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Minnesota Center for
Chemical and Mental Health
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CLINICAL TIP
RECOGNIZING MEDICAL CRISES:
DIABETES
Approximately 29.1 million people or 9.3% of the U.S. population
have diabetes.1 The risk for diabetes is increased among
individuals who have serious mental illness (SMI).2 Individuals with
bipolar disorder or diagnoses on the schizophrenia spectrum
are 2 to 3 times more likely to develop diabetes than the general
population.3,4 Depression also increases the risk for diabetes.5,6
The high prevalence of diabetes in the SMI population is a result
of biological, lifestyle, and environmental factors.1 Biological
factors may include physiological processes or pharmacological
side effects. Contributing lifestyle and environmental factors may
include little physical activity, poor diet, and lack of access to
quality preventive care, screening, and exercise facilities, which
can lead to obesity and increased risk for diabetes.
A recent analysis of death certificates in Minnesota found that
individuals with SMI have an average life expectancy that is
24 years less than the general population7 — a finding that is
supported by a number of similar analyses.8,9,10,11 Increased risk
for chronic health conditions like diabetes is one reason for
the decreased life expectancy among individuals with SMI. As
a provider, understanding diabetes and teaching individuals
with SMI how to be an active participant in their treatment is
essential for improving quality of life and helping people make
progress in recovery.
WHAT IS DIABETES?
Glucose, commonly referred to as sugar, is an important source of
energy for the body and the main source of energy for the brain.
Insulin, a hormone secreted by the pancreas, helps us to regulate
the amount of glucose in our bloodstream. Individuals who have
diabetes either do not produce insulin (Type 1 Diabetes Mellitus)
or have progressive insulin resistance (Type 2 Diabetes Mellitus),
resulting in an inability to regulate glucose in the bloodstream.12
HYPERGLYCEMIA
Hyperglycemia occurs when blood glucose is too high.13 A
good way to remember the difference between hyperglycemia
and hypoglycemia is to look at the prefixes. Hyper– means
too high (think hyperactive) while hypo– means too low (think
hypoactive). Hyperglycemia is characterized by a gradual onset
of symptoms, though most persons with high blood glucose
levels experience very few symptoms or have symptoms
For more information contact
the Minnesota Center for
Chemical and Mental Health at:
MNCAMH
Kayla Wagenmann, MN, RN, Piper Meyer-Kalos, PhD, LP
and Erik Vanderlip, MD
SIGNS & SYMPTOMS
table 1
HYPERGLYCEMIA
HYPOGLYCEMIA
• Elevated blood glucose
(will depend on patient)
• Blood glucose < 70 mg/dL
• Gradual onset of symptoms
• Cold, clammy skin
• Increase in urination
• Increase in appetite
followed by lack of appetite
• Weakness, fatigue
• Blurred vision
• Headache
• Glycosuria (sugar in the
urine)
• Nausea and vomiting
• Abdominal cramps
• Progression to diabetic
ketoacidosis (DKA) or
hyperosmolar hyperglycemic
syndrome (HHS).
• Rapid onset of symptoms
• Numbness of fingers, toes,
mouth
• Rapid heartbeat
• Emotional changes
• Headache
• Nervousness, tremors
• Faintness, dizziness
• Unsteady gait, slurred
speech
• Hunger
• Changes in vision
• Seizures, coma
for many years without recognizing them (see Table 1). It is
important to help persons identify symptoms and to screen for
diabetes on a regular basis as untreated hyperglycemia can lead
to fatal complications, such as diabetic ketoacidosis (DKA) and
hyperosmolar hyperglycemic syndrome (HHS), in the most severe
and acute cases.12 Signs and symptoms of DKA include shortness
of breath, fruity smelling breath, nausea and vomiting, and very dry
mouth. Signs and symptoms of HHS include excessive thirst, dry
mouth, increased urination, warm and dry skin, fever, confusion,
vision loss, convulsions, and loss of consciousness.
The most significant danger to persons with diabetes are the
complications that follow after long periods of exposure to high
blood glucose. These complications can include eye damage and
blindness, kidney failure, heart attacks and strokes, infections, and
even depression and dementia.
1404 Gortner Avenue,
170 Peters Hall, St. Paul, MN 55108
612•626•9042
[email protected]
http://mncamh.umn.edu
CLINICAL TIP
RECOGNIZING MEDICAL CRISES: DIABETES
1.
If blood glucose is < 70 mg/
dL, the client should eat 15
grams of a simple (fast-acting)
carbohydrate (i.e. 4 to 6 oz
of fruit juice or regular soda;
glucose tabs if available).
