Transcript UNC Hospitals Cardiac Rehabilitation Program Chapel Hill

UNC HOSPITALS CARDIAC REHAB PROGRAM
CHAPEL HILL, NC
Turning Challenges Into Opportunities: From Surviving To Thriving
Janet Garvey Baradell, PhD, RN, CS
Board Certified, Psychiatric-Mental Health
Clinical Nurse Specialist
PSYCHOSOCIAL INTERVENTIONS
Screening tools
Psycho-education
Skills training
Social support
Individual meetings
Motivational interviewing
Referrals
Support group
Collaboration with health care providers
PSYCHOSOCIAL ASPECTS
OF HEART DISEASE FOR
PATIENTS & FAMILIES:
FROM SURVIVING TO
THRIVING
Janet Garvey Baradell, PhD, RN, CS
Board Certified,
Psychiatric-Mental Health
Clinical Nurse Specialist
Adapted from Mayo Clinic .com
OUTLINE
• What brings you to cardiac rehab?
• Impact of heart illness on you
& your family
• Psychosocial risk factors
• Reducing your risk factors
Baradell 4
WHY ARE YOU HERE?
My doctor referred me
My spouse/family want me here
I want to prevent another heart event
I want to feel better
I want to reduce risk factors
I want to improve my quality of life
I want to reduce stress
Baradell 5
ILLNESS AND REHAB ARE STRESSFUL
FOR EVERYONE IN THE FAMILY
YOU
 Crisis!
impact, turmoil
resolution



Grief
denial, anger, bargaining,
depression, acceptance
Guilt
Face own mortality
 Fear/distrust body
 Stress
new demands, cost, time, role change:
dependent, burden, powerless,
role reversal
SPOUSE/PARTNER
“Caregiver Strain “:
 many of the same feelings you
felt, plus
 hub of communication
 vigilant, protective
 role changes:
insecure about the future, new
responsibilities, role reversal
 Caregiver Strain Index
Inconvenient, time consuming,
physically exhausting,
disagreements about care, daily
schedule, other family/work
demands, etc.
CAREGIVER STRAIN INDEX (CSI)
By M. Terry Sullivan, RN, MSW, MSN, CMC
Permission is hereby granted to reproduce this material for not-for-profit educational purposes only, provided
The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source.
Available on the internet at www.hartfordign.org. E-mail notification of usage to: [email protected].
•
•
•
•
•
•
Sleep is disturbed
Inconvenient
Physical strain
Confining
Family adjustments
Change in personal
plans
•
•
•
•
Demands on my time
Emotional adjustments
Behavior is upsetting
Upset by changes from
his/her former self
• Work adjustments
• Financial strain
• Feel overwhelmed
REACTIONS: FAMILY & FRIENDS
May be :

helpful or disappointing
 clingy, withdrawn,
indifferent
 afraid
 of what they don’t
understand
 to ask questions
WHICH PSYCHOSOCIAL ISSUES ARE RELEVANT
FOR HEART PATIENTS?
Smoking>PSYCHOSOCIAL RISK FACTORS>Hypertension>Obesity>Sedentary, etc.
Psychiatric Problems
Depression
Anxiety
Personality Traits
Type A Behavior Pattern
Type D Behavior Pattern
Stress
Baradell 9
20-40% OF HEART PATIENTS WILL
EXPERIENCE DEPRESSION OR ANXIETY
Chronic
Pain
40-60%
Substance
Disorders
20-40%
Heart
Disease
20-40%
Depression
Anxiety
Diabetes
10-20%
Neurologic
Disorders
Cancer
10-20%
10-20%
www.apm.org/unutzger
Baradell 10
PSYCHIATRIC PROBLEMS
Pozuelo, L. et al. 2009 Cleveland Clinic Journal Of Medicine. 76(1), 59-70. McGrady
A, McGinnis R, Badenhop D, Bentle M, Rajput M. Journal of Cardiopulmonary
Rehabilitation and Prevention. 2009;29:358-364.
Depression and Anxiety
reduce adherence to cardiac rehab
prescriptions
exercise, meds, nutrition, smoking
cessation, stress management
increase the likelihood of not completing
rehab
WNL (0-4) Mild (5-9)
Moderate (10-14)
Moderately severe (15-19)
Severe (20-27)
PATIENT HEALTH QUESTIONNAIRE: Depression
Over the last 2 weeks, how often have you been
bothered by any of the following problems?
(Circle your response.)
1. Little interest or pleasure in doing thing?
0
1
2
3
2. Feeling down, depressed, or hopeless?
0
1
2
3
3. Trouble falling or staying asleep, or sleeping too
much?
