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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 - PowerPoint PPT Presentation
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Introduction to Introduction to Chronic illnessChronic illness
Practice of Medicine - 1Practice of Medicine - 1
ObjectivesObjectives
Define a chronic illnessDefine a chronic illness Outline common chronic illnessesOutline common chronic illnesses Discuss health system challenges Discuss health system challenges
in caring for patient with chronic in caring for patient with chronic diseasedisease
DefinitionDefinition
An illness that lasts more than three An illness that lasts more than three monthsmonths
Persistent or recurringPersistent or recurring• meaningful impact on a person’s health meaningful impact on a person’s health
statusstatus• typically not curable.typically not curable.• Symptoms –absent, constant or Symptoms –absent, constant or
intermittentintermittent Disease process may be progressive or Disease process may be progressive or
stable.stable. Disease severity can range from mild Disease severity can range from mild
to fatal.to fatal.
DemographyDemography
Prevalence and distribution of Prevalence and distribution of chronic illnesses change with agechronic illnesses change with age• More common in older adults, More common in older adults,
minorities, and persons of lower minorities, and persons of lower socioeconomic status socioeconomic status
Common Chronic Common Chronic IllnessesIllnessesAge (yrsAge (yrs) ) 18 – 4418 – 44
45-64 45-64
>64>64
Common conditionsCommon conditions Chronic sinusitis, Chronic sinusitis,
hay fever, asthma, hay fever, asthma, HTNHTN
HTN, arthritis, HTN, arthritis, hearing problems, hearing problems, sinusitissinusitis
Arthritis, HTN, Arthritis, HTN, hearing impairment, hearing impairment, CAD, COPDCAD, COPD
Leading Causes of Leading Causes of Disability in US, 1996Disability 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
Men Women
Ischemic heart dz Ischemic heart dz
Traffic accidents Major depression
Lung cancer Stroke
HIV/AIDS Lung cancer
Alcohol abuse Arthritis
Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease Progressive lung Progressive lung
disease disease characterized by characterized by airflow limitation airflow limitation
abnormal abnormal inflammatory inflammatory response to response to noxious particles noxious particles or gasesor gases
HypertensionHypertension
Elevated Blood Elevated Blood PressurePressure
major risk factor formajor risk factor for• premature premature
cardiovascular cardiovascular diseasedisease
• heart failure heart failure • stroke stroke • chronic renal chronic renal
insufficiency and insufficiency and ESRD ESRD
OsteoarthritisOsteoarthritis
articular cartilage articular cartilage damage induced damage induced by a complex by a complex interplay of interplay of multiple factors multiple factors • genetic genetic • metabolic metabolic • biochemicalbiochemical• biomechanical biomechanical
secondary secondary inflammation inflammation
Coronary artery Coronary artery diseasedisease Myocardial injury Myocardial injury
due to decrease due to decrease in myocardial in myocardial oxygen supply oxygen supply
Diabetes mellitusDiabetes mellitus
Insulin deficiencyInsulin deficiency• Autoimmune Autoimmune
destruction of the destruction of the pancreatic beta cellspancreatic beta cells
• Tissue resistanceTissue resistance End organ damageEnd organ damage
• BrainBrain• KidneysKidneys• HeartHeart• RetinaRetina• CNSCNS
Health System Health System ChallengesChallenges
Increasing Prevalence Increasing Prevalence • Increased life expectancyIncreased life expectancy
Elderly population is Elderly population is growing rapidlygrowing rapidly
0%
5%
10%
15%
20%
1960 1980 2000 2020 2040Per
cent
age
of p
opul
atio
n by
age
gro
up
65 to 84 yrs
Over 84 yrs
Health System Health System ChallengesChallenges Patients with chronic illnesses use Patients with chronic illnesses use
a disproportionate share of a disproportionate share of medical servicesmedical services
80% of hospital days80% of hospital days 69% of hospital admissions69% of hospital admissions 83% of prescription drug use83% of prescription drug use 66% of physician visits66% of physician visits
RWJ, 1996
$220 Billion
$659 Billion
1996
Health System Health System ChallengesChallenges
Contrary to popular perceptions, Contrary to popular perceptions, many people with chronic illness many people with chronic illness are not old.are not old.
What does that mean What does that mean to you?to you?
Most of your career will be spent Most of your career will be spent in caring for patients with chronic in caring for patients with chronic illness!illness!
