Ado hamza abdullahi

BY
ADO HAMZA A.
(PH12,604)
SUPERVISED BY
PHARM. (MRS.) C.O.OLURISHE
( 08069458577)
INCIDENCE OF DEPRESSION, LOSS OF COQNITION AND THE
EFFECT OF THEIR MANAGEMENT IN PROGNOSIS OF
PATIENTS WITH
DIABETIC FOOT ULCERATION/AMPUTATION IN ABUTH

INTRODUCTION
 Diabetic foot ulcers (DFU) are serious complications of diabetes, preceding
84% of lower extremity amputations and increasing the mortality risk by 2.4
fold over diabetic patients without ulcers (Goodridge et al, 2005).
 A DFU is any full-thickness wound below the ankle in a diabetic patient,
irrespective of duration. Based on current studies, the annual population-
based incidence is 1 to 4% with a prevalence of 4 to 10%
 The estimated lifetime risk in 25% DFUs result from a complex interaction of
a number of risk factors. Once the protective layer of skin is broken, deep
tissues are exposed to bacterial infection that progresses rapidly.
.
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INTRODUCTION CONT’D
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 Depression is a common mental disorder that presents with depressed mood,
loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth,
disturbed sleep or appetite, and poor concentration (WHO, 2012).
 Patients with diabetes are at least twice at risk to suffer from depression,
anxiety and stress compared to the general population with associated poor
glycemic control which worsens diabetes complications, prognosis and quality
of life (Davies et al., 2015; Bener et al., 2016).
 Physiological features of depression (e.g. glucocorticoid dysregulation,
increased sympathetic activity, and alterations in inflammatory processes) may
contribute directly to hyperglycemia.

DEPRESSION AND DIABETES
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 These factors increase insulin resistance (IR), a potential explanation for a role of
depression in the development of diabetes (Lustman et al., 2002).
 Although their etiological relationship is unclear, together they present significant
challenges to disease management in individuals with DM(Holt et al, 2014).
 Comorbid depression and DM increase treatment costs, and clinical outcomes have not
yet demonstrated their treatments’ effectiveness (Ockene et al., 2012). Also, the difficulty
of DM management is amplified in vulnerable subgroups: individuals with disabilities,
low income, and low health literacy, as well as members of linguistically isolated ethnic
minority immigrant groups.

DEPRESSION AND DFU
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 Studies on the specific impact of DFU are limited, but it has been confirmed that
comorbidity, such as depression, is one of the key factors in predicting the outcome of
DFU. In DFU patients, comorbidity has the largest impact of HRQoL with depression
being associated with largest deficits (Maddigan et al., 2006).
 As outlined in the WHO Intervention Guide, preferable treatment options consist of basic
psychosocial support combined with antidepressant medication or
psychotherapy, such as cognitive behavior therapy, interpersonal psychotherapy or
problem-solving treatment. Antidepressant medications and brief, structured forms of
psychotherapy are effective.


DIABETES AND COGNITIVE
IMPAIRMENT
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• Cognitive impairment refers to changes in memory, mood, perception, reaction
times, attention, and concentration (Cranston et al., 2005).
• It increased about 1.5- 2.5 fold in patient with Diabetes (Mark, 2011).
• Cognitive dysfunction in patients with diabetes mellitus was first noted in 1922,
when patients with diabetes, who were “free from acidosis but usually not sugar
free,” were noted to have impaired memory and attention on cognitive testing.
• The poor glycemic control, hypoglycemia, and the macrovascular complications
contributed to the most common causes of the impaired cognitive function in
diabetic patients (McCrimmon et al.,2012).

DIABETES AND COGNITIVE IMPAIRMENT
CONT”D
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 The most common cognitive deficits identified in patients with diabetes are
slowing of information processing speed (Rhyan et al, 2003) and worsening
psychomotor efficiency

STATEMENT OF RESEARCH PROBLEM
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• Diabetic foot ulcer is common complication of diabetic patients. While the
impact of diabetic limb problem on physical health is well known , the
psychological impact of the condition is still largely un-accounted for.
• Depression often remains undiagnosed and may be untreated or
undertreated in people with diabetes (Bajwa et al,2015).
• Untreated depression may further exacerbate the progression of diabetes
(Vamos et al, 2009)), contributing to the high economic burden of health
care costs . Therefore, a better understanding of the effects of untreated
depression in diabetic patients becomes critical