0
1
2
3
4. Feeling tired or having little energy?
0
1
2
3
5. Poor appetite or overeating?
0
1
2
3
6. Feeling bad about yourself – or that you are
a failure or have let yourself or your family down?
0
1
2
3
7. Trouble concentrating on things, such as reading the
newspaper or watching television?
0
1
2
3
8. Moving or speaking so slowly that other people could
have noticed? Or the opposite – being so fidgety or
restless that you have been moving around a lot
more than usual?
0
1
2
3
9. Thoughts that you would be better off dead, or of
hurting yourself in some way?
0
1
2
3
10. If you checked off any problems, how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?
Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt
Kroenke, MD Nov. 15, 2009.
WNL (0-4) Mild (5-9)
Moderate (10-14)
Severe (15-21)
PATIENT HEALTH QUESTIONNAIRE: Anxiety
Over the last 2 weeks, how often have you been
bothered by any of the following problems?
(Circle your response.)
1. Feeling nervous, anxious or on edge
0
1
2
3
2. Not being able to stop or control worrying
0
1
2
3
3. Worrying too much about different things
0
1
2
3
4. Having trouble relaxing
0
1
2
3
5. Being so restless that it is hard to sit still
0
1
2
3
6. Becoming easily annoyed or irritable
0
1
2
3
7. Feeling afraid as if something awful might happen
0
1
2
3
8. If you checked off any problems, how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?
Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc.
Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.
PATIENT HEALTH QUESTIONNAIRE: Alcohol
1.
Do you ever drink alcohol (including beer or wine)?
2. Have any of the following happened to you more than once in the last 6 months?
a. You drank alcohol even though a doctor suggested that you stop drinking
because of a problem with your health
b. You drank alcohol, were high from alcohol, or hung over while you were
working, going to school, or taking care of children or other responsibilities
c. You missed or were late for work, school, or other activities because you
were drinking or hung over
d. You had a problem getting along with other people while you were drinking
e. You drove a car after having several drinks or after drinking too much
WNL (0)
"Yes" to any item 2 a -e
is suggestive of abuse
NO
[ ]
YES
[ ]
NO
YES
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of
things at home, or get along with other people?
Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999
Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.
ADDITIONAL QUESTIONS
What is the most stressful thing in your life right now?
______________________________________________________
______________________________________________________
______________________________________________________
NO
YES
[ ]
[ ]
Are you seeing a pastor, therapist, counselor, or psychiatrist
for psychotherapy or stress management?
[ ]
[ ]
Are you taking any medicine for anxiety, depression or stress?
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet
B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov.
15, 2009.
Suicide Inquiry (use along with SAFE-T)
http://www.stopasuicide.org/downloads/Sites/Docs/SAFE-T_One_Page_Final.pdf
I noticed that you answered "Yes" to question # 9 on the screening questionnaire
regarding thoughts about ending your life. I am concerned about you.
•
•
•
•
Ideation: Are you having these thoughts now?
Have you had thoughts like this before? (If yes,) Tell me about that.
How has your heart problem changed how you feel about living vs. dying?
Plan:
How did you think you might end your life?
When did you plan to end your life?
Do you have _____ (whatever the means were – gun, drugs, hanging, knives)
Intent:
How likely are you to carry out your plan to end your life?
What might be some reasons to go on living?
family, friends, faith, pets, work, anyone who relies on this person, belief that
things can get better, any significant relationship or person who cares about this
person, including you
How do you think this might affect your ______ (spouse, child, friend, etc.?)
In my experience, this is a tragedy, very hard on those who love/care about you.
I would be very sad if you ended your life…
I would be devastated.
Go to Risk Level/Intervention and follow guidelines for Level of Risk based on your
judgment.
ACCESSING MENTAL HEALTH SERVICES
If psychotherapists are not available in your
community, some suggestions are:
• To access public mental health services in each county,
AS OF JANUARY 2011
http://www.ncdhhs.gov/mhddsas/lmedirectory.htm
• Mental health providers – volunteer support group leader
• Self help groups: AA, NA, AlAnon, OA, Depression and
Bipolar Support Groups, Compassionate Friends,
Survivors of Suicide
• Online sites: Mayo Clinic, NIMH,
http://www.mayoclinic.com/health/DiseasesIndex/DiseasesIndex
http://www.nimh.nih.gov/index.shtml
http://www.adaa.org/
• Meditation groups
PERSONALITY TRAITS: COPING STYLES
Razzini et al., 2008
Personality Traits
Type A (Angry) Behavior Pattern:
driven, perfectionist, multitask, time pressure/deadlines,
competitive
hostile, critical and unhappy with others
Type D (DISTRESSED) Behavior Pattern:
Negative emotions, like anger, in response to multiple
situations and over time
social isolation to avoid experiencing negative emotions that
arise in social interaction
Seen in 28% of coronary artery disease patients and 53% of
hypertensive patients!!
