January 2017

Influence of mental health on diabetic foot outcomes

As evidence accumulates suggesting negative effects of depression, dementia, and other mental health issues on gait and foot-related outcomes in people with diabetes, researchers are looking at ways to screen for risk factors and psychosocial issues earlier in the continuum of care.

By Hank Black

A rush of research in recent years has helped buttress evidence of associations between diabetes and depression, dementia, and other mental health conditions that can adversely affect outcomes, especially in the presence of a diabetic foot ulcer.

“The amount of cognitive power that goes into dealing with basic diabetes is often taken for granted by the healthcare community, but it may have a direct impact on who develops foot ulcers and other complications of the disease,” said Jason Rucker, PT, PhD, clinical assistant professor in the Department of Physical Therapy and Rehabilitation Science at the University of Kansas Medical Center in Kansas City.

Having diabetes doubles the odds of having a comorbid depressive disorder.1,2 And patients with foot problems have, on average, significantly greater symptoms of depression, pain, and suicidal behavior than those without.3

In the US, the risk for major depression is increased as much as six times if a somatic disease (such as diabetes) is present, and the prevalence of comorbid depression ranges as high as 17% in patients with end-stage renal disease.4 Amputation, microvascular diseases, and poor glycemic control are associated with impaired global cognitive function and its domains among patients with diabetic foot issues aged 65 years or younger.5

The World Health Organization (WHO) estimated that the 12-month prevalence of mood disorders (including different subtypes of depression) in developed countries was between 3.1% (Japan) and 9.6% (US).6 In studies of both general populations and those in clinical settings, depression is more common among patients with diabetes (both type 1 and type 2) than their nondiabetic counterparts, with 12-month prevalence estimates typically falling in the 10% to 15% range.1,7

The American Diabetes Association’s 2017 Standards of Medical Care underscore the increasing importance of evaluating and managing patients’ psychosocial well-being.

The WHO World Mental Health Survey reported that the comorbid state of depression with diabetes causes even greater declines in perceived health than if the declines in perceived health for depression alone and for diabetes alone were added together. This finding suggests a negative interactive effect between depression and diabetes.8

“When the Affordable Care Act rolled in, we were told that if our patients had printed copies of instructions relating to the visit, maybe this would reinforce their ability to adhere to our treatment regimen,” said James S. Wrobel, DPM, associate professor of medicine at the University of Michigan in Ann Arbor. “But I get the sense this hasn’t occurred much. Patients only wear offloading devices twenty-two percent to twenty-eight percent of the time,9,10 and I believe much of it has to do with cognitive changes and active episodes of depression.”

Any patient with diabetes will tell you it’s a disease that is difficult, sometimes even scary, to live with, said Alicia McAuliffe-Fogerty, PhD, CPsychol, a clinical health psychologist and vice president of the lifestyle management team for the American Diabetes Association (ADA) in Alexandria, VA.

“People with diabetes are their own doctor on a day-to-day basis, making minute-to-minute treatment decisions that sometimes could mean life or death to them,” McAuliffe-Fogerty said. “You can educate a patient on how to care for their diabetes and provide them with guidelines, but if they are stressed, depressed, or nervous about treatment, these will impact their behaviors in self-managing the disease.”

Taking action

Evidence of a negative effect of anxiety, stress, and depression on the health status and self-care behaviors of people with diabetes has accumulated rapidly over the past few years, and some researchers are looking at potential ways to check for risk factors and signs of psychosocial issues earlier in the continuum of care.

In fact, the evidence prompted the ADA to include evaluation of and care for patients’ psychosocial well-being in its 2017 Standards of Medical Care.11 That followed a 2016 position statement12 that provides wide-ranging and specific guidelines for psychosocial assessments and care. The statement emphasizes that diabetes management is more successful when lifestyle and emotional status are an integral component of diabetes care.

“People with diabetes have a greater risk of depression and anxiety,” McAuliffe-Fogerty said. “But medical providers are not always taught to understand the impact that psychosocial factors have on people living with diabetes.”

To help psychologists prepare to treat the mental health issues of patients with diabetes, the ADA is collaborating with the American Psychological Association on an initiative, to begin this summer, that includes a diabetes education program, McAuliffe-Fogerty said. In addition, the organizations will create a directory of diabetes-friendly psychologists in each state to help patients and practitioners find referrals.

Several lower extremity practitioners interviewed for this article cited advantages of incorporating mental health screening questions in initial and subsequent patient visits to try to catch problems early and minimize their consequences.

“Recognition of the psychosocial aspects of diabetes is improving, and should be even greater now that the ADA has emphasized screening for issues such as depression and cognition,” according to Frank DiLiberto, PT, PhD, OCS, FAAOMPT, assistant professor in the Physical Therapy Department at Rosalind Franklin University of Medicine and Science in North Chicago. “It’s a very complex disease, but depression in particular is recognized as a barrier to patient adherence regarding the self-care aspects of diabetes, so clinically addressing depression or other barriers to self-care, such as cognition, may improve patient HbA1c levels, and possibly foot care and physical activity level.”

