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