Implications of Mental Illness & Polypharmacy
In addition to diabetes-related issues, Howard noted that as adults with I/DD age, they have a higher prevalence of psychiatric comorbidity. According to one analysis of the US 2018 Behavioral Risk Factor Surveillance System, the prevalence of reported mental distress among those with disabilities was 4.6 times that of their non-disabled counterparts. These conditions include psychosis, mood, anxiety, and substance disorders, as well as dementia. She observed that up to 92% of I/DD individuals have an underlying psychiatric diagnosis, and mental illness is 2.5 times more common than in the general population. At the same time, she noted, dementia often goes undiagnosed in this population. These issues can contribute to medication adherence challenges as well as issues that lead to or exacerbate obesity; and they can contribute to polypharmacy.
Howard observed, “Polypharmacy is a significant concern within the I/DD population. This issue is particularly prevalent due to factors such as high rates of comorbid conditions. It is also linked to the higher prescription rates of psychotropic medications for managing mood and behavior which can have significant side effects in patients in this population when they take multiple psychiatric medications and receive those medications at very high doses.” This increases the risk for side effects such as dizziness, tremors, gastrointestinal issues, vision problems, and changes in appetite. Multiple comorbidities that require numerous medications also can have an impact on treatment choices and interventions to manage diabetes in this population.
Before You Treat, Think "Goals"
Before addressing diabetes medications and management options, it is important to consider goals of care. Glycemic goals should be individualized and not one-size-fits-all. "This is very important in the I/DD population, especially given their complex medication lists and increased risks for adverse drug events,” said Brandon Van Amber, PharmD, manager of clinical operations for the Northeast District, PharMerica. However, it is important to start with a viable source of treatment guidance. He said, “We get our basic goals of diabetes therapy from the American Diabetes Association each year. Usually in January, they publish the standards of care, so we can use this to identify appropriate, realistic glycemic, or blood sugar, goals for our residents who have intellectual disabilities.”
Then it is vital to individualize glycemic and blood glucose goals accordingly. Van Amber said, “While it may be clear that somebody who gets diagnosed with diabetes should have a goal of hemoglobin A1C less than 7 and start with medications A, B, or C, that might not be the case for our residents with I/DD. We need to make sure that we're considering all their comorbidities, and the prognosis for their life expectancy.” Because of this population’s complex medication lists and high risk for adverse events, he noted, a conservative goal of an A1C of 8 might be a good place to start.