Grams of carbohydrate can be
found on the nutrition label of
most food items.
Kayla Wagenmann, MN, RN, Piper Meyer-Kalos, PhD, LP and Erik Vanderlip, MD
response to treatment. Once the client has recovered from the
attack, it is okay to include fat and protein as part of a meal with a
complex carbohydrate.12
RULE
of
15
2. Recheck blood glucose 15 minutes after eating
15 grams of simple carbohydrates.
3. If blood glucose remains ≥ 70 mg/dL, the client should
eat another 15 grams of a simple carbohydrate and
recheck blood glucose 15 minutes after eating.
4. If blood glucose does not improve to ≥ 70 mg/dL after
two or three doses of simple carbohydrates, contact the
health care provider or emergency services.
Signs and symptoms of hyperglycemia will vary per person,
so it is necessary to know the person’s provider orders for
seeking medical care in case of high blood glucose. In the event
of hyperglycemia, the client should continue to take diabetes
medications as ordered, check blood glucose frequently, drink
fluids on at least an hourly basis, monitor for ketones in the urine,
and contact the healthcare provider if indicated.12 The American
Diabetes Association recommends exercising to lower blood
glucose levels.14
HYPOGLYCEMIA
Hypoglycemia occurs when blood glucose falls below the normal
range. The normal range for a random blood glucose test is 70110 mg/dL.12, 15 It is important to recognize signs and symptoms of
hypoglycemia (Table 1) because untreated hypoglycemia can lead to
seizure, loss of consciousness or death.13
Once signs and symptoms of hypoglycemia have been recognized,
the individual should check blood glucose with a glucometer.
If blood glucose is < 70 mg/dL or if the client has a history of
hypoglycemia attacks with unknown blood glucose level, start the
“Rule of 15”.12
Once blood glucose has returned to a level ≥ 70 mg/dL after a
hypoglycemic attack, the client should eat a complex carbohydrate
(i.e. vegetables, legumes, whole-grain bread, brown rice, wholewheat pasta) to prevent another hypoglycemic attack.12
Note: Do not use foods such as candy bars, cookies, milk, or ice
cream to treat hypoglycemic attacks. The fat in these foods will
slow absorption of the glucose (carbohydrates) and delay the
SCREENING AND MANAGEMENT
In the last five years, screening and management of Type 1 and Type
2 diabetes have dramatically shifted thanks to a blood test called
the Hemoglobin A1C (A1C). The A1C is a percentage of hemoglobin
molecules in the blood with a glucose attached to them. Since
hemoglobin molecules turnover in our blood stream periodically,
this percent is correlated with a moving average of blood glucose
over a three month period. For healthy adults, the typical A1C is
4.8-5.6%. Diabetes can be diagnosed with an A1C of 6.5% or greater,
as shown in Table 2. When managing diabetes, the target A1C is 7%
for most nonpregnant adults. Depending on the individual, more or
less rigorous treatment goals may be required.
table 2
DIAGNOSING DIABETES
A1C (percent)
Fasting Plasma
Glucose
(mg/dL)
Oral Glucose
Tolerance
Test (mg/dL)
6.5 or above
126 or above
200 or above
Prediabetes 5.7 to 6.4
100 to 125
140 to 199
Normal
99 or below
139 or below
Diabetes*
About 5
*Diabetes can also be diagnosed through a random plasma glucose test. With this test,
diabetes is diagnosed when blood glucose is greater than or equal to 200 mg/dL and severe
diabetes symptoms are present.
For many adults diagnosed with Type 2 diabetes, initial therapy
does not require the use of insulin injections. Oral medication, diet,
and lifestyle approaches can help achieve target A1C goals. For
individuals in this initial treatment phase, daily glucose monitoring
with finger sticks isn’t necessary and requiring it can dissuade many
from proactively beginning to manage their diabetes. When people
transition to insulin therapy or for Type 1 diabetics who require
insulin, daily blood sugar monitoring is a necessary part of one’s
managing diabetes.
For more information regarding diabetes, visit the American
Diabetes Association website at www.diabetes.org.
References are available for download from our website: http://mncamh.umn.edu
Suggested Citation
Wagenmann, K., Meyer-Kalos, P., & Vanderlip, E. (2016). Recognizing
Medical Crises: Diabetes. Clinical Tip No. 4 (April, 2016): Minnesota
Center for Chemical and Mental Health, University of Minnesota.
MNCAMH is sponsored by funds from the Minnesota Department of Human Services Adult Mental Health Division and Alcohol and Drug Abuse Division.