What are the psychiatric symptoms of Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) can cause various psychiatric symptoms, including confusion, disorientation, agitation, hallucinations, and altered mental status, which are manifestations of the underlying metabolic abnormalities rather than primary psychiatric disorders. These symptoms occur because high blood glucose levels and ketone buildup affect brain function, leading to metabolic stress from acidosis, electrolyte imbalances (particularly sodium, potassium, and magnesium), and dehydration 1. Patients may present with anxiety, irritability, or even symptoms resembling psychosis.

Treatment Approach

Treatment focuses on addressing the underlying DKA with:

• Insulin therapy (typically IV insulin at 0.1 units/kg/hour)
• Fluid resuscitation (initially 1-2 liters of normal saline over 1-2 hours)
• Electrolyte replacement (particularly potassium when levels fall below 5.2 mEq/L) 1. The psychiatric symptoms typically resolve as the metabolic abnormalities are corrected, usually within 24-48 hours of treatment initiation.

Important Considerations

It's crucial to recognize these symptoms as manifestations of DKA rather than primary psychiatric disorders to ensure appropriate treatment. In elderly patients or those with pre-existing cognitive impairment, these symptoms may be more pronounced and persist longer, sometimes requiring additional supportive care during recovery. Prevention measures, such as gradual replacement of sodium and water deficits in patients who are hyperosmolar and the addition of dextrose to the hydrating solution once blood glucose reaches 250 mg/dl, may decrease the risk of cerebral edema in high-risk patients 1.

Key Points to Consider

• DKA can cause a range of psychiatric symptoms due to metabolic stress and electrolyte imbalances.
• Treatment should focus on correcting the underlying metabolic abnormalities with insulin, fluid resuscitation, and electrolyte replacement.
• Recognizing these symptoms as part of DKA is crucial for appropriate treatment and to avoid misdiagnosis as primary psychiatric disorders.
• Prevention measures can help reduce the risk of complications such as cerebral edema.

From the FDA Drug Label

The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death.

Psychiatric symptoms of DKA may include:

• Drowsy feeling
• Loss of appetite
• Personality changes and abnormal behavior are not explicitly mentioned as symptoms of DKA, but can occur in the context of hypoglycemia or hyperglycemia. 2

From the Research

DKA Psychiatric Symptoms

• Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can have significant psychiatric symptoms, including alterations in mental status and consciousness 3.
• A study found that patients with DKA can present with different levels of consciousness, and a close association between abnormalities found during a mental status evaluation and osmolality seems to exist 3.
• Psychiatric symptoms such as depression and anxiety can be common in patients with DKA, and the diagnosis of DKA presents an opportunity to screen for these conditions and offer appropriate intervention 4.
• A case-controlled study found that patients with recurrent DKA had a higher prevalence of diagnosed mental health disorders, likely depression, and severe diabetes distress compared to those with single episode DKA and controls 4.
• The study also found that DKA patients had significantly more unemployment, illicit drug use, and tobacco smoking, a lower level of formal education, and less regular medical contact compared with controls 4.

Management of DKA and Psychiatric Symptoms

• Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event, as well as frequent monitoring of the patient's clinical and laboratory states 3, 5.
• Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA, as well as patient education programs focusing on adherence to insulin and self-care guidelines during illness 5.
• New approaches such as extended availability of phone services, use of telemedicine, and utilization of public campaigns can provide further support for the prevention of DKA and management of psychiatric symptoms 5.

Risk Factors for DKA and Psychiatric Symptoms

• Infections, new diagnosis of diabetes, and nonadherence to insulin therapy are common precipitating causes for DKA 3, 5.
• Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors 5.
• Mental health disorders and adverse socioeconomic factors appear to be common in patients with DKA, and the diagnosis of DKA presents an opportunity to screen for these conditions and offer appropriate intervention 4.