LETTER TO THE EDITOR
Diabetes screening in elderly psychiatric inpatients Introduction Elderly psychiatric patients are at high risk of developing diabetes. Mental illnesses, dementia and their treatments, combined with advancing age and lifestyle factors, contribute to the excess metabolic disease burden in this population. The co-occurrence of mental illness with diabetes is associated with poorer diabetic control, higher rates of diabetic complications, worsened mental health symptoms, more hospital admissions, poorer quality of life and increased mortality (Mai et al., 2011). Metabolic screening among working age adults with mental illness remains suboptimal (Mitchell and Hardy 2013), whereas evidence regarding diabetic screening in elderly psychiatric inpatients is lacking. We aimed to establish firstly the proportion of patients admitted to a representative elderly acute care psychiatric inpatient unit who had diabetes, secondly to establish current local practice with regards to diabetes screening at the time of admission, and finally to establish the unit’s compliance with local and national diabetes screening and management standards (NICE, 2006; NICE, 2009; NICE, 2014) Method We conducted a retrospective case note audit of all patients admitted over 6 months to a 36-bedded acute elderly psychiatric inpatient unit in Northampton. Patients were identified from electronic patient records on the basis of clinical coding after Trust Audit committee approval. Results
Thirty-four (42.5%) patients were screened for diabetes at the time of admission, and a further six (7.5%) later in the course of the inpatient stay. Twenty-nine of 34 (85.3%) patients were screened using fasting plasma glucose, three of 34 (8.8%) with random plasma glucose, and two of 34 (5.9%) with HbA1c. Table 1 reports screening results and action taken. Only six of 70 (8.6%) screened for diabetes and discharged during the course of this audit had the result recorded in their discharge summary. Discussion Diabetes prevalence was 10%, below the current national prevalence estimate in over 65 years of age of 13–15% (Diabetes UK 2012). It is possible that some patients were missed as less that half were screened for diabetes. Low screening rates are likely to reflect a complex interplay of patient, physician and system factors. We noted that the type of laboratory investigation requested for diabetes screening varied. We suggest that the HbA1c should be used and should become the standard unless there are clinical indicators of impaired red cell turnover such as severe anaemia, renal or hepatic failure, that make this test less reliable. HbA1c is a practical solution as it is offers similar validity than a fasting glucose, but requires no fast. Of diabetic screening that was performed, abnormal results were found in a significant proportion of patients (29.4%). Elderly psychiatric inpatients must have comprehensive physical health screening during Table 1 Abnormal diabetes screening results and action taken Diabetes screening results and action taken
Of 80 patients identified, the majority were Caucasian (98.7%) and women (56.2%) with a mean age of 79 years. The most common psychiatric diagnoses were depression and dementia, followed by schizophrenia and bipolar affective disorder. Sixty-nine (86.3%) patients were prescribed psychotropic medicines, of those 23 (33.3%) were prescribed antipsychotics. Ten (12.5%) patients were smokers. Sixty-nine (86.3%) patients had sufficient information available to calculate body mass index of which 39 (56.5%) were overweight or obese. Eight (10%) patients were known to have diabetes at the time of admission. Copyright # 2014 John Wiley & Sons, Ltd.
Diabetes screening at the time of admission Yes No Total Not known to have diabetes Abnormal result Action taken No action taken Normal results Known diabetes Abnormal result Poorly controlled Action taken No action taken
N (%)
34 (42.5) 46 (57.5) 80 7/34 (20.6) 2/7 (28.6) 5/7 (71.4) 24/34 (70.6) 8 (10) 3/34 (8.8) 3/3 (100.0) 1/3 (33.3) 2/3 (66.7)
Int J Geriatr Psychiatry 2014; 29: 1097–1100
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Letter to the Editor
the course of their inpatient stay, often this is most likely to be performed at admission, and must include diabetes testing. Abnormal results must be noted, acted on and followed up and assertively managed. Results must be communicated to the patients and their primary care physicians. Institution where audit conducted Northamptonshire Healthcare Foundation NHS Trust.
References Mai Q, Holman CDJ, Sanfilippo FM, et al. 2011. Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 1(9): 118. Mitchell AJ, Hardy SA. 2013. Screening for metabolic risk among patients with severe mental illness and diabetes: a national comparison. Psychiatr Serv 64(10): 1060–1063. National Institute for Health and Clinical Excellence. 2006. Dementia: Supporting People With Dementia and Their Carers in Health and Social Care. NICE: London. National Institute for Health and Clinical Excellence. 2009. Depression in Adults With a Chronic Physical Health Problem: Treatment and Management. NICE: London. National Institute for Health and Clinical Excellence. 2014. Schizophrenia. NICE: London.
