Download بسم الله الرحمن الرحيم

‫بسم هللا الرحمن الرحيم‬
Presentation for
Physical health and sever
mental illness
1
Topic content
 Introduction
 Common physical health problem with SMI
 Reason why people with SMI many
experience
physical health problem
 Health behavior of people with SMI .
 Treatment related factor that affect the physical health of
people with SMI .

Nursing intervention
…
The link between mental illness and physical health :People with serious mental illness have higher morbidity and
mortality rates of chronic diseases than the general population.
People who have severe mental illness, like schizophrenia ,
depression and mania are at increased risk for a range of physical
illnesses and conditions, including coronary heart disease, diabetes
and greater levels of obesity and hypertension Thus, most if not all
types of mental disorder are associated with an increased rate of early
death
 the prevalence of many physical diseases is higher in persons
with severe mental illness than in the general population .
 mortality due to physical diseases is higher in persons with
severe mental illness than in the general population.
 , and the gap concerning mortality due to some diseases (like :ischemic heart disease) has been increasing in recent decades
2
 the access to physical health care of persons with severe mental
illness is reduced compared to the general population.
 the quality of physical health care received by persons with
severe mental illness is poorer than the general population
People with severe mental illness face a greater risk of developing
some physical health problems. For example, people who have
schizophrenia or bi-polar disorder have
1)
2)
3)
2-4 times greater risk of cardiovascular
disease
2-4 times greater risk of respiratory
disease
5 times greater risk of diabetes
issues
The issue of protection and promotion of physical health in persons
with severe mental illness is emerging as one of great public health
and ethical relevance worldwide. If we are really concerned about the
quality of life of our patients with severe mental disorders and with
the protection of their civil rights, we cannot ignore that physical
health is a crucial dimension of quality of life in these persons, and
that the access to a physical health care of the same quality as that
available to the rest of the population is a basic right of these persons
as human beings and as citizens.
policy
 The promotion of physical health care in people with severe
mental illness is today a key issue in our field. If we do not
regard it as a priority, we will not be able to state convincingly
that a better quality of life and the protection of the civil rights
of our patients is really what we strive toward.
 People with different illnesses or disorders will have different
illness experiences, including;
 the types of symptoms experienced .
 how daily life and ability to function 'normally' is affected
3
 and what types of treatment may be effective.
 Education and training of mental health professionals and
primary care providers is one more essential step..
 They should be educated about the importance of recognizing
physical illness in people with severe mental disorders.

They should be encouraged to familiarize themselves with the
most common reasons for under diagnosis or misdiagnosis of
physical illness in their patients..

 Another essential step is the development of an appropriate
integration between mental health and physical health care.

There is some debate in the literature about who should
monitor physical health in people with severe mental illness.
What really matters, however, is that there is always somebody
who cares every patient should have a professional who is
identified as responsible for his/her physical health care.
 On the other hand, mental health services should be able to
provide at least a standard routine assessment of their patients,
to identify or suspect the presence of physical health problems.
Physical health-check








During the health-check, the GP or practice nurse will :Take blood pressure
Take pulse rate
Do a urine or blood test
Measure weight
Ask about smoking
Ask about alcohol consumption
Check date of last smear test
What are cause the physical health problem :-
4
 Health behaviors – Smoking, diet, physical inactivity, alcohol &
substance misuse, sexual behavior
 Illness – Symptoms, poor spontaneous reporting of physical
health problems
 Services not geared to meet peoples needs … - Lack of
knowledge, lack of training, attitudes, confidence, lack of
integrated care
 Adverse effects of medication – Extra pyramidal side effects,
weight gain, glucose intolerance & diabetes, cardiovascular
effects, sexual dysfunction, neuroleptic malignant syndrome
 Environment – Poverty, poor housing, social exclusion
 Difficulties recognizing symptoms
 Barriers to accessing primary care
 Communication barriers
 Inequalities in screening & treatment
 Factor related to having SMI : The people with schizophrenia are less likely to spontaneously
report physical symptoms .
 Because they may be unaware of physical problem because of
cognitive deficit associated with the schizophrenia
 Also socio-economic of having mental disorder such as
poverty , poor housing ,reduce social networks , lack of
employment , social stigma ..
 Health behavior of people with SMI
 The most common increase morbidity and mortality rate in
people with SMI their habits : Rate of smoking
 Poor housing
 lack of Exercise
 Substance abuse
 Unsafe sexual practice
5
 (2003) comprehensive survey of 102 service users with
schizophrenia identified that : 70% were smoker
 86% of female over weight
 70% of male were over weight
 53 % had raised cholesterol
 All of these are related to their behavior
Premature Mortality : Six major causes of death in and increased relative risk in SMI:o Cardiovascular Disease 3.4 X
o Cancer Maybe lower rates except lung
o Stroke 2x in age < 50
o Respiratory disease 5x
o Accidents higher
o Diabetes ..
What do people with SMI die from?
Study by Bralet 150 people with schizophrenia over 8 years – 13
deaths : 3 suicides
 3 heart disease
 2 cancers
 2 respiratory diseases
 1 car crash
 1 homicide victim
 1 infectious disease
Individual Risk Factors Associated with Early Death
 Smoking
 High blood pressure
 High cholesterol
 Diet and obesity
 Inactivity
6
 Diabetes
 Accidents
Factors Associated with Premature Death ;







