Transcript Introduction to Chronic illness

Introduction to Chronic
illness
Practice of Medicine - 1
Objectives
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Define a chronic illness
Outline common chronic illnesses
Discuss health system challenges in
caring for patient with chronic disease
Definition
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An illness that lasts more than three
months
Persistent or recurring
meaningful impact on a person’s health status
typically not curable.
Symptoms –absent, constant or intermittent
Disease process may be progressive or
stable.
Disease severity can range from mild to
fatal.
Demography
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Prevalence and distribution of chronic
illnesses change with age
• More common in older adults, minorities,
and persons of lower socioeconomic
status
Common Chronic
Illnesses
Age (yrs)
 18 – 44
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45-64
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>64
Common conditions
 Chronic sinusitis, hay
fever, asthma, HTN
 HTN, arthritis, hearing
problems, sinusitis
 Arthritis, HTN, hearing
impairment, CAD,
COPD
Leading Causes of
Disability in US, 1996
Men
Women
Ischemic heart dz
Ischemic heart dz
Traffic accidents
Major depression
Lung cancer
Stroke
HIV/AIDS
Lung cancer
Alcohol abuse
Arthritis
Michaud, JAMA, 2001
Chronic Obstructive
Pulmonary Disease
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Progressive lung
disease
characterized by
airflow limitation
abnormal
inflammatory
response to noxious
particles or gases
Hypertension
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Elevated Blood
Pressure
major risk factor for
• premature
cardiovascular disease
• heart failure
• stroke
• chronic renal
insufficiency and ESRD
Osteoarthritis
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articular cartilage
damage induced by
a complex interplay
of multiple factors
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genetic
metabolic
biochemical
biomechanical
secondary
inflammation
Coronary artery disease
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Myocardial injury
due to decrease in
myocardial oxygen
supply
Diabetes mellitus
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Insulin deficiency
• Autoimmune destruction
of the pancreatic beta
cells
• Tissue resistance
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End organ damage
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Brain
Kidneys
Heart
Retina
CNS
Health System Challenges
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Increasing Prevalence
• Increased life expectancy
Percentage of population by age group
Elderly population is
growing rapidly
20%
15%
65 to 84 yrs
10%
Over 84 yrs
5%
0%
1960
1980
2000
2020
2040
Health System Challenges
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Patients with chronic illnesses use a
disproportionate share of medical
services
80%
 69%
 83%
 66%
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of
of
of
of
hospital days
hospital admissions
prescription drug use
physician visits
1996
$659
Billion
$220
Billion
RWJ, 1996
Health System Challenges
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Contrary to popular perceptions, many
people with chronic illness are not old.
What does that mean to
you?
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Most of your career will be spent in
caring for patients with chronic illness!
Physician-Patient Relationship
in Chronic Illness
A patient centered therapeutic
relationship
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characterized by continuity over time,
Empathy
interactions that empower the patient to play
an active role in medical decision making and
in their care.
Associated with better outcomes
(improved quality of life, less disability,
and fewer hospital admissions).
Patient-centered interview
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Always involve patient in setting agenda
• “How are you doing?”
• “What can I do for you today?”
• “What concerns or issues do you need to discuss
today?”
• “I really want to talk with you about your…….
but first I want to find out if you have anything
we need to talk about.
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Make questions functionally relevant.
Treatment Plan
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Baseline information
• Patient’s beliefs and knowledge
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Treatment goals and plans
• Ensure understanding
• Patient preferences and commitment
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Negotiate a plan
• Enpower the patient
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Affirmation of intent
Treatment not effective?
