Week 2-Long term conditions and wellbeing

Question 1

What is a Long-term condition? (Lambert & Keogh, 2015)

Answer 1

“LONG TERM CONDITIONS are characterised by their on-going duration and the fact that they are often managed throughout the life span…changes the life of the individual affected and generates a need to adapt and develop an understanding of the relationship between the demands of life and those of the condition”

-long-lasting and chronic forcing one to adapt to keep up with the demands

Question 2

What is a Long-term condition? (Guy’s & St Thomas’ Charity, 2018)

Answer 2

Health conditions for which there is currently no cure, but which can be managed with drugs and other treatments. A long-term condition is one that lasts a year or longer and impacts on a person’s life

Question 3

PRISMS Project: What are the 14 diverse LTCs? (Taylor et al., 2014)

Answer 3

Asthma, type 1 and type 2 diabetes, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders

Question 4

PRISMS Project: What are the commonalities of LTCs? (Taylor et al., 2014)

Answer 4

1. Related to other LTCs (Comorbidity is living with a long term condition and then producing a side condition)
2. Linked to behavioural factors
3. Linked to inequalities (More likely to get it if lower socioeconomic status)
4. Live much of life with the condition
5. Constant management
6. Complex LTCs (Can cause positive effects e.g., better understanding of self and body tuning, better coping mechanisms, better integration of health care such as fighting for better treatment and care for self, better empathy with other people’s conditions: which are ideal in job settings)

Question 5

What are the different elements of care in LTCs?

Answer 5

-Monitoring (blood)

-Avoiding foods

-Eating certain foods

-Regular trips to Drs or hospital

-Medication regime

-Looking out for various symptoms

Question 6

What are the stages of living with LTCs?

Answer 6

1. Pre-startOpportunity for prevention of LTC
2. Start: Detection and diagnosis (May have clear symptoms for immediate diagnosis or unclear overlapping symptoms)
3. Adjustment-new identity (May be difficult to navigate at first: health psychology helps patients to identify core aspects and beliefs of the individual to guide coping and support)
4. Learning to live with a LTC
5. Reducing additional risk (co-morbidity)
6. Self-management
7. Adapting and thriving

Question 7

What are the Core aims of LTCs care?

Answer 7

-To optimise the quality of life

-To reduce the impact on physical, social, emotional functioning

-To prevent multi-morbidity (i.e. other LTCs developing)

-To protect psychological well-being

-To diagnose early, help with adjusting to living with a LTC, supporting self-management

Question 8

What is the prevalence of LTCs?

Answer 8

-15 million people in England with LTCs

-Number of people living with LTCs is growing – especially those with multiple LTCs

-14% of people <40 years old (<=under 40 years old)

-58% of people >60 years old (>=over 60 years old)

-Those in the poorest social class have a 60% higher chance of having a LTC, 30% more severe, than those in the richest social class (clear link of socioeconomic status)

-“Some people living in a deprived area will have multiple health problems 10–15 years earlier than people in affluent areas” (Barnett et al., 2012)

Question 9

What is the prevalence LTC care in the NHS?

Answer 9

-50% of all GP appointments, 64% of all outpatient appointments, 70% of all bed days off work were related to LTCs

-Absorbs 70% of acute and primary care costs in the NHS

Question 10

What features in the NHS demonstrate that it is not fit for ‘multi-morbidity’?

Answer 10

-Single-condition services (not accommodating to co-morbidity)

-Lack of care coordination (to help with comorbidity)

-Lack of attention to wellbeing and mental health

-Fragmented care (more than medicine provided elsewhere)

-Informational continuity– patient records, consistent care

-Reactive not predictive services (looks on the now not the future)

-Lack of emphasis on self-care

-The NHS struggles to set a system of holistic care

Question 11

What should care be in the NHS?

Answer 11

-Person-centred

-Holistic

-Coordinated

-In partnership with professionals (Placing the emphasis more on the patient with their expertise)

-Draws on persons’ expertise

-Draws on resources in people’s communities

-Aims to be a harmonious orchestra with a conductor

Question 12

How did we go from the biomedical model of illness to the biopsychosocial model?

Answer 12

-Psychology has a key role here in helping change health care – e.g. identify how best to deliver person-centered, holistic care.

