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EP Summit 2015: QOL in AF Patient

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Sam Sears

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EP Summit 2015: QOL in AF Patient

  1. 1. QOL in AF Samuel F. Sears, Ph.D. Professor and Psychologist East Carolina University Department of Psychology Brody School of Medicine Department of Cardiovascular Sciences
  2. 2. Financial DisclosuresFinancial Disclosures • Founder, PresidentFounder, President ICD Coach and QOLApps, IncICD Coach and QOLApps, Inc • Research Grants:Research Grants: Funds to East Carolina UniversityFunds to East Carolina University – Medtronic, Inc.Medtronic, Inc. • Consultant:Consultant: – Medtronic, Inc.Medtronic, Inc. – St. Jude Medical, IncSt. Jude Medical, Inc • Speaking HonorariaSpeaking Honoraria – Medtronic:Medtronic: – St. Jude Medical, Inc.St. Jude Medical, Inc. – Boston ScientificBoston Scientific Samuel F. Sears, Ph.D.Samuel F. Sears, Ph.D.
  3. 3. • Patient:Patient: –Heart PalpitationHeart Palpitation = DANGER= DANGER What was He/She Thinking?What was He/She Thinking?
  4. 4. Desired = AF Patient PresentationDesired = AF Patient Presentation
  5. 5. FREQUENT = AF Patient PresentationFREQUENT = AF Patient Presentation
  6. 6. QOL =QOL = “Triple Play” of Health“Triple Play” of Health BiomedicalBiomedical •Engel, 1977 PsychologicalPsychological SocialSocial
  7. 7. FEEL NORMAL FEEL SAFE FULLY ENGAGED
  8. 8. Outline for TalkOutline for Talk • Review Patient Centric Research onReview Patient Centric Research on AF and Case StudyAF and Case Study • Identify Clinical Management PlanIdentify Clinical Management Plan
  9. 9. • AF demands psychological adjustment.AF demands psychological adjustment. • McCabe, Schumacher, & Baranson,McCabe, Schumacher, & Baranson, 20112011 • Focus GroupsFocus Groups:: – Finding meaning in AF symptomsFinding meaning in AF symptoms – Feeling uninformed and unsupportedFeeling uninformed and unsupported – Turning pointsTurning points – Steering clear of AF triggersSteering clear of AF triggers – Managing unpredictable and functional limitsManaging unpredictable and functional limits – Emotional DistressEmotional Distress – Accommodation of AF but tempered with hopeAccommodation of AF but tempered with hope Research on AF Patient ExperienceResearch on AF Patient Experience
  10. 10. QOL is an ACHIEVEMENTQOL is an ACHIEVEMENT not an ENTITLEMENT.not an ENTITLEMENT.
  11. 11. Self Management of Disease • Refers to actions by patient to reduce or minimize the effects of disease • Three major tasks: – Medical mgmt: • Adherence, Med decisions – Role mgmt: • Keep doing what you can – Emotional mgmt: • Stay positive & resist dep/anx Lorig et al.
  12. 12. Conservatively,Conservatively, 1 out of 41 out of 4 patientspatients acrossacross cardiac clinicscardiac clinics has problematic depressivehas problematic depressive and/or anxiety symptoms.and/or anxiety symptoms.
  13. 13. • Depression & Anxiety are common in AFDepression & Anxiety are common in AF Thrall, Lip, Carroll, & Lane, 2007Thrall, Lip, Carroll, & Lane, 2007 • In a sample of AF Patients:In a sample of AF Patients: – 38%38% depressive symptomsdepressive symptoms – 38%38% anxiety symptomsanxiety symptoms • Virtually no change over 6 monthsVirtually no change over 6 months • Depression symptoms predicted worse QOLDepression symptoms predicted worse QOL • Women had worse QOLWomen had worse QOL • Suggests that AF canSuggests that AF can wear you downwear you down AF Patient ResearchAF Patient Research
  14. 14. ““AF and psychosocial factorsAF and psychosocial factors are inter-related .”are inter-related .” • Suzuki & Kasanuki (2004) - Studied 240 Intermittent AF Patients - Purpose: Investigate impact of anxiety and AF - Findings: - 29.5% of AF patients experienced significant Anxiety Disorders - Anxiety greatly affected QOL and AF symptoms - Conclusions: Anxiety, stress, and AF related.
