Dr Siobhan MacHale Consultant Liaison Psychiatrist TUN conference Nov 27 th 2015 Outline Adjustment Adaptive maladaptive adjustment Concordance ID: 642803
Download Presentation The PPT/PDF document "Optimising patient adjustment and self ..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Optimising patient adjustment and self care strategies
Dr Siobhan MacHale Consultant Liaison PsychiatristTUN conference Nov 27th 2015 Slide2
OutlineAdjustment Adaptive
- maladaptive adjustmentConcordanceInterventionsDiscussionSlide3
Normal Reactions to an Abnormal SituationShock
Anger and IrritabilityDenialSadnessAcceptanceSlide4
Illness
Disease
Socio-Cultural
Psychological
PhysiologySlide5
Dialysis patient
Depression 20-30%
Anxiety 20-40%
Cognitive impairmentSlide6
Impact Uncertainty regarding the future Meaning of what has happenedLoss of controlLoss of independenceHelplessnessFatigue
FearDeathSlide7
ImpactRelationships – family
partner (sexuality, fertility) children friendsBody Image Self-esteem Leisure/Workdisfigurement sick role changescarring disability loss
Imagined financial
holidaysSlide8
(Di)stress is “Normal”
Continuum of Distress Mild - Moderate - Severe(Normal, adaptive) (Maladaptive, disabling)Slide9Slide10
Shock at diagnosis……
‘Following the diagnosis, and the crippling words of ‘youhave chronic kidney failure and need a transplant’ anyfurther meaningful discussion ended as questions took over
all thought’
Dr Duncan Thomas
Thomas, D. ‘The flip side of the coin – a doctor’s experience of renal failure’. Journal of Renal
Care, 2009: 35(1): 16-18Slide11
What are some of these consequences?Loss of confidence in the reliability of the
bodyLoss of trust in the failing organAssumption of health replaced by hypervigilance Sense of powerlessnessSlide12
Powerlessness - Machines
‘no matter how uncomfortable or inconvenient dialysis is, if the individual wants to live, then he or she is dependent upon a machine’ Susan StapletonSlide13
Powerlessness - Time
‘survival depends on compliance with the health care system demands’ Susan StapletonSlide14
Dependence/independence
prior to each dialysis session I have to be weighed. As I stand on the scales,I am reminded by the sign that you must have your weight verified by a member of staff At one time I might have been responsible enough to raise a family, but now I am not responsible enough to weigh myself’Slide15
Powerlessness Behaviour
PassiveFollow direction without comment or questionCan’t make small decisions when invited to do soFail to seek information
Fail to share information
Aggressive
Anger
Frustration
Aggression towards others
Missing dialysis sessions
Silence/VerbalSlide16
Maladaptive Coping Strategies e.g.Substance misuseEating
disordersNon concordence Slide17
Our RolePossible to identify negative reactions earlyReduce adverse impact of negative reactionsReduce morbidity and mortality
‘Preventive psychological care is an investmentthat underpins and secures medical and nursingachievements’Keith NicholsSlide18
32 yr old female
IDDMCRFHx of dep/ANSPK
CASE
EXAMPLESlide19
We know that adherence to medication is very difficult to sustain
WHO report on non-adherenceEstimated that over 30 -50% medicines prescribed for long term illnesses are not taken as directedBlum et al (2009) Systematic review32-90.9% adherence at 12 monthsNon-adherence is the normSlide20
Concordance in the Transplant SettingNoncompliance (action in accordance with a request or demand)
implies rigidly following the instructions of the healthcare provider – suggests noncompliance is the fault of the patient Adherence (behave according to) suggests patients can make rational decisions to take or not take their medsConcordance (agreement between persons)
suggests
an equal partnership between patient and healthcare provider
i.e. joint
decision
makingSlide21
What do we know about non-concordance?
