A schizophrenic patient with poorly controlled diabetes
Mr. T was in his late 50s and being treated for schizophrenia, noninsulin-dependent diabetes, and hypertension. He had lived in the same assisted-living facility for the past four years and had expressed satisfaction with the arrangements. He spent most of his time at the home resting, smoking, and walking to the local store. He attended adult day care briefly, but had not enjoyed the activity, preferring to remain alone during the day.
Mr. T was alert and oriented, and cooperative and responsive to questioning, but offered little information voluntarily. He reported no hallucinations but could sometimes be seen responding to internal stimuli and would occasionally complain of having unusual thoughts that disturbed him.
1. History and physical examination
After Mr. T was diagnosed with noninsulin-dependent diabetes mellitus in 2003, medications were added and titrated in a sequential manner, beginning with metformin (Fortamet, Glucophage, Glumetza, Riomet) and followed by glyburide (Diabeta, Glycron, Glynase, Micronase), acarbose (Precose), and isophane insulin (Humulin).
The patient received counseling regarding the diabetic diet but expressed little interest. The caretakers at his residence were asked to provide the patient with a diabetic diet, which they did, but Mr. T still had access to snacks that he would purchase on his own. When waiting in the clinic area, he would regularly be seen consuming candy and soda. He was polite when listening to suggestions that he avoid candy and drink diet sodas but never made any commitment to change behavior.
When Mr. T was initially diagnosed with diabetes, his hemoglogin (Hb) A1c was 13.7%. Over a six-year period, this level ranged from a low of 5.7% to a high of 10.7% when the patient was lost to treatment.
In keeping with recommendations from the American Diabetes Association (ADA), efforts were made to keep Mr. T's HbA1c <7%.1 During this time, the patient's weight fluctuated between 201 and 239 pounds with no clear pattern to the gains and losses. His medication regimen is listed in Table 1.
Mr. T had been taking a higher dose of quetiapine, but it was lowered because of the potential for atypical antipsychotics to elevate glucose levels.2 When medication adjustment and somewhat casual dietary counseling proved ineffective, more effort was made to assist the patient in modifying his diet. The caretakers at the patient's assisted-living facility were asked to remind him when he was not making choices consistent with a diabetic diet. Mr. T also received ongoing support from a social worker and was offered a referral to attend a group diet-and-exercise program, but he did not wish to participate.
Mr. T never complained about the increase in direct supervision of his diet, but several weeks into the plan, he became upset for no discernible reason. He was argumentative and refused to take his medication. He got on a bus and went to a nearby city. Mr. T knocked on the door of the boardinghouse he had lived in many years ago and asked if he could return. The landlady assented and took him to the hospital to find out about his medications. At that time, the social worker and a caretaker were informed of his whereabouts and told that he would not be returning to the assisted-living facility. Mr. T never provided an explanation for his sudden departure.
It is possible that the pressure placed on Mr. T to alter his unhealthy diet interfered too much with his perceived quality of life. Although an assisted-living facility provides a less restrictive environment than a hospital or nursing home, residents do not enjoy the same degree of freedom as when living independently.
It may be difficult to assess quality of life in patients who have a problem expressing their feelings. One study looked at how 35 patients hospitalized on an acute psychiatric ward with serious mental illness, including schizophrenia, rated items important to their quality of life.3 The most highly rated item was mental and physical health. However, two patients rated freedom as most important to their quality of life.
It is possible that Mr. T responded to the loss of the freedom to make his own choices regarding what to eat by moving to another home. The American Dietetic Association's (ADA's) position is that the dietary prescriptions of older persons residing in long-term-care facilities may be liberalized, with the primary goals being the provision of medical care that maintains health and the maintenance of quality of life.4
The ADA standards of care also allow for relaxation of the goals for HbA1c in older adults on an individualized basis. It is recommended, however, that glucose be controlled well enough to prevent acute diabetic complications. While Mr. T resided in an assisted-living rather than a long-term-care facility, some of the same principles may apply, as the severity of his mental illness made it unlikely for him to have been able to return to an independent lifestyle.
Mr. T might have been happier had the HbA1c goals been less stringent. His 24-hour dietary intake was not recorded. Doing so might have been useful in determining areas in which he was willing to make changes. Mr. T might also have been receptive to coaching strategies designed to improve diabetic control.
Coaching has been proposed as a way to communicate with diabetic patients in a collaborative, participatory way.5 In this process, a coach helps the patient set goals that are personally meaningful and work toward meeting those goals. Unlike teaching, mentoring, or therapy, the patient is very much involved in his or her own care and receives support and motivation from the coach. Such an approach might have allowed Mr. T to have more input into the dietary plan and feel more in control.
Mr. T's persistent psychotic symptoms likely made it difficult for him to participate in a group diet-and-exercise program. A grounded theory study found that good control of psychotic symptoms is the priority in a patient coping with diabetes and schizophrenia.6 This control allows the patient to focus on diabetes self-care. Perhaps Mr. T would have been more willing to address his diabetes care if more attention had been paid to his vague complaints of unusual thoughts.
Our quest to comply with evidence-based guidelines and obtain specific outcomes may have deprived Mr. T of eating too many of the foods that he enjoyed. This brings up the issue of how to balance the clinician's interest in preserving the patient's physical health with his or her quality of life and personal choices. Such balance may be particularly difficult to achieve when the patient is also suffering from a psychotic illness.
More frequent contact with the patient to assess misperceptions regarding the dietary plan and increased efforts to allow the patient to provide input may have increased Mr. T's comfort and willingness to adhere to the plan. Individual sessions with a nutritionist might also have been less threatening than a group diabetic class. In lieu of a group exercise plan, Mr. T could have been encouraged to take a daily walk. This case highlights the need to assess each patient and tailor a plan that is therapeutically sound while taking individual requirements and desires into consideration.
Marilyn J. Miller, PhD, CRNP, CS-P, and Deborah Qualls, LCSW-C, is a nurse practitioner and clinical specialist, and Ms. Qualls is a community residential care program coordinator, with the VA Maryland Health Care System in Perry Point.
- American Diabetes Association. Standards of medical care in diabetes—2010. Diabetes Care. 2010;33 Suppl 1:S11-61.
- Lambert BL, Cunningham FE, Miller DR, et al. Diabetes risk associated with use of olanzapine, quetiapine, and risperidone in veterans health administration patients with schizophrenia. Am J Epidemiol. 2006;164:672-681.
- Pitkänen A, Hätönen H, Kuosmanen L, Välimäki M. Individual quality of life of people with severe mental disorders. J Psychiatr Ment Health Nurs. 2009;16:3-9.
- Niedert KC; American Dietetic Association. Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc. 2005;105:1955-1965.
- Hayes E, McCahon C, Panahi MR, et al. Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes. J Am Acad Nurse Pract. 2008;20:155-162.
- El-Mallakh P. Evolving self-care in individuals with schizophrenia and diabetes mellitus. Arch Psychiatr Nurs. 2006;20:55-64.