Physician-Patient Physician-Patient Relationship in Chronic Relationship in Chronic IllnessIllness A patient centered therapeutic A patient centered therapeutic
relationship relationship • characterized by continuity over time, characterized by continuity over time, • EmpathyEmpathy• interactions that empower the patient to interactions that empower the patient to
play an active role in medical decision play an active role in medical decision making and in their care.making and in their care.
Associated with better outcomes Associated with better outcomes (improved quality of life, less (improved quality of life, less disability, and fewer hospital disability, and fewer hospital admissions).admissions).
Patient-centered Patient-centered interviewinterview
Always involve patient in setting Always involve patient in setting agendaagenda• ““How are you doing?”How are you doing?”• ““What can I do for you today?”What can I do for you today?”• ““What concerns or issues do you need to What concerns or issues do you need to
discuss today?”discuss today?”• ““I really want to talk with you about I really want to talk with you about
your……. but first I want to find out if you your……. but first I want to find out if you have anything we need to talk about.have anything we need to talk about.
Make questions functionally relevant.Make questions functionally relevant.
Treatment PlanTreatment Plan
Baseline informationBaseline information• Patient’s beliefs and knowledgePatient’s beliefs and knowledge
Treatment goals and plansTreatment goals and plans• Ensure understandingEnsure understanding• Patient preferences and commitmentPatient preferences and commitment
Negotiate a planNegotiate a plan• Enpower the patientEnpower the patient
Affirmation of intentAffirmation of intent
Treatment not Treatment not effective? effective? Compliance Compliance
• PersonalityPersonality• PsychodynamicsPsychodynamics• Interpersonal dynamicsInterpersonal dynamics• Financial constraintsFinancial constraints• Culture/beliefsCulture/beliefs• Cognitive factorsCognitive factors
Treatment Treatment re-evaluation/adjustmentre-evaluation/adjustment
Negotiate SolutionsNegotiate Solutions
Elicit patient’s perspectivesElicit patient’s perspectives• GoalsGoals• SuggestionsSuggestions• PreferencesPreferences• Weigh benefits/burdens of treatment Weigh benefits/burdens of treatment
optionsoptions Modify plan Modify plan Follow -upFollow -up
Smoking CessationSmoking Cessation
ObjectivesObjectives Outline adverse effects of Outline adverse effects of
smokingsmoking Outline benefits of smoking Outline benefits of smoking
cessationcessation Discuss two approaches to Discuss two approaches to
smoking cessationsmoking cessation
IntroductionIntroduction
Cigarette smoking is the major Cigarette smoking is the major preventable cause of diseasepreventable cause of disease
Results in over 400,000 deaths Results in over 400,000 deaths annuallyannually
Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease Progressive lung Progressive lung
disease disease characterized by characterized by airflow limitation airflow limitation
abnormal abnormal inflammatory inflammatory response to response to noxious particles noxious particles or gasesor gases
Lung CancerLung Cancer
Head and Neck CancerHead and Neck Cancer
Atherosclerotic Cardiovascular Atherosclerotic Cardiovascular Heart DiseaseHeart Disease
Myocardial injury Myocardial injury due to decrease due to decrease in myocardial in myocardial oxygen supply oxygen supply
EpidemiologyEpidemiology
Over 50 percent of adolescents try Over 50 percent of adolescents try smoking by 12smoking by 12thth grade grade
Most adult smokers start by age Most adult smokers start by age 1818
Tobacco dependence develop with Tobacco dependence develop with one year one year
80 percent of smokers have 80 percent of smokers have regrets by age 20 regrets by age 20
Risk FactorsRisk Factors
Exposure to second hand smokeExposure to second hand smoke Presence of smoker in householdPresence of smoker in household Comorbid psychiatric disordersComorbid psychiatric disorders Low self-esteem/self worthLow self-esteem/self worth Peer pressurePeer pressure Genetic link in twin studiesGenetic link in twin studies
PrevalencePrevalence
Mid 1960s: 42 percent of adultsMid 1960s: 42 percent of adults 2003: 22 percent of adults2003: 22 percent of adults High school studentsHigh school students
• 1997: 36 percent1997: 36 percent• 2003: 22 percent2003: 22 percent
Benefits of CessationBenefits of Cessation
Cardiovascular DiseaseCardiovascular Disease• Rapid decrease in new eventsRapid decrease in new events
Pulmonary DiseasePulmonary Disease• Improvement within one yearImprovement within one year
Malignancy (oral cavity, head/neck, Malignancy (oral cavity, head/neck, pancreas, lung, cervix)pancreas, lung, cervix)
Peptic ulcer diseasePeptic ulcer disease Reproductive disordersReproductive disorders OsteoporosisOsteoporosis
Methods for cessationMethods for cessation
Behavioral ApproachBehavioral Approach
Pharmacologic ApproachPharmacologic Approach
Behavioral ApproachBehavioral Approach
Clinician counseling: works!Clinician counseling: works!• Great motivating factorGreat motivating factor
Advice with a personal health Advice with a personal health message: works even better!message: works even better!
