Week 10

Question 1

How big a health issue is CVD in the uk

Answer 1

Heart and circulatory diseases kill 1 in 4 people in the UK

Question 2

Rates and outcomes of CVD in those with mental illness

Answer 2

People with severe mental illness have:
-higher incidence of CVD: HR 1.78 (95% Cl 1.60-1.98, n=31 studies)
-high CVD related mortality : HR 1.85 (95% Cl 1.53-2.24)
Includes conditions such as major depressive disorder, schizophrenia, bipolar disorder

Question 3

Public health outcomes framework relevant to CVD (examples)

Answer 3

Obesity in early pregnancy
Smoking in early pregnancy
Low birth weight of term babies
Prevalence of childhood overweight/obesity
Percentage of physical active children and young people
Proportion of the population meeting the recommended 5 a day
Percentage of individuals aged 40-74 who received an NHS health check

Question 4

NICE public health guidance 25, 2010

Answer 4

Reduce population level consumption of salt
Reduce population level consumption of saturated fat
Eliminate the use of industrially produced trans fatty acids for human consumption
Prevent marketing which encourages unhealthy diet in children
Transparency about commercial interests
Product labelling
Assess impact of government policy on CVD

Question 5

Making every contact count

Answer 5

Behaviour change based on brief interventions
Makes use of the millions of day to day interactions health service providers have with individuals
Targets behavioural risk factors
-tobacco use
-alcohol
-physical activity

Question 6

QOF

Answer 6

Maintain registers of patients with CVD
Maintain register of patients with BMI>30
Anti coagulation in patients with CHA2DS2-VASCULAR score>2
Antiplatelet prescription in patients with CHD
Antiplatelet or anticoagulants in patients with ischaemic stroke/TIA
Control of BP in patients with CHD

Question 7

NHS health checks

Answer 7

Individuals aged 40-74 without pre existing long term conditions
Designed to identify early signs of CVD, kidney disease, type 2 diabetes, and dementia
Questions on smoking, alcohol, and physical activity
BMI, BP, cholesterol
Cardiovascular risk assessment
Advice on improving lifestyle risk factors
Uptake is highest in older people and females
Uptake is lower in those living in most deprived areas
Just under half of those invited attended
General health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments

Question 8

Nuffield bioethics ladder of intervention

Answer 8

Eliminate choice
Restrict choice
Guide choice by disincentives
Guide choice by incentives
Guide choice by changing default policy
Enable choice
Provide info
Do nothing

Question 9

Other factors to consider

Answer 9

Individual autonomy versus welfare of the population (paternalism)
Free trade
Cost to economy
Public opinion
Political lobbying
Role of advocacy

Question 10

Geoffrey rose

Answer 10

Sick individuals and sick populations
Individual (high risk strategy) versus population approach to disease prevention
A large no. Of people at small risk may give rise to more cases of disease than the small no. Who are at high risk

Question 11

“High risk” strategy

Answer 11

Identify high risk individuals and provide appropriate health interventions to reduce future risk
Advantages: intervention appropriate to individual, subject motivation, physician motivation, cost-effective use of resources, benefit: risk ratio favourable
Disadvantages: difficulties and costs of screening, palliative and temporary, limited potential for individual/population, behaviourally inappropriate

Question 12

Population approach

Answer 12

Control the determinants of disease
Lower mean level of risk factors
Shift the population distribution of exposure
Advantages: radical, large potential for population, behaviourally appropriate
Disadvantages: small benefit to individual (prevention paradox), poor motivation of subject, poor motivation of physician, benefit: risk ratio worrisome

Question 13

Overview of topic of coping with chronic illness

Answer 13

Coping describes how we manage stressors, such as chronic illness
This allows us to achieve adaptation
-how we can adjust aspects of our thinking/emotions/behaviour so that we can live successfully with a chronic illness

Question 14

Coping (folkman and Lazarus 1980)

Answer 14

Psychological mechanism for managing external stress, may be action oriented (doing something) and thought based

Question 15

Chronic illness

Answer 15

Lasting 3 months or more, cannot be prevented by vaccine or cured by medication or self resolve. 80% of >65s have at least one chronic health condition

Question 16

Stress (Hans 1993)

Answer 16

Stress is ‘whatever stresses people’

Question 17

Some early models of coping

Answer 17

Canons flight or fight model:
-threat leads to increased arousal in order to escape
Selye’s general adaptation syndrome:
-“alarm” increases activity, “resistance” is attempt to cope, “exhaustion” when cant resist anymore

Question 18

Problems with previous models

Answer 18

Did not address individual variability or psychological factors
Response was very automatic and physiological and so consistent- does not reflect clinical practice

Question 19

Transactional model of stress (Lazarus)

Answer 19

Primary appraisal- “is this stressful”
-irrelevant
-benign and positive
-harmful and a threat
-harmful and a challenge
Secondary appraisal-“can i cope with this”
-evaluating internal coping strategies
Interaction with external world and how appraises it is key