  15. 15. Anxiety Vs. AFAnxiety Vs. AF SHARED SYMPTOMSSHARED SYMPTOMS  PalpitationsPalpitations  Fast Heart RateFast Heart Rate  Chest DiscomfortChest Discomfort  Shortness of BreathShortness of Breath  DizzinessDizziness  FatigueFatigue  Light-headedLight-headed AF only SYMPTOMSAF only SYMPTOMS • Exercise discomfortExercise discomfort – SOBSOB – PainPain – WeaknessWeakness • Presence of Other cardiacPresence of Other cardiac problemsproblems – CHFCHF – Recent cardiac proceduresRecent cardiac procedures
  16. 16. Psychopathology and AFPsychopathology and AF • Gehi, Sears, Goli, Walker, Chung, …Mounsey, (2012).Gehi, Sears, Goli, Walker, Chung, …Mounsey, (2012). JCEJCE • 300 patients with documented AF300 patients with documented AF • Psych. distress associated withPsych. distress associated with more AF symptomsmore AF symptoms, even, even after adjustment for confounders.after adjustment for confounders. • Severity of depression and anxiety symptoms alsoSeverity of depression and anxiety symptoms also associated withassociated with medical utilizationmedical utilization related to AF.related to AF. • Suggests symptoms and psychological distress warrantSuggests symptoms and psychological distress warrant co-managementco-management
  17. 17. Stress and Atrial FibrillationStress and Atrial Fibrillation • Triggers of the Experience of AF: • Hansson, Madsen-Hardig, & Olsson (2004) - Studied 100 Intermittent AF Patients - Purpose: Identify triggers associated with AF symptoms - Findings: Stress 54% - Physical exertion 42% - Tiredness 41% - Coffee 25% - Infections 22% - Conclusions: Patients believe stress is most common trigger.
  18. 18. • Psychological features predict outcomes.Psychological features predict outcomes. Ong, Cribbie, Harris, et al., 2006Ong, Cribbie, Harris, et al., 2006 • Symptom attentionSymptom attention predicted worse mentalpredicted worse mental and physical QOLand physical QOL • OptimismOptimism predicted better mental QOL, butpredicted better mental QOL, but not physical QOLnot physical QOL Personality Quality of Life Hypervigilance: Symptom Attention
  19. 19. Continuum of CARDIAC FEARContinuum of CARDIAC FEAR Denial AppropriateDenial Appropriate HYPERHYPER CardiophobiaCardiophobia ConcernConcern VigilanceVigilance Concerns about your heart are reasonable. Balance those concerns with reassurance. ANXIETYPLAN
  20. 20. • Patient:Patient: –Heart PalpitationHeart Palpitation = DANGER= DANGER • Family Member:Family Member: – Heart PalpitationHeart Palpitation = DANGER= DANGER • Physician:Physician: –Heart Palpitation:Heart Palpitation: AF = Make PlanAF = Make Plan What was He/She Thinking?What was He/She Thinking?
