-DKA is around 15%
- Risk factors – low socioeconomic status, adolescence, women, high HbA1c, history of mental illness
- Ask about
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- Recent life events and stressors
- Employment and relationships
- Diabetes-related distress (Can do the diabetes distress scale, or abridged DDS-2 screening scale)
- Drugs/ETOH
- Their understanding of risks
- Suicidal thoughts
- Eating (could phrase it as ‘some people have told me they…, do you sometimes feel that way?)
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- Refer to a psychiatrist with an interest in diabetes
- Psychotherapy is proven to reduce diabetes-related admission (reminders don’t really work). Address acceptance, anger, threat to independence, difficult emotions, motivation, hopelessness
- Social services input to deal with housing etc (diabetes is classed as a disability)
Recurrent severe hypoglycaemia
- Can be accidental
- Can be a suicide / self-harm attempt – ask (attempted suicide is 3-4x higher in T1DM than in general population)
- Occasionally malingering
- Most cases of insulin overdose are self-harm/attempted suicide
- For management of insulin overdose, see prescribed drug toxicities
T1DE (Type 1 diabetes and disordered eating)
- Insulin omission for weight loss. Can cause recurrent DKA. Others restrict carbs but use insulin appropriately
- Linked to body dysmorphia
- Standardised mortality rate is 12 x higher
- Fairly common (and bulimia itself is twice as common in T1DM than normal population)
- Most have a normal weight / BMI
- HbA1c can be normal
- Ask about it – screen all diabetics for eating disorders (and especially if poor adherence to treatment)
- See eating disorders, and check the MEED guidelines
- Avoid refeeding syndrome