Reduced Use/Inefficient Use of Medical Services
Poverty
Systemic Barriers to Ideal Health Care
Psychotropic medications
Individual health habits
Smoking
Inactivity
Obesity/poor nutrition
Smoking and sever mental illness ; Many epidemiological studies have assessed rate of smoking in
people with schizophrenia , bipolar disorder range 585 to 88%
up to 3 time higher than general population
 In UK prevalence smoke rate 74% in 2002 25 cigarettes a day
Causes of high rate of smoking
 Neurobiological
 Psychological
 Behavior
 Cultural
 Neurobiological factor: Nicotine alleviate certain psychiatric symptoms as negative
symptoms , cognitive dysfunction, side effect of antipsychotic
medication
 Dopamine factor
 Increase dopamine release through inhaling nicotine may reduce
negative symptoms and improve attention and selective processing
of information that usually impaired in people with schizophrenia

Psychosocial and behavior factor :7






Many epidemiological studies founded:People with schizophrenia smoke out of habits routine
For relaxation
Way of making social contact
For pleasure
They believe they are addicted
Mental health culture : Smoking is ingrained in culture of psychiatric so the most
wrong to encourage to stop smoking , because you well increase
violent behavior because that means self medication
 It is improved mood and reduce anxiety
Why Do People With Mental Illness Smoke
 Nicotine increases alertness. This may enhance concentration,
thinking and learning. This may be a benefit to people with
schizophrenia whose illness or medication leads to cognitive
problems.
 Nicotine can help relaxation, and it can also reduce negative
feelings such as anxiety, tension and anger. So smoking may
help people with mental illness deal with stressful situations.
 For pleasure and because they believe they are addicted
 Nicotine may reduce positive symptoms, such as hallucinations
for a short period.
 There is some evidence to suggest that smoking is associated
with reduced levels of antipsychotic induced Parkinsonism.
 Smoking can help to relieve boredom and provide a framework
for the day.
 Smoking can improve social interaction, something that may be
of particular benefit to people with negative symptoms
Impact smoking in people with SMI who take medication :-
8
 Cytochrome p450 metabolism some drug like antipsychotic
antidepressant .
 Polycyclic hydrocarbon in tobacco induced this inzyme and
increase metabolism and therefore lower the plasma
concentration of these medication so the smoker often need
more medication compared with non smoker
 The plasma concentration of clozapen increase
dramatically in pt following abrupt smoking cessation
leading to toxicity