  21. 21. Continuum of CARDIAC FEARContinuum of CARDIAC FEAR Denial AppropriateDenial Appropriate HYPERHYPER CardiophobiaCardiophobia ConcernConcern VigilanceVigilance Concerns about your heart are reasonable. Balance those concerns with reassurance. ANXIETYPLAN
  22. 22. CASE: QOL THREAT • Male Patient in His late 60sMale Patient in His late 60s • Former ArmyFormer Army • Symptomatic AF occasionallySymptomatic AF occasionally • Medical Hx: Paroxsymal AFMedical Hx: Paroxsymal AF – Mild CHF, HTNMild CHF, HTN • Psychological:Psychological: ResistingResisting “age”; Hides symptoms“age”; Hides symptoms • Electrophysiology: Multiple Rx options:Electrophysiology: Multiple Rx options: • Decision: Conservative first,Decision: Conservative first, then decision forthen decision for ablationablation
  23. 23. CASE: QOL THREAT • 11stst Ablation failed: Pt decides to go with medsAblation failed: Pt decides to go with meds • Symptoms return before a vacationSymptoms return before a vacation – SpouseSpouse “makes him come in to clinic”“makes him come in to clinic” – Ablation is reconsidered by MD and spouseAblation is reconsidered by MD and spouse – Claims he willClaims he will “follow orders”“follow orders” • Referral to Cardiac Psychology ServiceReferral to Cardiac Psychology Service • Psych EvalPsych Eval:: • Pt wants toPt wants to “get fixed” and “move on”“get fixed” and “move on” • Mild anger, dep, anx; Marital stressMild anger, dep, anx; Marital stress
  24. 24. CASE: QOL THREAT • Psychosocial Evaluation: To understandPsychosocial Evaluation: To understand “wear“wear and tear” of AF and its impactsand tear” of AF and its impacts • Summary ofSummary of PatientPatient’s beliefs’s beliefs:: – PalpitationPalpitation = Lack of discipline =DANGER= Lack of discipline =DANGER – ComplainingComplaining = Lack of discipline =DANGER= Lack of discipline =DANGER – WIFE: ALL HEART PROBS ARE DANGEROUS!WIFE: ALL HEART PROBS ARE DANGEROUS! • DX: Psychological Factors Affecting a MedicalDX: Psychological Factors Affecting a Medical ConditionCondition
  25. 25. CASE: QOL THREAT TREATMENT PLAN :TREATMENT PLAN : • Inter-disciplinary care and educationInter-disciplinary care and education – Symptom tolerance and educationSymptom tolerance and education – Decision support: Pros and Cons discussionDecision support: Pros and Cons discussion – QOL goalsQOL goals • Increase Pt Awareness of optionsIncrease Pt Awareness of options • Second ablation planned and Pt is doing well.Second ablation planned and Pt is doing well.
  26. 26. CASE: QOL THREAT • OUTCOMEOUTCOME:: – Pt increased control and mgmt of emotions:Pt increased control and mgmt of emotions: feels morefeels more emotionallyemotionally “disciplined”“disciplined” – Reported better understanding of AFReported better understanding of AF – Underwent 2Underwent 2ndnd ablation and reports significantablation and reports significant benefit at presentbenefit at present – GOAL: Pt current satisfied and reports goodGOAL: Pt current satisfied and reports good QOLQOL
  27. 27. Outline for TalkOutline for Talk • Review Patient Centric Research onReview Patient Centric Research on AF and Case StudyAF and Case Study • Identify Clinical Management PlanIdentify Clinical Management Plan
  28. 28. Osler (1932): Treat the Disease in the Body & Attend to the Person with Disease. •We all do that.
  29. 29. Comprehensive Care is an Important Aspiration. May be difficult to achieve in every case. Suggestions: +Develop an informed referral source. +Provide systematic, brief, support in routine care.
  30. 30. ““Coping with AF requires aCoping with AF requires a MENU of strategies.”MENU of strategies.” • Confident ThinkingConfident Thinking • Confident BehaviorConfident Behavior • Confident RelationshipsConfident Relationships Psychosocial ThemesPsychosocial Themes
  31. 31. ““Routine Confidence”Routine Confidence” ““The major purpose for Confidence to CardiacThe major purpose for Confidence to Cardiac patients is to achieve Your Quality of Life.”patients is to achieve Your Quality of Life.”