Conflict of interest MK owns shares in GlaxoSmithKline. Key points
• • • •
Clinicians should be aware of the increased risk for diabetes amongst elderly psychiatric patients. Psychiatrists should be familiar with evidencebased guidelines for diabetes screening. Diabetes screening should form part of the physical health assessment at the time of admission. Psychiatrists must act on abnormal invesigations and communicate results as a matter of course with primary care colleagues.
1
MARLENE KELBRICK1,* AND MARCO PICCHIONI2,3 Specialty Registrar, General Adult Psychiatry, Leicestershire Partnership NHS Trust, Clinical Leadership Fellow St Andrews Academic Centre, Northampton, UK 2 St Andrew’s Academic Centre, Northampton, UK 3 Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, King’s College, London, UK *Email: [email protected]; [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4152
Information processing speed remains low in school teachers a decade after recovery from depression Depression is well known to be associated with cognitive dysfunction, although it is unclear to what extent these symptoms resolve after recovery (Hasselbalch et al., 2011). The majority of studies into post-depression cognitive abnormalities have assessed clinical populations with considerable confounding factors. The current study aimed to investigate whether post-depression cognitive abnormalities were evident in a non-clinical group with minimal confounding factors and to test the null hypothesis that lifetime duration of depression does not have a linear relationship with cognitive dysfunction. Cognitive function of a ‘remitted’ group (n = 21) with a history of two or more depressive episodes was compared with that of 21 controls with no Copyright # 2014 John Wiley & Sons, Ltd.
depression history. Participants were drawn from a larger longitudinal study, which commenced in 1978, during which lifetime depression history (in weeks) had been compiled (Wilhelm and Parker, 1989). Current exclusion criteria included current depression according to the Patient Health Questionnaire -9 (PHQ-9; Kroenke et al., 2001), depressive episode in the last 12 months, antidepressant treatment, history of substance or alcohol misuse, smoking, neurological damage, suicide attempt and psychiatric disorder other than unipolar depression. Participants undertook tests of premorbid intelligence, processing speed, verbal learning and memory, visual memory, verbal fluency and cognitive flexibility between March 2010 and March 2013. Int J Geriatr Psychiatry 2014; 29: 1097–1100
Diabetes screening in elderly psychiatric inpatients Introduction Elderly psychiatric patients are at high risk of developing diabetes. Mental illnesses, dementia and their treatments, combined with advancing age and lifestyle factors, contribute to the excess metabolic disease burden in this population. The co-occurrence of mental illness with diabetes is associated with poorer diabetic control, higher rates of diabetic complications, worsened mental health symptoms, more hospital admissions, poorer quality of life and increased mortality (Mai et al., 2011). Metabolic screening among working age adults with mental illness remains suboptimal (Mitchell and Hardy 2013), whereas evidence regarding diabetic screening in elderly psychiatric inpatients is lacking. We aimed to establish firstly the proportion of patients admitted to a representative elderly acute care psychiatric inpatient unit who had diabetes, secondly to establish current local practice with regards to diabetes screening at the time of admission, and finally to establish the unit’s compliance with local and national diabetes screening and management standards (NICE, 2006; NICE, 2009; NICE, 2014) Method We conducted a retrospective case note audit of all patients admitted over 6 months to a 36-bedded acute elderly psychiatric inpatient unit in Northampton. Patients were identified from electronic patient records on the basis of clinical coding after Trust Audit committee approval. Results
Thirty-four (42.5%) patients were screened for diabetes at the time of admission, and a further six (7.5%) later in the course of the inpatient stay. Twenty-nine of 34 (85.3%) patients were screened using fasting plasma glucose, three of 34 (8.8%) with random plasma glucose, and two of 34 (5.9%) with HbA1c. Table 1 reports screening results and action taken. Only six of 70 (8.6%) screened for diabetes and discharged during the course of this audit had the result recorded in their discharge summary. Discussion Diabetes prevalence was 10%, below the current national prevalence estimate in over 65 years of age of 13–15% (Diabetes UK 2012). It is possible that some patients were missed as less that half were screened for diabetes. Low screening rates are likely to reflect a complex interplay of patient, physician and system factors. We noted that the type of laboratory investigation requested for diabetes screening varied. We suggest that the HbA1c should be used and should become the standard unless there are clinical indicators of impaired red cell turnover such as severe anaemia, renal or hepatic failure, that make this test less reliable. HbA1c is a practical solution as it is offers similar validity than a fasting glucose, but requires no fast. Of diabetic screening that was performed, abnormal results were found in a significant proportion of patients (29.4%). Elderly psychiatric inpatients must have comprehensive physical health screening during Table 1 Abnormal diabetes screening results and action taken Diabetes screening results and action taken
Of 80 patients identified, the majority were Caucasian (98.7%) and women (56.2%) with a mean age of 79 years. The most common psychiatric diagnoses were depression and dementia, followed by schizophrenia and bipolar affective disorder. Sixty-nine (86.3%) patients were prescribed psychotropic medicines, of those 23 (33.3%) were prescribed antipsychotics. Ten (12.5%) patients were smokers. Sixty-nine (86.3%) patients had sufficient information available to calculate body mass index of which 39 (56.5%) were overweight or obese. Eight (10%) patients were known to have diabetes at the time of admission. Copyright # 2014 John Wiley & Sons, Ltd.