Monitoring for depression may be particularly important in patients with diabetic foot ulcers. In a five-year follow-up of a cohort of 253 individuals presenting with their first foot ulcer, Winkley et al found baseline depressive disorder was significantly associated with a two-fold increase in mortality compared with patients who were not depressed.13

Who is in the best position to detect and monitor mental health issues in people with diabetes?

“It’s probably everybody together,” Wrobel said. “Particularly at higher levels of complications, they’re seeing multiple doctors and other professionals. Podiatrists and primary care physicians may be the ones they see most, but therapists and others may also have long-running knowledge of a patient and be in a position to observe subtle cognitive or functional changes.”

A team approach can help.

“Although diabetes care in general is steadily improving, no practitioner should work in isolation,” said Audrey Zucker-Levin, PT, PhD, MBA, associate professor in the Physical Therapy Department at the University of Tennessee Health Science Center in Memphis. “It’s established that you need a whole team working with a patient with diabetes, including a mental health professional, although it’s not necessarily done that way.”

Success in building a team that includes those with a mental health background is often problematic, depending on where the patient lives and how easy it is for them to get to their care provider, Zucker-Levin said.

“Perhaps telemedicine will get more emphasis; a patient could Skype with a psychologist, for example,” she said.

Last year, an Australian group published a feasibility study on the use of an automated web- and phone-based intervention to convey cognitive behavior therapy to patients with diabetes who are not able to access services in person, wish to manage their mental health themselves, or both.14 In this single-cohort study, 89 volunteers with diabetes and at least mild depressive symptoms used the program for seven weeks.

Web-based measures of relevant symptoms, functional impairment, diabetes-specific variables, and user satisfaction were completed at baseline, postintervention, and three-month follow-up. Retention rates were 54% at postintervention and 36% at follow-up. Researchers found sustained improvement in depressive symptoms and mental health comorbidities, including anxiety, functioning, and diabetes-specific distress.14

Physical activity

Another potential intervention is regular physical activity, which a 2014 study found can help promote cognitive status and foot self-care in overweight patients with type 2 diabetes.15

“We’re starting to see associations between the duration and severity of diabetes and cognitive impairment,” said DiLiberto, who studies how foot and ankle biomechanics relates to diabetic foot ulcers and fall risk. “In my area of study I know of three emerging studies that are looking at incorporating psychologists and/or using behavioral strategies to improve patient adherence to foot self-care or activity programs—these studies may help us understand how certain psychosocial aspects influence activity levels and consequent HbA1c levels and, potentially, ulceration rates.”

Neuropathy-related physical and psychosocial dysfunction is a risk factor for depressive symptoms in patients with diabetic peripheral neuropathy and should be a focus in clinical care, according to a 2005 study by Vileikyte et al.16 They found a relationship between clinical measures of neuropathy severity and depressive symptoms, and that neuropathic symptoms of pain, unsteadiness, and reduced feeling in the feet each are independently associated with depressive symptoms and together account for that relationship.

Unsteadiness was the symptom with the strongest association to depressive symptoms, likely due to patient perception of low self-value because of the inability to play their usual family role.16 Four years later the same group also reported patients with unsteadiness at baseline are not only more likely than those with less unsteadiness to experience depressive symptoms at the time of assessment, but are also more likely to experience increased depressive symptoms in the future, unrelated to changes in unsteadiness.17 Increases in perceived unsteadiness over time further contribute to increases in depressive symptoms, irrespective of baseline unsteadiness.

DiLiberto noted that, though it can be a counterintuitive concept for clinicians focused on reducing plantar pressures, decreased activity can actually increase the risk of foot ulceration in a person with diabetes and neuropathy, and programs focused on improving activity levels do not demonstrate an increased risk for ulceration (see “Exercise and neuropathy: Not mutually exclusive,” July 2011).

“The evidence is that this population, even with neuropathy, probably should be exercising,” he said. “Since we do not currently have an activity level program shown to decrease the risk of ulceration, exploring other factors such as depression and even cognition may ultimately lead to improved self-care, physical activity level program adherence, and outcomes—such as lower ulceration rates, ‘slowing’ the severity of neuropathy, and overall improved health.”

Cognitive and motor function

Gait can be affected when a person is sad or depressed,18 or when cognition declines due to age-related dementia.19 In a 2014 study of middle-aged people with type 2 diabetes, Spanish researchers found structural brain changes occurred in both cases and were correlated with functional brain changes, mainly in the fronto­temporal area.20 Worse executive function and memory functioning, for example, are associated with less grey matter density, among other structural changes. Executive dysfunction is associated with problems related to gait21 and functional abilities22—both of which can contribute to increased risk of falls,23 greater dependence,24 institutionalization, and mortality.25

“We often tend to think of cognitive and motor functions as being independent of one another, but that really isn’t the case. When we start to see changes in the frontal lobes of the brain, we often find that both cognitive and motor changes are present,” Rucker said. “There’s strong evidence from multiple populations that signs of cognitive decline, and particularly a decline in executive function, are associated with a reduction in gait speed and increase in gait variability. Basically, patients begin to slow down and stagger.”