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Compliance
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Personality
Psychodynamics
Interpersonal dynamics
Financial constraints
Culture/beliefs
Cognitive factors
Treatment re-evaluation/adjustment
Negotiate Solutions
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Elicit patient’s perspectives
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Goals
Suggestions
Preferences
Weigh benefits/burdens of treatment
options
Modify plan
Follow -up
Smoking Cessation
Objectives
 Outline adverse effects of smoking
 Outline benefits of smoking cessation
 Discuss two approaches to smoking
cessation
Introduction
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Cigarette smoking is the major
preventable cause of disease
Results in over 400,000 deaths
annually
Chronic Obstructive
Pulmonary Disease
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Progressive lung
disease
characterized by
airflow limitation
abnormal
inflammatory
response to noxious
particles or gases
Lung Cancer
Head and Neck Cancer
Atherosclerotic Cardiovascular
Heart Disease
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Myocardial injury
due to decrease in
myocardial oxygen
supply
Epidemiology
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Over 50 percent of adolescents try
smoking by 12th grade
Most adult smokers start by age 18
Tobacco dependence develop with one
year
80 percent of smokers have regrets by
age 20
Risk Factors
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Exposure to second hand smoke
Presence of smoker in household
Comorbid psychiatric disorders
Low self-esteem/self worth
Peer pressure
Genetic link in twin studies
Prevalence
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Mid 1960s: 42 percent of adults
2003: 22 percent of adults
High school students
• 1997: 36 percent
• 2003: 22 percent
Benefits of Cessation
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Cardiovascular Disease
• Rapid decrease in new events
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Pulmonary Disease
• Improvement within one year
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Malignancy (oral cavity, head/neck,
pancreas, lung, cervix)
Peptic ulcer disease
Reproductive disorders
Osteoporosis
Methods for cessation
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Behavioral Approach
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Pharmacologic Approach
Behavioral Approach
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Clinician counseling: works!
• Great motivating factor
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Advice with a personal health
message: works even better!
Tobacco use status should be
documented at every visit
• Assess for second hand smoke
Behavioral Approach
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Assess stage of motivation
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Precontemplation
Contemplation
Determination
Action
Maintenance
Five "R's" for smokers
who are unwilling to quit
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Relevance: Encourage the patient to indicate why quitting is
personally relevant, being as specific as possible.
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Risks:
Ask the patient to identify potential negative
consequences of tobacco use.
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Rewards:
Ask the patient to identify potential benefits of
stopping tobacco use.
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Roadblocks: Ask the patient to identify barriers or
impediments to quitting
Repetition: The motivational intervention should be repeated
every time the patient visits the clinic
Adapted from Fiore, MC, Bailey, WC, Cohen, SJ, et. al. U.S. Department of Health and Human Services. Public Health Service. Octr 2000
Five "A's" for patients who
are willing to quit smoking
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Ask:
Every single patient and document tobacco
use status.
Advise: Strongly urge all tobacco users to quit in a clear,
strong, personalized manner.
Assess: Determine the patient's willingness to quit smoking
within the next 30 days.
Assist: Provide aid for the patient to quit.
Arrange: Schedule follow-up contact, either in person or by
telephone.
Action Plan
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Set quit date
Should ideally be within two weeks
Encourage preparation for quitting
• Tell family and friends and elicit support
• Review previous quit attempts
• Anticipate nicotine withdrawal symptoms
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Decide on treatment strategy
Follow up
Pharmacotherapy
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Nicotine Replacement therapy
• Reduces withdrawal symptoms
• Continuous quit rates 5 -27%
• Best when combined with behavioral therapy
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Bupropion
• Acts by enhancing noradrenergic and dopaminergic
receptors
• Rate of cessation: 44 vs. 19 percent placebo
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Varenicline (Chantix)
• Partial agonist of nicotinic acetylcholine receptors
• More effective than bupropion in trials
Potential hazards of
smoking cessation
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Withdrawal symptoms: irritability,
insomnia, anxiety, restlessness
Weight gain
Depression
Worsening comorbid disease:
exacerbation of ulcerative colitis,
schizophrenia
Relapse
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Most smokers make many attempts to quit
before success
Assess for improper use of cessation aides
Assess for compliance
Consider referral to smoking cessation
program
Intensive individual or group counseling