STATEMENT OF RESEARCH PROBLEM
CONT’D
 Patients with DFU are more likely to have poorer health related quality of life
(HRQoL) than those without ulcers and even than those who had amputation.
 This is because the DFU patients live with the fear of recurrence of ulceration,
repeated bouts of infections and potential life-long disability (Price et al,
2004).
 Studies have confirmed that comorbidities have the largest impact of HRQoL
with depression being associated with the largest deficits (Maddigan et al,
2006).
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JUSTIFICATION
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• The relative increase in the incidence of diabetic complications in Nigeria and
Increase in the number of diabetic foot ulcer cases leading to increase in
amputation of lower extremities
• Depression and cognition problems are rarely assessed in patients with diabetic
foot ulcer .
• Given the poor outcomes in patients with diabetes and comorbid depression
(Lustman et al, 2000) and the availability of effective intervention for patients
with diabetic foot complications (Simon et al, 2008), it is important to prevent and treat
depression, cognitive impairment and review guidelines accordingly.

JUSTIFICATION CONT’D
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 Most research on psychological consequences of diabetic limb problems
were done on diabetic foot and some on amputations. From these studies,
it was found that the most frequent psychological manifestation were
depression and Mental Disorder (Britneff et al., 2013).
 For patients with depression and cognitive deficits, adherence to diabetes
self-management goals may be especially challenging, (Raymont et al.,
2016)

AIM
 To determine the incidence of depression, loss of cognition and the effect of
their management in the prognosis of patients with diabetic foot ulceration
/amputation in ABUTH.
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SPECIFIC OBJECTIVES
 To determine the incidence of depression and cognitive impairment in diabetic foot ulcer
patients
 To determine the significant factors that linked depression and cognitive impairment to
diabetic foot ulcer patients
 To determine if depression, cognitive impairment is properly diagnosed and managed in
diabetic foot ulcer patients
 To determine if the management of depression, cognitive impairment in diabetic foot
ulcer patients affects clinical outcomes in DFU
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METHODOLOGY

METHODOLOGY CONT’D
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 Sample size
The population of patients with diabetic foot ulcer on admission or had
attended ABUTH from 2015- 2017 period were 51 in number,
However, the total number of patients for the year 2017 are 26, as such
22 patients were used for the study

STUDY DESIGN
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•The study was conducted in Medical wards and medical out-patient clinic in
ABUTH Zaria, over a period from January to October 2017.
•The patients subjective and objective data were assessed using the patients
folder, interacting with the patients and their Caregivers.
•A questionnaire was also designed and employed for assessing and confirming
the diagnosis of depression and cognitive impairments and part of the prognosis
•Data obtained includes Patients’ demographics , subjective and objective
information

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 Inclusion Criteria
 Ages ranging from 30yrs and abovE
 Both male and female patients
 Diagnosed depressive patients with diabetic foot ulcer and or amputation
 Medical ward patients and MOPD patients
 Diabetic foot ulcer patients (outpatient and inpatient)

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 Exclusion Criteria
 Diabetic patients that are not diagnosed with diabetic foot ulcer
 patients that were diagnosed with major depression before having diabetic foot
ulcers
 patients that have Alzheimer’s or dementia before being diagnosed with
diabetic foot ulcers or diabetes
 advanced psychiatric patients , alcoholic and drug abused patients.

METHODS FOR DIAGNOSING DEPRESSION
AND CI
19
Methods employed for diagnosis of depression and cognitive impairment
re as follows
• Patient Health Questionnaire- 9 (DSM IV) method of diagnoses of
depression
• Hamilton Rating Scale for depression
• Mini mental status examination (MMSE) for assessing cognition
• Confirming the treatment guideline for Managing Depression And
cognitive impairment with the patients treatment sheets
• Assessing the prognosis and how the patients’ lives are affected

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 PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and
measuring depression
 PHQ-9 incorporates DSM IV depression diagnostic criteria with other leading
major depressive symptoms into brief self-report tool.
 The tool rates the frequency of the symptoms which factors into severity index
 The tool is brief and usefull in clinical practice(Kroenke et al,2001)

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 Hamilton Rating Scale for depression is designated for adults and used to rate
the severity of depression by probing ;
• mood
• Insomnia
• Agitation or retardation
• Anxiety
• Weight loss
• Somatic symtoms
• Feelings of guilt
• Suicidal ideation

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• Minimental Status Examination test was administered to determine the extend
of cognitive impairment
• It contains 6 dormains which includes
• Attention and Calculation
• Orientation
• Registration
• Language
• Complex command