Clinically, however, that decline may not be obvious.

“We practitioners should be picking up on those subtle changes in our patients, but frankly may not be doing a great job of it,” Wrobel said.

Executive function involves the ability to plan, organize, and sequence activities, including the ability to perform dual tasks. A 2014 study from the UK found executive function was particularly compromised in patients with type 2 diabetes compared with controls, and that the patients with diabetes demonstrated impaired postural stability under dual-task conditions.26

Rucker noted that cognitive tests, such as the brief Mini-Medical State Exam and Montreal Cognitive Assessment, can give clinicians a sense of whether a patient has significant impairment. Adding a cognitive task to a simple Timed Up & Go (TUG) test can give a quick estimate of how well a patient can dual-task, he said.

“Unfortunately, there’s no standardized way to administer or interpret this test, but one method is to ask the patient to count backwards by threes from a set number while performing the TUG. We look at how much the patient’s gait speed changes while they’re dual-tasking, and how well they perform the cognitive task,” Rucker said.

Another option is the Walking and Remembering Test,27 which calls for the patient to walk along a narrow pathway under single- and dual-task conditions; it requires a little more effort to administer but also provides more information, he said.

Impaired executive function, which can affect self-care, may help explain the reported association between cognitive status and risk of foot ulcers in patients with diabetes. In a 2016 study, Israeli researchers assessed 194 patients with diabetes and found that those with foot ulcers had significantly lower cognitive scores than those who were ulcer-free.28

“Diabetes is a very complicated disease to manage, and if you have a lower level of executive function, effective self-care is that much more difficult. We are seeing evidence that people with cognitive impairments tend to have worse glycemic control and are at an increased risk for complications like foot ulcers and amputations,” Rucker said. “Even in young people with diabetes, there is evidence that diminished executive function seems to lead to poorer food choices, which is obviously a big problem in the context of this disease.”

More research on the cognitive deficits that may accompany diabetes and how they impact everyday functioning is needed, he said. Specific instruments that assess dual-task performance, reaction time, and processing speed could be administered to newly diagnosed type 2 diabetes and used to identify and monitor any deterioration of cognitive function and the usefulness of therapeutic interventions on cognitive function.29

“Hopefully we can use these cognitive and cognitive-motor tests to identify at-risk people early, before they have major medical events, such as falls or foot ulcers,” Rucker said.

Due to improved treatment and other factors, patients with diabetes are living longer.30 This improved longevity, however, is accompanied by an increased risk of geriatric health complications, including cognitive impairment and dementia.31

“That’s the challenge we have now,” Wrobel said. “Diabetic foot ulcers usually show up as a late complication, and aging, of course, may include cognitive declines that make carrying out self-care duties difficult. We have to understand that there are multifactorial reasons for the challenges people face when they have this disease and these complications.”

Perhaps the recent development of a risk score for the prediction of 10-year dementia risk in patients with type 2 diabetes will help. The risk score proposed by Exalto et al can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials, the authors suggested.32

Diabetes distress

The psychological burden of diabetes on a basic level—feelings of irritability, inadequacy, nervousness, sadness, and more—can be associated with low well-being and social functioning even in the absence of clinical depression; growing awareness of these symptoms has led to the popularization of the term “diabetes distress.”33 Hungarian physiologist Hans Selye used the term “distress” to distinguish between stress initiated by negative, unpleasant stressors and positive stress.34 Distress is an emotional response toward adverse or unpleasant stressors, whereas depression is a diagnosis based primarily on having five of nine symptoms, without respect to cause or context.33

Diabetes distress and depression are correlated and overlapping constructs, but are not interchangeable, and evidence has shown diabetes distress mediates the association between depression and glycemic control.35 According to the ADA, overwhelming distress can negatively affect self-management, including foot self-care. Even the fear of hypoglycemia and its potential sequelae of peripheral neuropathy, foot ulcers, and limb amputation is a major component of diabetes distress.12

McAuliffe-Fogarty has had type 2 diabetes for 30 years and has experienced diabetes distress at different junctures, she said.

“People think the psychological problems like depression are the be-all and end-all. And as a psychologist myself, I understand that. But we also know that these more normative issues are also a huge concern,” she said.

Some of the evaluative tools the ADA recommends in its position statement take just a few minutes to administer, and are designed to screen patients efficiently for referral to a mental health professional, McAuliffe-Fogerty said. The hope is that these instruments, administered initially after diagnosis and routinely through the care continuum, can lead to more timely treatment.

Hank Black is a freelance writer in Birmingham, AL.

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