12-10-22 – The impact of Heart Disease on the Quality of Life

Question 1

Learning outcomes

Answer 1

• Define quality of life and its measurement in heart disease
• Describe the determinants of quality of life in heart disease
• Describe the relationship between depression and heart disease

Question 2

How does WHO and NICE define Quality of Life (QOL)?

Answer 2

• WHO and NICE definitions of Quality of Life (QOL)
• WHO – ‘individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.’
• NICE – ‘a combination of a person’s physical, mental and social wellbeing; not merely the absence of disease

Question 3

What is 1 Quality-adjusted year (QALY) equal to?

How are QALYs calculated?

How is this measured?

Answer 3

• One quality-adjusted life year (QALY) is equal to 1 year of life in perfect health.
• QALYs are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality-of-life score (on a 0 to 1 scale).
• It is often measured in terms of the person’s ability to carry out the activities of daily life, and freedom from pain and mental disturbance.’

Question 4

What are the 3 different measure types of QOL?

Answer 4

• 3 different measure types of QOL:
  1) Uni-dimensional – focuses on one aspect e.g mental wellbeing
  2) Generic multi-dimensional – looks across several factors
  3) Disease specific multi-dimensional – looks across several factors associated with a particular disease

Question 5

What are 4 different ways we measure health status?

Answer 5

• Some different ways we measure health status:
  1) Mortality rates
  2) Morbidity rates
  3) HIV rates
  4) Measurement of functioning

Question 6

What are 5 determinants of QOL in Heart Disease?

How do they all link together?

How does cardiac disease affect QOL compared to other disease?

What has the biggest impact on QOL with cardiac disease patients?

Answer 6

• 5 determinants of QOL in Heart Disease:

1) Physical functioning (BIO)
* Symptom count after major cardiac event e.g MI

2) Psychological functioning (PSYCHO)
* Mental wellbeing

3) Social functioning (SOCIAL)
* Social positioning in society
* E.g friends, families, hobbies, ability to perform in society as they did prior to getting ill

4) Occupational functioning
* Can they still work like they did previously

5) Perception of health status (PERCEPTION)

• Cardiac and gastrointestinal disease have the greatest impact on Quality of Life compared to other chronic disease
• Mental health has the biggest impact on QOL with patients of cardiac diseases

Question 7

In what 3 cases does Physical functioning have a positive impact on QOL?

Answer 7

• 3 cases Physical functioning has a positive impact on QOL:
  1) Minimal/no physical symptoms
  2) Able to carry out usual physical activities
  3) Healthy sexual relationships
• And vice versa

Question 8

What 4 ways does psychological functioning impact QOL?

What is psychological distress a predictor of?

What does psychological distress lead to?

Answer 8

• Ways Psychological functioning impact QOL:

1) Impacts on disease process

2) May also impact on treatment concordance (may not sick to treatment)

3) Patients subjected to prolonged stress need coping strategies and psychological resilience

4) Impacts on ability to retain and understand information

• Psychological distress is a predictor of hospitalisation
• Psychological distress → Poor quality of life

Question 9

In what 4 ways does psychological function impact relationships?

Answer 9

• 4 ways psychological function impact relationships:

1) Psychological function important in building rapport

2) Psychological distress can impede social support

3) Psychological distress can impair personal relationships (including sexual)

4) Psychological distress can create problems in relationships with health professionals

Question 10

What 7 things is psychological distress following MI/CABG risk factor for?

Answer 10

• Psychological distress following MI/CABG is a risk factor for:
  1) Early mortality
  2) Low return to work
  3) Difficulty making lifestyle changes
  4) Problems with concordance with medical care
  5) Increased use of health services
  6) Post-traumatic stress disorder (PTSD)
  7) Readmission to hospital

Question 11

What are 12 psychological challenges of Cardiac disease?

Answer 11

• Psychological challenges of Cardiac disease:
  1) Fear/reduced life expectancy
  2) Anxiety
  3) Depression (most significant negative impact on QOL)
  4) Loss of control
  5) Loss of independence/financial status
  6) Denial
  7) Anger
  8) Hopelessness
  9) Being treated differently by others
  10) Impact of making/failing to make desired lifestyle changes
  11) Sense of failure
  12) Potential impaired cognitive function impacting on memory and confidence

Question 12

What is anxiety in relation to QOL?

What are 2 key symptoms of anxiety?

How often do they occur?

What are 7 associated symptoms of anxiety?

Answer 12

• Anxiety is a negative determinant of QOL
• Symptoms of anxiety:
  1) Excessive anxiety and worry about a number of events or activities
  2) Difficulty controlling the worrying
• At least one of these, most days, most of the time for at least 2 weeks
• Associated symptoms of anxiety:
  1) Disturbed sleep
  2) Decreased or increased appetite and/or weight
  3) Fatigue or loss of energy
  4) Agitation or slowing of movements
  5) Poor concentration or indecisiveness
  6) Feelings of worthlessness or excessive or inappropriate guilt
  7) Suicidal thoughts or acts

Question 13

Describe the vicious cycle of anxiety.

What are 6 physical effects?

What are 3 cognitive effects?

How do all of these effects affect the person?

What can occur if patients get stuck in this cycle?

Answer 13

• The vicious cycle of anxiety is where anxiousness causes illness, and illness causes anxiousness
• Worrying thoughts can produce adrenaline
• When no danger to run away from:
• Physical effects:
  1) Dizziness
  2) Dry mouth
  3) Shortness of breath
  4) Heart racing,
  5) Butterflies in stomach,
  6) Hyperventilation
• Cognitive effects:
  1) Racing thoughts
  2) Anxious thoughts
  3) Preoccupation with and catastrophizing about bodily sensations
• All of these effects make the person fell ill
• If patients get stuck in this cycle, this can lead to avoidance behaviours e.g not doing the exercise part of cardiac rehabilitation out of fear of provocation of condition

Question 14

How does ‘good’ social functioning affect QOL?

