Introduction to Chronic illness

1. Introduction to Chronic illness Practice of Medicine - 1

2. Objectives • Define a chronic illness • Outline common chronic illnesses • Discuss health system challenges in caring for patient with chronic disease

3. 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.

4. Demography • Prevalence and distribution of chronic illnesses change with age • More common in older adults, minorities, and persons of lower socioeconomic status

5. 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 Common Chronic Illnesses

6. Leading Causes of Disability in US, 1996 Michaud, JAMA, 2001

7. Chronic Obstructive Pulmonary Disease • Progressive lung disease characterized by airflow limitation • abnormal inflammatory response to noxious particles or gases

8. Hypertension • Elevated Blood Pressure • major risk factor for • premature cardiovascular disease • heart failure • stroke • chronic renal insufficiency and ESRD

9. Osteoarthritis • articular cartilage damage induced by a complex interplay of multiple factors • genetic • metabolic • biochemical • biomechanical • secondary inflammation

10. Coronary artery disease • Myocardial injury due to decrease in myocardial oxygen supply

11. Diabetes mellitus • Insulin deficiency • Autoimmune destruction of the pancreatic beta cells • Tissue resistance • End organ damage • Brain • Kidneys • Heart • Retina • CNS

12. Health System Challenges • Increasing Prevalence • Increased life expectancy

13. Elderly population is growing rapidly

15. Health System Challenges • Patients with chronic illnesses use a disproportionate share of medical services • 80% of hospital days • 69% of hospital admissions • 83% of prescription drug use • 66% of physician visits

16. 1996 $659 Billion $220 Billion RWJ, 1996

17. Health System Challenges • Contrary to popular perceptions, many people with chronic illness are not old.

19. What does that mean to you? • Most of your career will be spent in caring for patients with chronic illness!

20. 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).

21. 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.

22. 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

23. Treatment not effective? • Compliance • Personality • Psychodynamics • Interpersonal dynamics • Financial constraints • Culture/beliefs • Cognitive factors • Treatment re-evaluation/adjustment

24. Negotiate Solutions • Elicit patient’s perspectives • Goals • Suggestions • Preferences • Weigh benefits/burdens of treatment options • Modify plan • Follow -up

25. Smoking Cessation Objectives • Outline adverse effects of smoking • Outline benefits of smoking cessation • Discuss two approaches to smoking cessation

26. Introduction • Cigarette smoking is the major preventable cause of disease • Results in over 400,000 deaths annually

27. Chronic Obstructive Pulmonary Disease • Progressive lung disease characterized by airflow limitation • abnormal inflammatory response to noxious particles or gases

28. Lung Cancer

29. Head and Neck Cancer

30. Atherosclerotic Cardiovascular Heart Disease • Myocardial injury due to decrease in myocardial oxygen supply

31. 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

32. 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

33. Prevalence • Mid 1960s: 42 percent of adults • 2003: 22 percent of adults • High school students • 1997: 36 percent • 2003: 22 percent

34. 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

35. Methods for cessation • Behavioral Approach • Pharmacologic Approach

36. 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

37. Behavioral Approach • Assess stage of motivation • Precontemplation • Contemplation • Determination • Action • Maintenance

38. 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

39. 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.

40. 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

41. 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

42. Potential hazards of smoking cessation • Withdrawal symptoms: irritability, insomnia, anxiety, restlessness • Weight gain • Depression • Worsening comorbid disease: exacerbation of ulcerative colitis, schizophrenia

43. 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