Data was systematically analyzed as appropriate using statistical package
for social sciences (SPSS) software version 23 (California Inc., USA). A
two sided p < 0.05 at 95% confidence interval (CI) was considered
statistically significant for t-test to determine the statistical association
between the variables
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DATA ANALYSIS

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RESULTS

Table 1: Demographics
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Demographics Frequency %
Gender Male
Female
7
15
31.8%
68.2%
Age
30-40
41-50
51-60
>61
3
7
8
4
13.6%
31.8%
36.4%
18.2%
Family history of depression Yes
No
1
21
4.5%
95.5%
History of psychiatric illinesses Yes
No
2
19
9.1%
86.4%
Employment status Civil servant
Self employed
House wife
6
6
10
27.3%
27.3%
45.5%
Marital status Single
married
0
22
0%
100%

DEFENCE
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0
5
10
15
20
25
NORMAL MILD MODERATE SEVERE
Percentage%
Figure 2: Relation Between DFU and Cognitive Impairment Using MMSE
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5

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CLINICAL OUTCOME
35
 The 9.09% and 13.6% of the respondents assessed with depression and
cognitive impairment by the physicians had amputation and the ulcers were
completely cured, their cognitive problems was normal-minimal, the patients
were motivated and had insight on their health condition and
readiness/concerned to take appropriate measures in taking care of themselves
to curtail recurrence of the ulcers.

CLINICAL OUTCOME
36
 Amongst the respondents not assessed for depression and cognitive
impairment,13.6% had amputation, 31.8% had surgical debridement and the ulcer
was cured, 27.27% are currently on antibiotics while 9.9% of the respondents are
having grade 1 and grade 2 DFU each.
 Among the respondents not assessed with depression/cognitive impairment by the
Doctors, but from our research had different grades of depression 9.09% had
recurrent case of DFU.

DISCUSION
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 It is found that up to a third of patients with DFU have depressive disorders. This is in
conjunction with our research work in which the incidence of depression in DFU patients
was found to be 50% (Roy et al., 2012).
 From this research 50% of the respondents were screened to have depression out of
which 31.8% are having minimal symptoms of depression , 40.9% are having mild
symptoms of depression and none with severe depression using PHQ-9 scale. Most of the
respondents were having mild depression which is in conjunction with a research carried
out by (Valenstein et al, 2001 :Wilhelm et al, 2017) and in which a report of primary care
physicians failing to detect depression in about 35-70% of diabetic patients.

DISCUSSION Cont’d
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 Mild symptoms of depression in diabetes have been largely overlooked
(Pibernick et al,2011).
 They are also consistent with a large Australian survey of people with
complications of diabetes, where only 13% reported that had received a
diagnosis of depression (Speight et al., 2011) despite 22% to 35% of
respondents reporting clinically significant depressive symptoms this suggests
under treatment of depression in the study sample.

DISCUSSION Cont’d
DEFENCE
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 Depression often remains undiagnosed and may be untreated or undertreated in
people with diabetes (Bajwa et al, 2015).
 Managing depression in patients with diabetic complications has been found to be
beneficial. Rubin and colleagues (Rubin et al., 2004) have found that pharmacologic
and psychological approaches are effective for depressed diabetic patients, and that
successful treatment also produces improvements in glycemic control, overall
functioning and quality of life
 Only the severity of DFU was found to be significant at p value of 0.028. Age
,gender, cormobidities were found to be insignificant at p values higher than 0.05.
This is inconsistent with the research carried out by Mohammad et al,2013.

CONCLUSION
DEFENCE
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 The incidence of depression and cognitive impairment in diabetic foot ulcer
was found to be 50% and 77.27% respectively.
 Depression and cognition problems are rarely assessed in patients with diabetic
foot ulcer .
 Given the poor outcomes in patients with DFU and comorbid depression and
the availability of effective intervention for patients with diabetic foot
complications (Simon et. al, 2008), it is important to prevent and treat
depression, cognitive impairment and review guidelines accordingly.

RECOMMENDATION
41
• Screening of diabetic foot ulcer patients for depression and cognitive
impairment has become paramount and should be made a policy in
endocrinology unit in order to achieve better prognosis and clinical outcomes.
 The physicians should be aware that the incidence of depression/cognitive
impairment is higher in patients with complications of diabetes i.e. DFU.

LIMITATIONS
42
• The population of the respondents did not meets the calculated sample size.
This is because of the reduced number of admissions of new DFU cases in the
medical wards as a result of some factors including the Juhesu strike and
Resident Doctors strike.

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References cont’d
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REFERENCES CONT’D
45
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