Tobacco use status should be Tobacco use status should be documented at every visitdocumented at every visit• Assess for second hand smokeAssess for second hand smoke
Behavioral ApproachBehavioral Approach
Assess stage of motivationAssess stage of motivation• PrecontemplationPrecontemplation• ContemplationContemplation• DeterminationDetermination• ActionAction• MaintenanceMaintenance
Five "R's" for smokers Five "R's" for smokers who are unwilling to who are unwilling to quitquit Relevance: Encourage the patient to indicate why quitting is Relevance: Encourage the patient to indicate why quitting is
personally relevant, being as specific as possible.personally relevant, being as specific as possible. Risks: Ask the patient to identify potential negative Risks: Ask the patient to identify potential negative consequences of tobacco use. consequences of tobacco use.
Rewards: Ask the patient to identify potential benefits of Rewards: Ask the patient to identify potential benefits of stopping tobacco use. stopping tobacco use.
Roadblocks: Ask the patient to identify barriers or Roadblocks: Ask the patient to identify barriers or impediments to quittingimpediments to quitting Repetition: The motivational intervention should be repeated Repetition: The motivational intervention should be repeated every time the patient visits the clinicevery 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 Five "A's" for patients who are willing to quit who are willing to quit smokingsmoking Ask: Every single patient and document tobacco Ask: Every single patient and document tobacco use status.use status.
Advise: Strongly urge all tobacco users to quit in a clear, Advise: Strongly urge all tobacco users to quit in a clear, strong, personalized manner.strong, personalized manner.
Assess: Determine the patient's willingness to quit Assess: Determine the patient's willingness to quit smoking smoking
within the next 30 days. within the next 30 days. Assist: Provide aid for the patient to quit.Assist: Provide aid for the patient to quit.
Arrange: Schedule follow-up contact, either in person or Arrange: Schedule follow-up contact, either in person or by by
telephone. telephone.
Action PlanAction Plan
Set quit dateSet quit date Should ideally be within two weeksShould ideally be within two weeks Encourage preparation for quittingEncourage preparation for quitting
• Tell family and friends and elicit supportTell family and friends and elicit support• Review previous quit attemptsReview previous quit attempts• Anticipate nicotine withdrawal Anticipate nicotine withdrawal
symptomssymptoms• Decide on treatment strategyDecide on treatment strategy• Follow upFollow up
PharmacotherapyPharmacotherapy
Nicotine Replacement therapy Nicotine Replacement therapy • Reduces withdrawal symptomsReduces withdrawal symptoms• Continuous quit rates 5 -27%Continuous quit rates 5 -27%• Best when combined with behavioral therapyBest when combined with behavioral therapy
Bupropion Bupropion • Acts by enhancing noradrenergic and dopaminergic Acts by enhancing noradrenergic and dopaminergic
receptorsreceptors• Rate of cessation: 44 vs. 19 percent placeboRate of cessation: 44 vs. 19 percent placebo
Varenicline (Chantix) Varenicline (Chantix) • Partial agonist of nicotinic acetylcholine receptorsPartial agonist of nicotinic acetylcholine receptors• More effective than bupropion in trialsMore effective than bupropion in trials
Potential hazards of Potential hazards of smoking cessationsmoking cessation Withdrawal symptoms: irritability, Withdrawal symptoms: irritability,
insomnia, anxiety, restlessnessinsomnia, anxiety, restlessness Weight gainWeight gain DepressionDepression Worsening comorbid disease: Worsening comorbid disease:
exacerbation of ulcerative colitis, exacerbation of ulcerative colitis, schizophreniaschizophrenia
RelapseRelapse
Most smokers make many attempts to Most smokers make many attempts to quit before success quit before success
Assess for improper use of cessation Assess for improper use of cessation aidesaides
Assess for complianceAssess for compliance Consider referral to smoking cessation Consider referral to smoking cessation
programprogram Intensive individual or group counselingIntensive individual or group counseling