  32. 32. CONFIDENCE MATTERS!CONFIDENCE MATTERS! •Confident ThinkingConfident Thinking •Confident BehaviorConfident Behavior •Confident RelationshipsConfident Relationships ““Confidence involves your thinking, yourConfidence involves your thinking, your behavior, and your relationships.”behavior, and your relationships.”
  33. 33. CONFIDENTCONFIDENT THINKINGTHINKING
  34. 34. ““Confidence in Self-Management Plan isConfidence in Self-Management Plan is necessary .”necessary .” – DoctorsDoctors – MedicinesMedicines – Clinic VisitsClinic Visits – In AF KnowledgeIn AF Knowledge – Family SupportFamily Support – Personal EffortsPersonal Efforts – Spirituality/FaithSpirituality/Faith Confident ThinkingConfident Thinking
  35. 35. FEEL NORMAL FEEL SAFE FULLY ENGAGED
  36. 36. Confident ThinkingConfident Thinking  Confident Knowledge  Self-Management PlanSelf-Management Plan  Confirmed SafetyConfirmed Safety  Survivorship Commitment vs.Survivorship Commitment vs. VictimhoodVictimhood
  37. 37. Maslow’s Hierarchy of Human Needs SurvivalSurvival SecuritySecurity Social AcceptanceSocial Acceptance Self-esteemSelf-esteem Self-actualizationSelf-actualization
  38. 38. ““A shift from VICTIM to SURVIVORA shift from VICTIM to SURVIVOR reduces stress.”reduces stress.” • SURVIVORSHIP:SURVIVORSHIP: – An active mental approach to copeAn active mental approach to cope – Emphasizes the positive and the future, rather than the pastEmphasizes the positive and the future, rather than the past – Engages others in the questEngages others in the quest • VICTIMHOOD:VICTIMHOOD: – A passive process that emphasizes loss and limitationsA passive process that emphasizes loss and limitations – Emphasizes how no one else can understand their experienceEmphasizes how no one else can understand their experience Confident ThinkingConfident Thinking CARDIAC SURVIVOR
  39. 39. CONFIDENTCONFIDENT BEHAVIORBEHAVIOR
  40. 40. Confident BehaviorConfident Behavior  Avoidance Behavior is a Problem. – Fear of Increased Heart Rate – Fear of Stroke  Avoidance Ultimately Increases Anxiety.  Behavior Therapy is key.
  41. 41. ACTIONACTION: CONFIDENT Behaviors: CONFIDENT Behaviors – TESTING THE LIMITS SAFELY:TESTING THE LIMITS SAFELY: – WhatWhat activityactivity or activities did you used to like to do?or activities did you used to like to do? – What modifications can you make to return to them?What modifications can you make to return to them? • Mental vs. Physical vs. ApprovalMental vs. Physical vs. Approval – WhatWhat stepssteps are needed to get clearance?are needed to get clearance? – Doctor/nurse advice, cardiac rehab, a partnerDoctor/nurse advice, cardiac rehab, a partner Exercise Treadmill Test as Therapy?
  42. 42. CONFIDENTCONFIDENT RELATIONSHIPSRELATIONSHIPS
  43. 43. Confident RelationshipsConfident Relationships  Isolation is a common response to distress. – Feeling different or damaged – Future beliefs: Hope vs. Futility  Fear is Contagious.Fear is Contagious.  Relationships benefit from attention to allRelationships benefit from attention to all partners.partners.
  44. 44. ““Who can be a safety net?Who can be a safety net? Confident RelationshipsConfident Relationships • Health Care TeamHealth Care Team • Family TeamFamily Team • Support Group TeamSupport Group Team
  45. 45. CONFIDENCE MATTERS!CONFIDENCE MATTERS! How do I live more confidently?How do I live more confidently? •Confident ThinkingConfident Thinking •Confident BehaviorConfident Behavior •Confident RelationshipsConfident Relationships ““Confidence involves your thinking, yourConfidence involves your thinking, your behavior, and your relationships.”behavior, and your relationships.”

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