-We started with a biomedical model which acted like a car (i.e., one part is broken so we will fix this one bit) and this is how doctors were taught and how the NHS was set up

-Now we understand that a biopsychocial model is essential for providing a gold standard of quality care (focusing on the whole of the car to ensure all of it is ok)

Question 13

What top 4 risk factors did King’s Fund (2018) find impacted people’s health significantly?

Answer 13

1. What we eat
2. Our level of alcohol
3. Smoking
4. Our level of activity/inactivity

-The more you align with, the more likely you are to develop a LTC

Question 14

What did Fransen et al, 2014; Kings fund, 2018 find in relation to risk factor prevalence?

Answer 14

-7 in 10 people exhibit 2 or more of these ‘big 4’ risk factors

-More risk factors = higher mortality risk

Risk linked to the 3 Ps:
1. Prevention
2. Personal responsibility (Not useful to blame people and over simplistic)
3. Health inequalities (again this is not the individual’s fault and could be a problem when addressing improvements to LTC care e.g., race, sex, socioeconomic status etc.,)

-These risk factors are embedded into our cultures and day-to-day lives

-Your ability and capacity to respond to something not a moral duty (Steven Hayes-personal responsibility)

Question 15

What are some wider risk factors for LTCs?

Answer 15

-Genetics & Epigenetics
-Blood pressure, cholesterol, digestion functioning
-Immune System Response
-Autonomic Nervous System functioning
-Medication use/adherence
-Stress management
-Alcohol/Substance abuse
-Smoking
-Sleep
-Nutrition intake
-Physical Activity
-Housing (e.g., mould)
-Living environment (e.g., safety of streets, greenery nearby etc.,)
-Social influences
-Finances
-Work setting/Shift patterns

Question 16

What is the role of mental health in LTCs?

Answer 16

-Having a LTC may increase the risk of developing a mental health problem (e.g. becoming depressed or anxious)

This may be due to:
-Psychological impact of living with a LTC
-Reductions in quality of life & functioning
-Side effects of medications (e.g. sedation)
-Physiological changes due to illness (e.g. hormone imbalances)

OR flipping it the other way around, Having a mental health problem may increase risk of poorer physical health – e.g., hypertension is more likely in those with depression (therefore mental health and LTCs are very intertwined)

This may be due to:
-Side effects of psychotropic medications (e.g. obesity)
-Chronic stress leading to damage to cardiovascular / immune system
-Maladaptive coping (e.g. avoidance-behaviours - alcohol / poor diet)
-Poor self-care / management of health condition

Question 17

What is the overlap between LTCs and mental health problems in England? (Naylor et al., 2012 aka King’s Fund)

Answer 17

LTC:
-30% of England’s population (approx 15.4 million)
-30% of people with a LTC have a mental health problem (approx 4.6 million)

MH:
-20% of England’s population (approx 10.2 million people)
-46% of people with a MH problem have a LTC (approx 4.6 million)

-Different sets and symptoms going on at the same time for some individuals

Question 18

Why is there a call for integrating physical and mental health care?

Answer 18

-Because there are high rates of mental health conditions among those with LTCs

-There is reduced life-expectancy for people diagnosed with severe mental illness, largely due to poor physical health (shows there needs to be better integrated care for patients to improve overall well-being both physically and emotionally)

-There is little psychological support currently available for people adjusting to and living with LTCs (+ it likely isn’t varied enough to suit individual needs)

Question 19

What are some elements of self-management in a medical setting?

Answer 19

-Attending appointments / travel (e.g., car parking)

-Coordinating health care appointments (e.g., may be overlapping appointments needed to re-arrange, follow up appointment from doctor that never happens that patient must follow up with)

-Information processing (e.g., factors enhance IP capacity such as our receptiveness due to being anxiety primed for an appointment, or the way it is presented)

-Health literacy (e.g., given a certain medication and how to take it but then struggling with detailed info such as do I take it with food? THEREFORE health literacy is how the details such as above is presented)

-Therefore there are many barriers which can overcome one having a sense of agency with their health (whether due to financial, physical or mental reasons)

Question 20

What are some elements of self-management in a home setting?

Answer 20

-Healthy lifestyle (finances could limit this e.g., healthy food)

-Taking /applying / scheduling medication (LTC may inhibit this or other issues e.g., ADHD)

-Adaptations to home, work, leisure

-Managing / detecting symptoms, relapses or flare ups (should not be something that is managed alone i.e., healthcare professionals must be better integrated into someones care routine).