What are the 3 examples of good social functioning?

Answer 14

Good” social functioning has a positive effect on QOL

• Examples of good social functioning:

1) Good family/friend support and the ability to maintain and develop these relationships

2) Having a meaningful role within society

3) Being able to take part in social activities

Question 15

What are 4 factors in Occupational functioning that lead to improved QOL?

What must we try to do as a doctor regarding occupational functioning?

Answer 15

• 4 factors in Occupational functioning that lead to improved QOL:

1) Ability to return to work (links to self-worth and self-esteem)

2) Returning to work and performing well

3) Financial reward associated with work and stability

4) Significant positions/roles outside of work

• As a doctor, we should be trying to get our patients involved into their work again
• Instead of constantly writing sick notes, we should try and establish a timeline that establishes when the patient can return to work, as this will encourage them and lead to an improved QOL

Question 16

How does perception of health status differ for each patient?

What factors is perception of health status influenced by?

Answer 16

• Perception of health status is very variable: patients with the same pathophysiology will perceive their health differently
• Factors perception of health status influenced by:

1) An individual’s experience as a child, family relationships, occupational status, social support and wider community or culture

2) Previous experience of health services

3) Mental health and depression

4) Personal understanding of the illness – denial

Question 17

What is illness behaviour?

What does this define?

What 3 ways can sick role bring secondary gains?

What negative effects can this have?

Answer 17

• Illness behaviour is evaluating symptoms, seeking medical help to bring relief, and seeking support from family
• Defines a social role with expectations for both the sick and the healer
• This can bring secondary gains through sick role:
  1) Increased sympathy and attention for the sick person
  3) special favours – being waited on by carer/family member
  4) no school/work/duties for sick person
• Can prolong illness behaviour and negatively impact on perception of health status and therefore on Quality of Life
• The patient’s perception can be changed to believe that they can’t undertake normal activities

Question 18

How is low mood linked to heart disease?

What may occur in some patients?

Answer 18

• Low mood is a normal reaction to a heart problem / to a significant negative event
• It will usually pass and is not severe
• But some patients may have more persistent or severe reaction → depression

Question 19

What are 4 Significant Losses associated with CAD?

What are they often related to?

Answer 19

• 4 Significant Losses associated with CAD:
  1) Loss of health
  2) Loss of self-confidence
  3) Loss of independence, relationships
  4) Loss of self-worth
• These losses are often related to cardiac misconceptions and to own perceptions

Question 20

What is anxiety in relation to QOL?

What are 2 key symptoms of anxiety?

How often do they occur?

What are 7 associated symptoms of anxiety?

Answer 20

• Anxiety is a negative determinant of QOL
• Symptoms of anxiety:
  1) Excessive anxiety and worry about a number of events or activities
  2) Difficulty controlling the worrying
• At least one of these, most days, most of the time for at least 2 weeks
• Associated symptoms of anxiety:
  1) Disturbed sleep
  2) Decreased or increased appetite and/or weight
  3) Fatigue or loss of energy
  4) Agitation or slowing of movements
  5) Poor concentration or indecisiveness
  6) Feelings of worthlessness or excessive or inappropriate guilt
  7) Suicidal thoughts or acts

Question 21

What are 2 statistics in the epidemiology of heart disease?

What 3 things is Depression predictive of?

Answer 21

• 2 statistics in the epidemiology of heart disease:
  1) Estimated 15-45% affected after MI
  2) 41% higher health care costs than in non-depressed patients
• 3 things Depression is predictive of:
  1) Poor mortality, social and functional outcomes
  2) Depression is the most common/significant feature of poor QOL
  3) Depression is a major risk factor for relapse in cardiac patients

Question 22

What is a tool for assessing severity of depression?

What are the 4 levels of depression?

Answer 22

• HADS (Hospital Anxiety and Depression Scale) is a tool that uses self-reported information to assess level of psychological distress and severity of depression
• The 4 levels of depression:

1) Subthreshold depressive symptoms
* Fewer than 5 symptoms

2) Mild depression
* Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment

3) Moderate depression:
* Symptoms or functional impairment are between ‘mild’ and ‘severe”

4) Severe depression
* Most symptoms, and the symptoms markedly interfere with functioning

Question 23

What 6 treatments can we consider to treat depression following a cardiac event?

What does treatment selection depend on?

Answer 23

• To treat depression following a cardiac event, we will likely use a combination of interventions depending on severity, consider:
  1) Psychological therapy
  2) Lifestyle advise and self-help
  3) Maximising physical health / status
  4) Drug treatments
  5) Specialist mental health services
  6) Cardiac rehabilitation

Question 24

What is cardiac rehabilitation?

What does cardiac rehabilitation have a positive impact on?

How does it affect all-cause mortality and cardiac mortality?

How does it affect healthcare costs?

What positive psychological effects does cardiac rehabilitation lead to?

Answer 24

• Cardiac rehabilitation is a supervised program that includes: Physical activity. Education about healthy living, including how to eat healthy, take medicine as prescribed, and quit smoking.
• Cardiac rehabilitation has a positive impact on psychological health / adjustment and QoL
• Cardiac rehabilitation leads to a 20% reduction in all-cause mortality and a 27% reduction in cardiac mortality
• Cardiac rehabilitation reduces healthcare costs
• Positive psychological effects does cardiac rehabilitation lead to:
  1) Relationships improve
  2) Low anxiety
  3) Motivated to change
  4) High internal locus of control
  5) Sex life improves