NADD Bulletin Volume XI Number 3 Article 2

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Practical Behavioral Solutions to Enhancing Healthcare with Persons with Dual Diagnoses

Jeff Marinko-Shrivers, Ph.D.
Jeanie Zsambok, Ph.D.
The Ohio State University

Mind-Body relationships are significant considerations in the care for individuals with disabilities. Simply put, if your body is not well, then neither is your mind.  If your mind is not well, then your body is not well.  It is important not to separate the mental and physical disorders as these disorders often inter-relate and have a compound effect on the wellness of the individual. 

Four areas of Health Behaviors important to enhancing the well being of individuals with disabilities are: (a) eating and nutrition; (b) exercise and physical fitness; (c) sleep, and (d) effective utilization of professional services.  Whereas many people without disabilities fail to monitor their well-being with regard to these areas and may not have the knowledge-base to effectively improve in these four areas, it is equally true that persons who rely on the care-giving of others do not have the independent ability to engage in these health-behaviors. As a result, nutritional deficiencies, poor physical condition, physical health problems, poor sleep habits and sleep disturbances, and diminished effectiveness of health care delivery can occur.  The position of the authors, as behavioral psychologists, is that the behavioral model shows two ways to change one’s behavior--change what happens before or after the problem occurs. With regards to solutions to enhance the well-being of individuals with dual diagnoses, the focus will be on changing the antecedents (the before) to avoid the problem or problem behaviors and on reinforcing consequences (the after) that promote effective Health Behaviors.

Eating three meals per day does not always equal proper nutrition.  There are multiple ways to improve nutrition and it is advised to utilize a nutritionist to provide for meal planning.  Serving sizes are more important than most people realize. Over-weight individuals may have been affected by weight gain due to medications side-effects and medical conditions such as hypothyroidism, as well as a past history of poor exercise and diet.  When providing meals according to proper serving sizes, you are likely to get complaints from the individual.  To reduce the likelihood of complaints and  improve the feeling of fullness, it may be useful to drink 8 ounces of water before meals; and offer meals at specific times each day, since many people eat, whether hungry or not, when time of  day cues eating behavior.  Further, if a complaint arises, request that the individual wait 20 minutes, and if they are still hungry, they can let you know.   Cooking foods in low fat oils, baking foods instead of frying foods, buying low fat, and low sugar foods may also reduce the impact of excessive caloric intake.

Medications may also affect nutritional status by causing increased excretion of nutrients, interfering with nutrient absorption, or decreasing the body’s ability to change nutrients into usable forms.  These effects are gradual and the effects will be more evident in long-term use of medications.  Table 1 exhibits some effects of medications on food and possible solutions for reducing those effects.  Always consult a physician and nutritionist before implementing solutions suggested herein.

 

Insert Table 1

Effects of Medications on Nutrition and Possible Solutions

 

Common Medications:Possible Long Term or Overuse Effect:Possible Solutions   

Diuretic (“water pills”)*May result in loss of electrolytes, mainly potassium.Include foods high in potassium. (e.g., tomatoes, oranges, cantaloupes, bananas, sweet potatoes.)  

Oral contraceptivesFolacin and vitamin C deficiencies if diets are already inadequate in these nutrientsSources of folacin are spinach and other greens, asparagus, broccoli, lima beans.  Vitamin C sources include oranges, grapefruits, tomatoes, cabbage.  

Anticonvulsant drugs (prescribed to prevent seizures)Vitamin D and folacin deficienciesEnriched milk.  The use of vitamin supplements by patients on anticonvulsants should be medically monitored.  

Anti-hypertensive medication (hydralazine) (prescribed for high blood pressure)Decrease vitamin B6 (neuritis may be noted by joint aches)*Good sources of B6: whole grain breads, cereals, egg yolks, bananas, potatoes.  

 

Adapted from Bobroff, L. (1988). Avoiding Food and Drug Interactions. 

*Adapted from Taber’s 20th Edition Cyclopedia Medical Dictionary 

 

End Table 1

A converse but equally concerning problem is the effect of foods on drug absorption and utilization by the body.  One of the most discussed and dangerous drug-food interactions occurs with the monoamine oxidase (MAO) inhibitors and aged or fermented foods.  MAO inhibitors are used to treat depression and high blood pressure.  They react with a substance called tyramine in foods such as aged cheese, wines, chicken livers, pickled herring, and fava beans. As a result blood pressure increases to dangerous levels causing severe headaches, brain hemorrhage and, sometimes death.   Table 2 displays a list of food- drug interactions and possible solutions.  Always consult the physician for parameters for taking medications and before implementing these solutions.

Insert Table 2

 

Foods Affecting Drug AbsorptionEffectPossible Solution   

Calcium from milk and milk products (yogurt, etc.)Decrease absorption of some antibiotics Determine with physician or pharmacist when to take antibiotics and when to have milk products.  

Ascorbic acid containing juices such as orange juice and grapefruit juices enhance absorption of ironImproves iron absorptionIf taking iron supplement, take it with these juices.

   

Grapefruit Juice**Alters (usually increases) plasma levels of the medicationDo not take grapefruit juice if taking medications.  There are more than 20 medications known to be affected by grapefruit juice  

Beverages such as soda pop, high acid fruit or vegetable juices Cause  excessive stomach acidity which can dissolve some drugs before the reach the intestine, where they would be absorbed into the bodyTake medications with water unless otherwise directed.  