Nicotine replacement : Begin NRT on the quit date, (apply patches the night before)
 Use a dose that controls the withdrawal symptoms
 NRT provides levels of nicotine well below smoking
 Prescribe in blocks of two weeks
 Arrange follow up to provide support
 Use a full dose for 6 to 8 weeks then reduce the dose gradually
over 4 weeks.
Nurse can do to help client
 Explore the good thing and not so good thing about smoking
and not so good thing and good thing about stopping
 Psychological support need to make successful quiet and
prevent relapse
 Health education information can be provided in balance , non
judgmental way
 Supporting with pharmacological NRT
ASSIST the quit attempt
 Provide assistance in developing a quit plan;
 Help a patient to set a quit date;
 Offer self-help material;
 Explore potential barriers and difficulties
 Review the need for pharmacotherapy.
 Refer to a quit line and/or an active call back programme
Nurse can do
9
 Decrease number of smokers in every setting.
 Increase the number of smokers advancing toward quitting.
 Increase the number of smokers who have been given advise to
quit.
Barriers to Successful Cessation
 Provider inattention/pessimism
 Co-dependency and mental illness
 Mental health staff smoke
 Historic attitudes about smoking in mental health community
 No coverage for cessation drugs
 Improper use of the drugs
ADVISE on coping strategies
 Drinking alcohol is strongly associated with relapse
 Inform friends and family and ask for support
 Consider writing a ‘contract’ with a quit date
 Removal of cigarettes from home, car and workplace;
 Give practical advice about coping with Withdrawal symptoms
occur mostly during the first two weeks
 Relapse after this time relates to cues or distressing events.
 Remind patients of the health benefits of quitting
Why do people with SMI experience physical health problem
 Adverse effect of psychotropic medication on health: Both Antipsychotic drug make weigh gain
 Some antipsychotic drug make excessive salivation like
clozapen and olanzepam….
.
Baseline before or at start drug initiation
 Weigh and high and body mass index should be recorded
 Personnel and family history of obesity and diabetes
 Fast blood glucose after one month for clozapen and olanzepen
 Reduce energy and fat intake
 Increase fiber and fruit and vegetables intake
 Increase physical activity to 20 min a day
10
Medication impact of sexual interest
 In medicated people the effect of medication on number of
neurotransmitter will interfere with sexual function
 All antipsychotic are dopamine antagonist except airpirazol
dopamine involve in sexual arousal and orgasm .so blocking
dopamine may contribute to reduce libido and disturbance in
orgasm
 The drug rely on dopamine antagonist to provide their
antipsychotic effect and removed the brake on prolactine
secretion leading to hyperprolactin
 Raised in prolactine level will occur decrease in testosterone
hormones in both men and women leading to sexual dysfunction
 Hyperprolactin side effect of both typical and atypical
antipsychotic drug
 Routine blood test can be take for prolactine level
Physical Activity: Benefits
 Prevention of Wt Gain and to achieve weight loss
 Bone health in kids.
 Function in older adults.
 Increased cardiorespiratory fitness.
 Increased muscular strength.
 Decreased blood pressure.
 Decreased depressive symptoms.
 Improved sleep quality.
Amounts of Exercise : Inactive or sedentary <30 min/wk, <10min/qd
 Health benefits accrue at 60 min/wk
 Low level 90 min/wk. Even low levels lead to dramatic decr in
risk of premature death
 For substantial health benefits 150 min cumulative moderate
intensity exercise a week.
 Greater benefits accrue at higher levels
 300 minutes for weight loss
 Special Considerations Physical Activity SMI
11






Inactive; start low, go slow.
Fear of heart attack with sensation of increase HR.
Lack of familiarity with the sensation of muscle soreness.
Traumatic bodily relationships.
Balance issues on moving treadmills medication effects.
Cold temperatures.
Interventions:
 Fitness equipment at every facility, esp aerobic (exercise bikes,
elliptical)
 Staffed for pts and open for staff use
 Relationships with local health clubs for equip.