Question 20

Stressor- primary appraisal

Answer 20

“In the beginning i told them they must be dreaming… it’s a bad bad dream”
“People cannot stand this… feeling that you have to be positive”
“I was deeply sad and scared… i was scared to death on the way to the hospital”

Question 21

Secondary appraisal

Answer 21

“I stood outside the breast centre and screamed, shouted and swore”
“Theres no denying that i panicked at the beginning. Then i seemed to be overtaken by an icy, practical calm, ok i thought deal with it”

Question 22

Folkman (1986)

Answer 22

Problem focused:
-aimed at resolving the stressful situation or event
-taking control
-seeking information
-removing oneself
Emotion focused:
-disclaiming
-escape avoidance
-accepting responsibility or blame
-self control
-positive reappraisal

Question 23

Problem focused coping

Answer 23

Take action to reduce demands of stressor
Or to increase resources so able to manage it
E.g revision plan, setting agenda, studying for extra qualifications to enable career change, counselling for failing relationship

Question 24

Emotion focused coping

Answer 24

Attempts to manage emotion caused;eg:
-seeking emotional support
-denial
-venting anger
-distraction
-praying
-exercise
-alcohol/drugs
-humour
-DSH
-suicide

Question 25

Does stress cause illness

Answer 25

Some personality traits more common in high stress jobs Higher life stress- report more physical symptoms Stressful jobs have higher rates CHD Increased mortality

Question 26

How does stress cause illness

Answer 26

Chronic stress causes prolonged interaction between physio/bio/psychological factors -atherosclerosis well researched -acute stress more likely to provoke MI Stress also changes behaviour: -increased smoking -increased alcohol -poor diet -lack of exercise -increased accidents

Question 27

How people cope

Answer 27

Coping is context dependent and dynamic Eg depends on if there is a practical solution Times/reosurces/money available Personality factors and past experience

Question 28

Coping with pain

Answer 28

Appraising stress as a threat produces a negative emotional responses, and vulnerability Appraising stress as a challenge is a positive response which focuses on growth and mastery (Lazarus and Folkman 1984) Pain in patients often have negative and maladaptive appraisals about the situation and their own ability to control pain and thus tend to appraise their pain as a threat (Turk and Flor, 1999) Rely more on emotion focused coping (smith and wallston 1992) Active (problem focused) coping associated with better physical and psychological functioning Passive coping (eg emotion-focused coping) associated with poor physical and psychological functioning (Jensen et al 1991) Associations have also been reported between depression and emotion focused coping strategies in chronic pain (endler et al 2003) Learned helplessness Individuals with high self esteem seem to rely more on problem focused coping in chronic pain and are less depressed (Mruk 1999)

Question 29

Personality psychological factor influencing coping

Answer 29

Hippocrates 4 humors Type A and type B Jung: thinking feeling, sensation, intuition Myers-Briggs Extrovert, introvert

Question 30

Emotional stability/instability

Answer 30

Emotional stability- continuously striving for greater sense of emotional health, both intra-physically and intra-personally Emotionally stable individual able to tolerate delay in satisfaction of needs, frustration, able to engage in long term planning and capable of revising his expectation in terms of demands of the situations Emotional instability- trait characteristics of rapid, sometimes exaggerated changes in mood, strong emotions or feelings (uncontrollable laughing or crying or heightened irritability or temper) Personality trait and disorder EI 2% of the general population and 10% of psychiatry outpatients

Question 31

Resilience: Rutter 2012

Answer 31

Resilience is not a general or stable characteristic nor is it solely an outcome of adaptation in individuals or systems Resilience is a complex process that manifests at specific moments in order to face certain circumstances Resilience is inferred from the dynamic interactions of their components of risk and adaptation Resilience: individual differences in response to environmental threats

Question 32

Impact of chronic illness

Answer 32

Emotional distress (general/disease specific) Restrictions and disruptions to normal life Learning how to manage the illness New ‘tasks’ Changing risk factors to help prevent progression Side effects of treatment Loss of self

Question 33

Impact on families

Answer 33

Community care increases pressure on families Physical, psychological, social, financial consequences of informal caring Objective and subjective burden Caregivers needs (often given low priority)

Question 34

How can we help

Answer 34

Information provision Social support Self management training Stress management training Psychotropic medication or formal psychological therapy eg cognitive behavioural therapy CBT

Question 35

Aims of coping interventions

Answer 35

Reduce distress Help to manage illness effectively Minimise impact of illness on daily life Prevent progression and minimise risk of further health problems Each intervention may have multiple benefits

Question 36

Information provision

Answer 36

Good communication skills Good interpersonal skills Leaflets Internet (incl forums) Helplines CDs/DVDs Expert patients

Question 37

Social support

Answer 37

Social isolation increases risk of mortality in many chronic illnesses Can be to increase self esteem, advice, companionship, physical help etc

Question 38

Self management training

Answer 38

Helps patients to gain ‘internal control’ over illness Increase self efficacy and optimism Adjunctive therapy

Question 39

Management

Answer 39

Problem solving Cognitive restructuring Behavioural change plans Relaxation and mindfulness Positive self talk (self instruction training) Often most effective with patient and carer present