Liver and green leafy vegetables.These foods decrease effect of anticoagulants (blood-thinning drugs). They contain vitamin K which promotes blood clotting   

Natural licoriceIncreases blood pressure and can counteract the effect of high blood pressure medications   

Alcohol Interacts with more than 50% of the top 100 prescribed medications including antibiotics, allergy meds, and sleeping pills.  Annually, an estimated 47000 emergency room admissions each year are due to alcohol-medication interactions

Adapted from Bobroff, L. (1988). Avoiding Food and Drug Interactions. **Adapted from Spratto & Woods (Eds.) 2004 Edition PDR Nurse’s Durg Handbook

 

End Table 2

The second health behavior that will affect the mind and body is that of daily exercise.  Whereas, in the US population, the percentage of individuals participating in  vigorous leisure exercise for at least 10 minutes at a frequency of 5 or more times per week is about 10%, it was reported that 61% never engage in exercise (Pleis & Lethbridge-Cejku, 2006).  Exercise is essential for good health and it can be made fun.  There are many ways to adapt an exercise program for persons with developmental disabilities as well.  Equipment modifications, joining an exercise group, or developing one at your agency will foster the interest in exercise.  As with all exercise programs, it is important to review such a program with the individual’s physician.  Starting  slow, learning some stretching exercises, wheel chair racing, swimming, dances, trips to the mall, pedometer challenges and tracking mileage (converting steps to miles) are just some ways to modify and increase a person’s interest in exercise.  Behavioral solutions to improve exercise include putting it on the Daily Activities Calendar, working exercise into regular daily routines, and awarding prizes for achieving participation goals.   Some of the benefits of exercise include: (a) reduction in depression and anxiety; (b) reduction in aggression; (c) greater calorie expenditures; (d) increasing strength, and (e) improved sleep (Martinsen, 2005; Penedo & Dahn, 2005; Tkachuk & Martin,1999).  For these reasons, the authors’ position is that exercise and diet is an essential part of any behavior support plan and promotes a healthy lifestyle that otherwise would not be known or engaged in by the consumer.

Sleep also affects one’s mind and body.  Persons with disabilities and mental illness often have associated sleep disturbances.  To promote good sleep habits, support providers should assist individuals to: obtain 7 to 9 hours of sleep per night; maintain a consistent bedtime; make environmental modifications such as assuring that no TV is in the bedroom, or assure that it is not turned on at night; restrict caffeine at least six hours before bedtime; keep the bedroom dark and slightly cool; and develop a bedtime routine that includes calming activities such as a bath or quiet (instrumental) music.

Lastly, the promotion of health among persons with disabilities involves team efforts to arrange for the communication of issues to physicians and between physicians.  Regular visits to physicians, tracking of medication changes, physical exam data, and lab results need to be included in the individuals “portable file.”  Additionally, talking with physicians about any benefit of vitamin supplements and the effect of long-term use of medications on nutrition and health and a titration plan should be periodically discussed.  Women should have annual visits to a gynecologist.  This latter recommendation has been noted by the authors to be frequently missed for a variety of reasons.  However, the importance can not be overstated as precancerous cells are much easier to treat than to deal with an advanced cancer. Arranging pleasurable activities following appointments such as a visit to an ice-cream store for low fat ice-cream or going out to buy a favorite music CD may help motivate the person with dual diagnoses to adhere to the frequent unpleasantness of multiple physician appointments and blood draws.  

Ideally, the primary care doctor would also coordinate and gather information from the specialists, but communications between doctors may not always be timely or efficient.  The authors advocate the identification of a Physician Liaison within the residential setting to coordinate appointments, labs, and communications to the physicians.  Some responsibilities of the liaison would include assuring that the doctors receive lab reports prior to visits, and if none were previously ordered, to again determine that none are needed prior to the appointment.  The Physician’s Liaison would also keep the “portable file” updated. Although the portable file is not meant to be a complete file, it can be useful in transporting and sharing physician’s reports, labs, medication changes, across physician specialty settings where the respective medical files are updated as needed.

In summary, the authors posit that the physical health and mental health of the persons we serve can be positively affected by the promotion of behavioral supports that are simple and thought out by the team in putting forth the setting conditions (e.g., consistent bedtime, consistent bedtime routines, activities schedule with specific meal times and exercise times), setting behavioral goals (e.g., participatory exercise goals, restricting caffeine before bedtime), and providing reinforcement contingencies (e.g., free movie coupon for exercising 5 days per week, a music CD after your blood draw).  

References

Bobroff, L. (1988). Avoiding food and drug interactions.  Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida.

Martinsen, E. W. (2005). Exercise and depression.  International Journal of Sport and Exercise Psychology, 3, 469-483.

Penedo, F. J. & Dahn, J. R. (2005). Exercise and well-being: A review of mental and physical health benefits associated with physical activity.  Current Opinion in Psychiatry, 18, 189-193.

Pleis, J. R., & Lethbridge-Cejku, M. (2006). Summary health statistics for U.S. adults: National Health Interview Survey, 2005.  National Center for Health Statistics. Vital Health Stat 10 (232).

Spratto, G. R., & Woods, A. L. (Eds.), 2004 Edition PDR Nurse’s Drug Handbook Clifton Park: Delmar Learning.

Tkachuk, G. A. & Martin, G. L. (1999). Exercise therapy for patients with psychiatric disorders: Research and clinical implications. Professional Psychology: Research and Practice, 30, 275-282.

Venes, D. (Ed.) (2005). Taber’s 20th Edition Cyclopedia Medical Dictionary, Philadelphia: F. A. Davis