Not specific to disease typeNot significantly related to gender, intelligence, education, occupation, income or ethnicityNot consistent over time, or for individualsNot easily fixed by reminding people, informing people, instructing people or scaring peopleSlide22
“ Drugs don't work in patients who don't take them “ ( C. Everett Koop, M.D. US Surgeon General , 1981-9 )Slide23
Kiley
et al 1993 105 renal transplant recipients followed x18 months minConcordance determined by cyclosporine whole blood levels > 30 ng/mL, maintenance of ideal body weight (< 20% gain), and percentage of missed clinic visits (< 20%). Four groups identified: (1) overall concordant (n = 25),
(
2)
nonconcordant
with
diet
(n = 29, females more likely),
(
3)
nonconcordant with medication (n = 27, males more likely)(4) overall
nonconcordant (n = 29) Slide24
Most patients will be non
-concordantsome of the time
Concordance rates vary
Between patients
Within the same patient
over
time and
across treatments
Thus
it is much more accurate to view
non-concordance
as a behaviour which most people engage in some of the time, rather
than stable characteristics of the “non-concordant patient
”Hotspots eg adolescence/transitionSlide25
Our patientsSlide26Slide27
Poor HCP-Patient CommunicationLow patient satisfaction +/- recallCognitive difficultiesProblems in planning/executive function or prospective memory
Financial or other barriersPatients know what to do & how BUT are reluctant becauseTREATMENT DOESN’T MAKE SENSE +/or
WORRIES
/CONCERNS ABOUT TREATMENTSlide28
Summary of evidenceSlide29
What does non-concordance predict?Perceived non-
concordance with pre-transplant dialysis seen as a predictor of post-transplant non-concordance But treatment regimens differ markedly Haemodialysis demands thrice-weekly attendance, strict fluid and dietary control and multiple medications. Post-transplant requires strict adherence to medications, but fewer fluid / dietary restrictions
and
few
hospital attendances
While
non
-concordance
with immunosuppressive medications is a
recognised
cause of transplant failure, any association between pre- and post-transplant non-compliance remains unclear
Non-concordance with medication regimens after kidney transplantation is a major risk factor for acute rejection and graft lossKidney transplant recipients highest rate compared with recipients of other types of solid organ transplantSlide30
MeasurementDirect eg monitoringobservation
of medication intake drug assay levels Objective, may interfere with engagementIndirect measures eg patient interviews/ questionnairescollateral reporting,Dialysis fluid levels/wt change electronic pill counters/prescription refills,
clinical outcomes
subjective
and can be
influenced
Multiple sources most reliableSlide31
OVERVIEWSlide32
Immunosuppressive medication
nonadherence
(IMN)Slide33
Immunosuppressive medication non adherence IMNAAcute rejection
Graft loss (x7)Reduced renal functionIncreased health care costs ($ 21 600 /3 yrs)Studies to dateHeart/lung/liver pre tx MNA predicts 1st year IMNAOptimal timing for intervention unknown
1-2 yrs follow up
Renal TransplantSlide34Slide35Slide36
RESULTSSlide37Slide38
Strategies
to Improve Concordance
- EDUCATION
-
Normalise
non-adherence, use a non-judgemental and collaborative stance
- Accept
that your patient
does
not want to let you down so
might not tell you the truth
- Ask patients if they know why they need their medication (make sense of treatment)- Ask patients if they have concerns about taking their
meds over time (negative consqs)- Use the consultation to anticipate and plan Predict barriers, write down solutions Create a bridge between consultations
If you provide a threat message, you have to support self-efficacy Increased anxiety and guilt can lead to avoidance, rather than adherenceOnline
programs and
information:
CDC
Adherence
360
NHS
Motivational interviewing
Relaxation and stress reduction training Slide39
LIVING WITH CHRONIC ILLNESS
EducationBetter Health Better Living ProgrammeBeaumont.ie/marcSlide40Slide41
WEBSITES
www.beaumont.ie/renalunit www.beaumont.ie/marcwww.ika.ie www.nkf.co.uk www.Ihatedialysis.com www.nkf@kidneys.org www.nipka.org
www.getselfhelp.co.uk www.helpguide.org. Slide42
Internationally recognised
Evidence basedEfficacious psychosocial educational intervention model for various disease populationsimproves HRQoL and reduces health distress, with gains maintained at follow-up
Licensed
,
manualised
programme from Stanford University with 20 years of established research in multiple disease
conditions
CDSM PROGRAMMESlide43
BETTER HEALTH, BETTER LIVING (CDSMP)
What is Better Health, Better Living?Psycho-educational workshop for people with chronic conditionsParticipants meet for 2.5 hour sessions once a week for 6 weeksLed by 2 trained leaders , HCPs and peer leaders (patient volunteers) or just peer leaders
Designed to be taught in a community setting
What they learn
Techniques to deal with problems such as frustration, fatigue, pain and isolation
Exercise Methods
Communicating effectively with family, friends and medical professionals
Nutrition
Relaxation
Appropriate use of medication
Decision making in medical care
How they learn it
Action plans
(weekly goals)Group discussion (brainstorming, problem solving)Manualised , scripted educational ‘
lecturettes’Group process and modellingSlide44
CDSMP META ANALYSES FINDINGS
23 studies (1984 – 2009) 8,688 participants (2,902 in RCTs 5,779 in longitudinal studies) Slide45
Mindfulness & Relaxation Centre (MARC)www.beaumont.ie/marcSlide46
On line CBT (that’s free)MoodgymE-couchSlide47
32 yr old female
CRFLDChildren in carePost transplant issues
CASE
EXAMPLESlide48
Those who can develop insight and work with biopsychosocial
management Those who cannot (a minority)2 GROUPSSlide49
Discussion