Has a seven-fold increased risk of sudden, cardiac death
“STRESS”: LIFE EVENTS
Baradell, J. Abbreviated Daily Hassles Scale. 1988; Lazarus & Folkman, 1984
 Stress is anything that makes a demand on you:
 caused by internal or external demands
Internal Thoughts/Feelings – self generated pressure to
return to work, provide care for others, be perfect,
unrealistic expectations about time or effort necessary to
recover or helplessness, hopelessness, despair
External stresses: time pressure /deadlines for work, school
or family obligations, traffic, crime, weather
 caused by positive or negative events
Positive: births, weddings, graduations, pay raise,
promotion, new home
Negative: finances, work, marital conflicts, health problems,
death, divorce
 Accumulates over a lifetime
STRESSERS
Stress in America survey in
August by Harris Interactive
for the American
Psychological Association
The adults surveyed said that
stress affected behavior and
often had physical
consequences:
• •31% say they skipped a
meal.
• •40% say they overate or ate
unhealthy foods.
• •44% say they lay awake at
night.
http://www.usatoday.com/yourlife/health/
medical/mentalhealth/2010-11-09apastress09_VA1_N.htm
accessed 11-10-10
WHY ARE PSYCHOSOCIAL RISK FACTORS RISKY???
Pozuelo, et al., 2009; Razzini et al., 2008; Blumenthal, 2008; Jiang, 2008; Parissis et al.,
2007Carney, et al., 2004
 Body seeks homeostasis:
balance in level of arousal and relaxation
 “Stress” activates the Fight or Flight Response:
a defensive response that disrupts homeostasis
 After stress subsides, relaxation restores homeostasis
 Not all stresses must induce Flight or Flight Response
 Chronic stress causes
 hyper-arousal
of the Sympathetic Nervous System, and
 impairment of the Parasympathetic Nervous system to produce relaxation
resulting in feeling “switched on” or “keyed up”
 Stress contributes to the development of Coronary Artery Disease
Endothelial Disease - a systemic disease that damages the lining of arteries
Baradell 21
“FIGHT OR FLIGHT” RESPONSE
Sympathetic Nervous System
Sympathetic Nervous System
Body reacts to stress by
activating the HPA Axis:
The Stress of Life (Selye, 1956, 1976, 1984)
Physical Impact
 Increases:
 heart rate, BP, force of contraction
 rapid, shallow breathing
 blood sugar, triglycerides &
cholesterol
 sodium and water retention
 muscle tension
 clotting
 belly fat
Psychological Impact
Parasympathetic Nervous System:
stimulation of Vagus nerve produces
relaxation/homeostasis
 Alert
 Fearful
 Rapid thinking with impaired
memory
 Expect the worst
 Freeze
CORONARY ARTERY DISEASE
http://www.heartsite.com/html/cad.html
23
PROGRESSION OF CAD
http://www.heartsite.com/html/cad.html
Normal coronary artery
Fibers encase fatty streaks
creating plaque; inflammation
Fatty streaks
Fatty streaks begin to interfere
with blood flow
Ruptured plaque and
clot formation
Clot continues to grow,
blocking artery – Heart Attack
AN INFLAMMATORY PROCESS
REDUCING RISK FACTORS
Baradell 25
EFFECTIVE TREATMENTS
FOR HEART PATIENTS
Pozuelo, et al., 2009; Blumenthal, 2008; Jiang, 2008; Manzoni, et al., 2008; Razzini et al., 2008;
Parissis et al., 2007; Carney, et al., 2004
• Exercise:
may be the most effective at reducing all risk factors, as well as,
reducing depression
• Stress Management, including relaxation training or
meditation:
reverses “Fight or Flight”, may reduce inflammation, and platelet
stickiness – all protective
• Antidepressants:
SSRI’s citalopram (Celexa) and sertraline (Zoloft); mirtazapine
(Remeron) was not effective in treatment of depression in heart
patients
• Psychotherapy:
effective in reducing depression and anxiety and improving quality of
life , has not consistently shown reduced mortality
Baradell 26
Relaxation Training for Anxiety:
A Ten-Years Systematic Review With Meta-Analysis
Gian Mauro Manzoni; Francesco Pagnini; Gianluca Castelnuovo; Enrico Molinari
BMC Psychiatry. 2008; ©2008 Manzoni et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
• Progressive relaxation and meditation are effective in
reducing anxiety
(ES: Progressive Relaxation=.8 and meditation=.7, high effect)
• Homework practice improves effectiveness
Baradell 27
RELAXATION – RESTORES HOMEOSTASIS
by stimulating the Parasympathetic Nervous System
Diaphragmatic
Breathing
Passive Mind
Progressive
Muscle
Relaxation
baradell
RELAXATION CD
5 Tracks With Instructions:
• Mindful Breathing - 3 minutes
Practice Mindful Breathing several times a day:
mid-morning and mid-afternoon and anytime you notice negative emotions
like anger or impatience; feel “fight/flight/freeze” sensations or notice rapid
thinking or negative thinking (judging self or others, replaying an event,
worrying about a future event, creating a story in your head about a future
event – as if it were TRUE)
• Progressive Relaxation and Mindfulness Meditation
Practice twice a day for 2 weeks, using 1 of these tracks, then
once a day – morning practice seems most beneficial
–
–
–
–
Mindful Relaxation with Imagery - 9 minutes
Progressive Relaxation - 12 minutes
Progressive Relaxation -13 minutes
Mindfulness Meditation – 20 minutes
Mindfulness Meditation classes: Program on Integrative Medicine @ UNC-Chapel Hill:
http://pim.med.unc.edu/ or call 966-8586
Baradell 29
STRESS MANAGEMENT STRATEGIES
An Active Partnership for the Health of Your Heart (AHA & ASA)
https://www.krames.com/OA_HTML/ActivePartnership.html#TabTop
Consider priorities
 Avoid
unnecessary stress:
do I own it?
