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Introduction to Chronic illness Practice of Medicine - 1 Objectives Define a chronic illness Outline common chronic illnesses Discuss health system challenges in caring for patient with chronic disease Definition • • • 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 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 45-64 >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 Progressive lung disease characterized by airflow limitation abnormal inflammatory response to noxious particles or gases Hypertension Elevated Blood Pressure major risk factor for • premature cardiovascular disease • heart failure • stroke • chronic renal insufficiency and ESRD Osteoarthritis articular cartilage damage induced by a complex interplay of multiple factors • • • • genetic metabolic biochemical biomechanical secondary inflammation Coronary artery disease Myocardial injury due to decrease in myocardial oxygen supply Diabetes mellitus Insulin deficiency • Autoimmune destruction of the pancreatic beta cells • Tissue resistance End organ damage • • • • • Brain Kidneys Heart Retina CNS Health System Challenges 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 Patients with chronic illnesses use a disproportionate share of medical services 80% 69% 83% 66% of of of of hospital days hospital admissions prescription drug use physician visits 1996 $659 Billion $220 Billion RWJ, 1996 Health System Challenges Contrary to popular perceptions, many people with chronic illness are not old. What does that mean to you? 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 • • • 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 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. Make questions functionally relevant. Treatment Plan Baseline information • Patient’s beliefs and knowledge Treatment goals and plans • Ensure understanding • Patient preferences and commitment Negotiate a plan • Enpower the patient Affirmation of intent Treatment not effective? Compliance • • • • • • Personality Psychodynamics Interpersonal dynamics Financial constraints Culture/beliefs Cognitive factors Treatment re-evaluation/adjustment Negotiate Solutions Elicit patient’s perspectives • • • • 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 Cigarette smoking is the major preventable cause of disease Results in over 400,000 deaths annually Chronic Obstructive Pulmonary Disease 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 Myocardial injury due to decrease in myocardial oxygen supply Epidemiology 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 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 Mid 1960s: 42 percent of adults 2003: 22 percent of adults High school students • 1997: 36 percent • 2003: 22 percent Benefits of Cessation Cardiovascular Disease • Rapid decrease in new events Pulmonary Disease • Improvement within one year Malignancy (oral cavity, head/neck, pancreas, lung, cervix) Peptic ulcer disease Reproductive disorders Osteoporosis Methods for cessation Behavioral Approach Pharmacologic Approach Behavioral Approach Clinician counseling: works! • Great motivating factor 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 Assess stage of motivation • • • • • Precontemplation Contemplation Determination Action Maintenance Five "R's" for smokers who are unwilling to quit Relevance: Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Risks: Ask the patient to identify potential negative consequences of tobacco use. Rewards: Ask the patient to identify potential benefits of stopping tobacco use. 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 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 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 • • Decide on treatment strategy Follow up Pharmacotherapy Nicotine Replacement therapy • Reduces withdrawal symptoms • Continuous quit rates 5 -27% • Best when combined with behavioral therapy Bupropion • Acts by enhancing noradrenergic and dopaminergic receptors • Rate of cessation: 44 vs. 19 percent placebo Varenicline (Chantix) • Partial agonist of nicotinic acetylcholine receptors • More effective than bupropion in trials Potential hazards of smoking cessation Withdrawal symptoms: irritability, insomnia, anxiety, restlessness Weight gain Depression Worsening comorbid disease: exacerbation of ulcerative colitis, schizophrenia Relapse 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