Question 21

What are some key characteristics of effective self-management? (Taylor et al., 2014)

Answer 21

-Multi-faceted

-Tailored not generic

-Culture/beliefs-specific

-Specific to disease trajectory

-Collaborative Dr-patient relationship

-Health care organisation that promotes self-care

*Evidence from RCTs shows that no single component here is any more important that another

Question 22

What did Taylor et al (2014) say about supporting self-management?

Answer 22

“Supporting self-management is inseparable from the high-quality care for long-term conditions…health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded (seeing if any adjustments need to be made) aspect of care.” (i.e., self management should be part of the conversation and intertwined as a common aspect of healthcare)

Question 23

What are Psychological Interventions for LTCs?

Answer 23

-CBT predominantly

-Varied in duration, format & content

-Nurses/CBT therapies/psychologists

-Promising results sustained at 12 months (QoL, functioning)

-Only 6 high quality RCTS

-Lack of evidence overall (identified 2000 papers, BUT had to filter out a lot of them as not a lot of high-quality reviews or relevant enough papers)

-Additionally, people’s mindsets especially since a LTC takes a toll on people’s perceptions, may influence the outcome of CBT and thus not be useful e.g., it may be better to have a support group or therapy tailored to allowing negative emotions to be let out rather than forcing a positive mindset.

Question 24

What are the goals of Intervention Approaches for LTCs + examples?

Answer 24

-Seek to overcome the varied challenges of living with LTCs

Examples:
IA: Chronic Kidney disease – peer support, education, group therapy
Intervention target: Enhance motivation for self-care, increase treatment adherence

IA: Fear of Recurrence Therapy (FORT) for women with breast or gynaecological cancer
IT: Reduce fearful cognition, improve anxiety levels

IA: Group education and therapy for COPD patients
IT: Regain sense of autonomy over life, improve quality of life

Question 25

What are the 3 systematic reviews of interventions for Chronic Kidney Disease? (Mason et al, 2008; Matteson et al, 2010; Strand et al, 2012)

Answer 25

What did it try to change:
Peer support to enhance motivation for self-care, also emphasis on autonomy and reducing anxiety

What did it include:
Education provision (e.g. disease features, required dietary changes), written resources, group problem-solving sessions, encouraging/prescribing exercise plans, hypnotherapy, coaching

How was it delivered:
Dieticians, psychologists, social workers, nurses, patient peers.

-Many people with kidney disease are unaware of symptoms until they reach an advanced stage

-No skills on teaching self-care more focusing on motivation

-They’re so different on who’s delivering these as researchers want to see the trade off with each type to find an intervention that’s accessible and cost-effective which is a difficult trade off to get right

Question 26

COPD: What’s the ‘Meeting, Compliance, Responsibility, Autonomy’ Intervention? (De Giorgio et al., 2017).

Answer 26

Included:
-Guided meditation
-Education about disease
-Anatomical model of illness
-Illness perception drawings (Created visual illness perceptions)

Lead to:
-Understanding of disease
-Adherence
-QoL
-Autonomy

-COPD=a group of lung conditions which causes breathing difficulties e.g., bronchitis

-This condition tends to worsen overtime

Question 27

What is involved in the FORT intervention for Cancer? (Maheu et al., 2016).

Answer 27

-6 group sessions

Theory-base:
-Self-regulatory model
-Uncertainty in illness model
-Cognitive model of worry

-Aims to reduce anxiety and improve quality of life

1. Distinguish worrisome symptoms from benign ones.
2. Identify FCR triggers and inappropriate coping strategies.
3. Facilitate the learning and use of new coping strategies, such as relaxation techniques and cognitive restructuring.
4. Increase tolerance for uncertainty.
5. Promote emotional expression of specific fears that underlie fear of cancer recurrence.
6. Re-examine life priorities and set realistic goals for the future

-Targeted the fear of recurrence of cancer (i.e., it returning)

-Researchers felt CBT alone would help them as it would be inappropriate when it typically focuses on reducing irrational thoughts (which is not apparent here) (but at the end of the day there are rational thoughts that need to be supported e.g., how will husband cope alone, emotional aspects struggling with cancer etc.,).

-Specifies specific illness perceptions (S-R M)

-Despite being multi-faceted, it is heavily focused on what it targets and wants to achieve