 Adapt
change the way you think or feel to
reduce your suffering; get socially
involved; Job redesign, transfer, or
change; family communication,
compromise, negotiate
 Accept
things you can’t change
acceptance doesn’t mean agreement
Self Actualization:
lack of prejudice, creative, spontaneous,
acceptance of reality, problem solving
Esteem:
confidence, achievement, self respect; respect
of others
Love/Belonging:
family, friends, sexuality
Security:
physical and emotional safety; job/school;
adequate finances; family and social
connections; organize to meet priorities; home
maintenance
Physiological:
smoking cessation; exercise 5-6 times a
week for 45-60 minutes; practice daily
relaxation or meditation; sleep; medications;
nutrition & alcohol
Goal: MET level ≥ 8
(Maslow adapted)
Baradell 30
ANGER MANAGEMENT
ANGER
KILLS!
 Count to 10, Breathe
 Think before you act – what am I angry
about?
 Talk it out – seated, no raised voices;
say what the problem is
& how you feel; ask for what you want;
compromise
 If you aren’t able talk it out,
get away & cool off;
then, get back together
Baradell 31
ALCOHOL GUIDELINES
IF YOU DRINK:
 Men: up to 2 drinks per day
 Women: 1 drink per day
 1 Drink = 1 oz hard liquor;
4-5 oz wine (about ½ cup);
12 oz beer
 WHY?
 interacts with medications:
eliminating them more rapidly or slowly
 increases risk of bleeding
 causes or worsens fatigue, insomnia, anxiety & depression
Baradell 32
SOCIAL SUPPORT
Companions and Lovers
Sexual relations, with a committed
partner allows you to feel “normal”
 Ask your doctor when it’s safe
 Orgasm is within 80% THRR
 To reduce workload:
non-cardiac spouse on top
use side-lying or seated positions
2 hrs after meal
 When in doubt about sexual function,
try it out – in private
Baradell 33
SOCIAL SUPPORT
Health
Spouse
care
ChildrenFriends
Cardiac team
Rehab
Coworkers
Cardiac Survivors
Support Group
Neighbors
Parents
Siblings
Volunteering
You
Grocery
Store
Prayer
Group
AA
OA
NA
Senior
Center
Church
Pets
Exercise
Meditation
Garden
Group
Group
Club
Baradell 34
HELPFUL REFERENCES
Full Catastrophe Living. 1990, Jon Kabat Zinn. PhD.
Dr. Dean Ornish’s Program for Reversing Heart Disease. 1990, Dean
Ornish, MD.
10 Simple Solutions to Stress: How to Tame Tension & Start Enjoying
Your Life. 2007, Claire M. Wheeler, MD, PhD.
Instant Calm: Over 100 Easy-to-Use Techniques for Relaxing Mind and
Body. 1995, Paul Wilson.
Motivational Interviewing: Preparing People for Change, 2nd ed. 2002,
William Miller, PhD and Stephen Rollnick, PhD.
Motivational Interviewing in Health Settings: A Review. Britt, E. Hudson, S.
Blampied, N. Patient Education and Counseling, 53 (2004) 147-155.
(full text was online)
CONCLUSIONS
“Stress management
in cardiac rehab
can reduce death
rates in cardiac
patients”
Linden W, Phillips MJ, Leclerc J.
Psychological treatment of cardiac
patients: a meta-analysis. Eur Heart J
2007; 28:2972-2984.
Baradell 36