Access to fitness centers in the community

Education
 Links to obesity and cardiovascular illness and death
 Benefits/Barriers
 Types/Low cost options
 Getting started; Medical Clearance
 Posters
 Physical activity opportunities for each patient
 Structured group format
 Milieu changes such as stairs to cafeteria, walking to appts on
campus
 Encouragement of walking in all sites.
 Enhance and document physical activity opportunities in
vocational and residential settings
 Motivational interventions to eliminate culture of lethargy
Overweight and Obesity
 Definitions: Healthy Weight Body Mass Index (BMI) 18-24.9
 Overweight;
BMI 25-29.9
12
 Obesity
 Extreme obesity
BMI 30-34.9
BMI >35
Obesity and Mental Illness
 Epidemic in mentally ill
 Multiple studies show increased incidence of overwt. and
obesity in schizophrenia, esp women
 Majority recognize the wt problem, want to/have tried to weigh
less Certain 2nd gen antipsychotic (SGA) can cause rapid wt gain
(7 -30% of body wt) from 1st sev. months of therapy up to a yr or
longer
 .Significant wt increases coincided with clozapine introduction
Wt gain ranked as top “bad thing” about taking meds in UK survey
 Lifestyle modifications preferred approach
Common Elements of Weight Reduction Programs
 Goal Setting of Realistic short-term goals
 Strategies to increase physical activity and decrease sedentary
behavior
 Nutritional focus teaching and demo of healthy eating habits
 Self-monitoring of nutritional intake and physical
Interventions: Client Education : Client Education about Nutrition and Weight Management
 Nutrition label reading
 Macronutrient information (protein, carbs, fats, fiber)
 Eating behaviors and physiology;
 recognizing and responding to hunger, slow eating
 Substitution of healthy foods for less healthy foods;
 emphasis on addition of healthy foods rather than deprivation
 Portion size
 High calorie drinks
 Goal setting; one change at a time.
 Grocery shopping
 Food preparation
 Fast food, restaurant eating
13
Interventions: Milieu
 Vending machines and canteens
 Provision of healthy alternatives
 Water
 Fresh fruit
 Low fat dairy products
 Substitute juice for water at med dispensing
 Printed materials and posters at cafeteria
 Inpatient take out food
 Emphasis on discretionary income, financial aspects recommended
 Engage staff; “biggest loser” contests
Regular Physical Activity
During physical activity, our brain produces “endorphins”, or
chemicals that provide relief from high stress levels. The good news
is that high intensity activity is not required to experience this relief.
Regular physical activity can also reduce
the symptoms of depression and anxiety.
Diabetes and fasting blood glucose : (WHO) defined diabetes as a fasting plasma glucose of more
(126 mg/d L)
 In an asymptomatic individual, the diagnosis should be
confirmed with a second fasting measurement on another day.
The measurement of HbA1c may be used in the future for
diagnosing diabetes
 In all forms of diabetes, inadequate control of glycamia will
result in complications of diabetes.
 These complications include
 diabetic neuropathy
 diabetic retinopathy
 diabetic kidney disease
 increased risk of infection
 Patients with type 2 diabetes are likely to require additional
pharmacological management, but this should be no different
from the general population, for which guidelines are available
from the EASD and the American Diabetes Association (ADA)
14
Lower Risk for CVD
 Blood cholesterol
 10%  = 30%  in CHD (200-180)
 High blood pressure (> 140 SBP or 90 DBP)
 4-6 mm Hg  = 16%  in CHD; 42%  in stroke
 Cigarette smoking cessation
 50%-70%  in CHD
 Maintenance of ideal body weight (BMI = 25)
 35%-55%  in CHD
 Maintenance of active lifestyle (20-min walk daily)
 35%-55%  in CHD
 Management of adverse drug-related effects on cardiovascular
disease risk factors ; Choice of psychotropic medication should take account of potential
effects of different agents on CVD risk factors, such as weight and
glucose levels and lipid profiles, especially in patients who are
overweight or have diabetes or are at high total CVD risk factors.
 Clinical decision-making is always complex and has to consider
efficacy aspects as well. A dilemma may arise with clozapine which
is recommended by many guidelines as the antipsychotic of choice
for those with refractory schizophrenia as clozapine is associated
with the highest risk of weight gain and related CVD risk factors.
interventions for management of CVD risk factor : Smokers should be encouraged to stop smoking all forms of
tobacco. Those who demonstrate a readiness to quit can be
referred to a smoking cessation service which can offer
behavioral counseling, nicotine replacement therapy or other
pharmacological intervention.
 Maintaining a healthy body weight and shape by healthy eating
and regular physical activity is the a key component of lowering
CVD risk and prompt action is needed in patients who are
overweight at initial assessment or who show signs of early
weight gain with antipsychotic medication
15
 Patients should be advised to take 30 minutes of moderately
vigorous activity at least a brisk walk on most days of the week
 Avoidance of hypoglycemia is best achieved by involving the
patient's family and cares in the education process about the
risks and consequences of hypoglycemia.
 Patients should be encouraged to eat lean meat, fish and low fat
dairy products and to replace saturated fat with
monounsaturated and polyunsaturated fats from vegetable and
marine sources Those with mildly elevated cholesterol levels
may be able to reach target levels through diet alone
management Blood pressure : High blood pressure in severely mentally ill patients is often
missed. Target blood pressure levels of less than 140/90 mmHg
are recommended.
 Lifestyle changes, such as stopping smoking,
 reducing salt intake,
 weight reduction
 and increased exercise,
 Pharmacological therapy
this may be sufficient to reduce mildly elevated blood pressure
What can be done
 Treatment of Common Mental Illnesses with Cognitive Behavioural
therapy highly effective (8 sessions)
 Psycho-social support to cancer patients decreased pain and
depression and in half of studies reduced progression
 More daily “uplifts” increased bodies natural killer cells (immunity)
 Putting people in a positive mood leads to greater pain tolerance
 Assigning people to hospital rooms with a pleasant view decreased
pain and reduced length of stay
Choosing Health
Six key priorities :16
 Tackling health inequalities
 Reducing the number of people who smoke
 Tackling obesity
 Improving sexual health
 Improving mental health and well being
 Reducing harm and encouraging sensible drinking
Potential Obstacles
 Lack of motivation
 Effects of medication
 Lack of money
 Boredom
 Mental health culture
 Attitudes and beliefs of health staff
The main treatment:Our aim is to improve the physical health of mental health service
users in Ceredigion by
 Engaging people in activities that reduce their risks of illness
 Removing obstacles
 Raising awareness
17