Diabetes screening at the time of admission Yes No Total Not known to have diabetes Abnormal result Action taken No action taken Normal results Known diabetes Abnormal result Poorly controlled Action taken No action taken
N (%)
34 (42.5) 46 (57.5) 80 7/34 (20.6) 2/7 (28.6) 5/7 (71.4) 24/34 (70.6) 8 (10) 3/34 (8.8) 3/3 (100.0) 1/3 (33.3) 2/3 (66.7)
Int J Geriatr Psychiatry 2014; 29: 1097–1100
1098
Letter to the Editor
the course of their inpatient stay, often this is most likely to be performed at admission, and must include diabetes testing. Abnormal results must be noted, acted on and followed up and assertively managed. Results must be communicated to the patients and their primary care physicians. Institution where audit conducted Northamptonshire Healthcare Foundation NHS Trust.
References Mai Q, Holman CDJ, Sanfilippo FM, et al. 2011. Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 1(9): 118. Mitchell AJ, Hardy SA. 2013. Screening for metabolic risk among patients with severe mental illness and diabetes: a national comparison. Psychiatr Serv 64(10): 1060–1063. National Institute for Health and Clinical Excellence. 2006. Dementia: Supporting People With Dementia and Their Carers in Health and Social Care. NICE: London. National Institute for Health and Clinical Excellence. 2009. Depression in Adults With a Chronic Physical Health Problem: Treatment and Management. NICE: London. National Institute for Health and Clinical Excellence. 2014. Schizophrenia. NICE: London.
Conflict of interest MK owns shares in GlaxoSmithKline. Key points
• • • •
Clinicians should be aware of the increased risk for diabetes amongst elderly psychiatric patients. Psychiatrists should be familiar with evidencebased guidelines for diabetes screening. Diabetes screening should form part of the physical health assessment at the time of admission. Psychiatrists must act on abnormal invesigations and communicate results as a matter of course with primary care colleagues.
1
MARLENE KELBRICK1,* AND MARCO PICCHIONI2,3 Specialty Registrar, General Adult Psychiatry, Leicestershire Partnership NHS Trust, Clinical Leadership Fellow St Andrews Academic Centre, Northampton, UK 2 St Andrew’s Academic Centre, Northampton, UK 3 Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, King’s College, London, UK *Email: [email protected]; [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4152
Information processing speed remains low in school teachers a decade after recovery from depression Depression is well known to be associated with cognitive dysfunction, although it is unclear to what extent these symptoms resolve after recovery (Hasselbalch et al., 2011). The majority of studies into post-depression cognitive abnormalities have assessed clinical populations with considerable confounding factors. The current study aimed to investigate whether post-depression cognitive abnormalities were evident in a non-clinical group with minimal confounding factors and to test the null hypothesis that lifetime duration of depression does not have a linear relationship with cognitive dysfunction. Cognitive function of a ‘remitted’ group (n = 21) with a history of two or more depressive episodes was compared with that of 21 controls with no Copyright # 2014 John Wiley & Sons, Ltd.
depression history. Participants were drawn from a larger longitudinal study, which commenced in 1978, during which lifetime depression history (in weeks) had been compiled (Wilhelm and Parker, 1989). Current exclusion criteria included current depression according to the Patient Health Questionnaire -9 (PHQ-9; Kroenke et al., 2001), depressive episode in the last 12 months, antidepressant treatment, history of substance or alcohol misuse, smoking, neurological damage, suicide attempt and psychiatric disorder other than unipolar depression. Participants undertook tests of premorbid intelligence, processing speed, verbal learning and memory, visual memory, verbal fluency and cognitive flexibility between March 2010 and March 2013. Int J Geriatr Psychiatry 2014; 29: 1097–1100
