Most seniors have one or more chronic illnesses and yet our healthcare system is based on an acute care model. One germ and one cure. The doctor and technology are in control and the patient is the passive recipient of pharmacological miracles and technology triumphs. However, according to the Centers for Disease Control and Prevention, 70% of all deaths in the US are due to chronic disease and the top four are cardiovascular disease, cerebrovascular disease, cancer and COPD. Of those over the age of 65 it is estimated 85% have one or more chronic diseases. If you are a psychologist working with geriatrics in Long Term Care you are working in the context of chronic conditions. LTC is no place for the Cartesian myth that the mind and body are separate. Rather clinical success depends on en embodied mind.

So what is a chronic disease? A chronic disease does not have a single cause, specific onset or stable symptoms. The course is marked by exacerbations and remissions in symptoms. Unpredictability is the rule. Treatment requires biopsychosocial interventions with coping, self-management and palliative care.

There are four types of chronic illnesses (Sperry, 2006):

·        Life-threatening diseases such as fast growing cancers, stroke or heart attacks.

·        Manageable diseases like diabetes, hypertension, osteoarthritis, chronic sinusitis

·        Progressively disabling diseases like Parkinson’s, lupus, RA and multiple sclerosis

·        Those not life-threatening but with waxing and waning course like fibromyalgia and chronic fatigue syndrome

Other important distinctions between acute and chronic illness include (Cummings et. al., 2005):

·        Acute illness onset is abrupt and CI is gradual

·        Acute illness is time limited and CI is indefinite

·        Acute illness tends to have a single cause and the causes of CI are multiple and changing

·        Acute illness prognosis is accurate and the prognosis in CI is uncertain

·        Technology is effective in acute illness and indecisive in CI

·        There is a cure for acute illness but rarely a cure for CI

·        Uncertainty is pervasive in CI

·        Professionals have the important knowledge in acute illness and both the patient and professionals have complementary knowledge in CI.

Patients who are told they have a chronic illness usually start with a crisis as they try to answer questions like these:

·        Will I be incapacitated?

·        Do I face a life of pain?

·        Can I make the changes they ask?

·        Will I be dependent and a burden?

·        What will be the impact on my family?

·        Will I be able to do the things I enjoyed?

·        Will we be wiped out financially?

·        Will I be isolated and alone?

·        Is this all my fault?

·        Is there a God?

·        Will I live?

Since cures are rare in chronic disease the best outcome we can expect is adjusting to the illness and disability. There seems to be a pattern that most patients follow. There seem to be phases of recovery that most patients share.  Patricia Fennel (2003) who authored Managing Chronic Illness: Using the Four Phase Treatment Approach, describes four phases:

• Crisis
• Stabilization
• Resolution
• Integration

Kenneth Sharoff (2004) who practices in Maryland and who authored Coping Skills Therapy for Managing Chronic and Terminal Illness describes five phases:

• Crisis Phase
• Post-crisis Phase
• Alienation Phase
• Consolidation Phase
• Synthesis Phase

Both agree that patients may move through the phases at different rates and that patients may return to an earlier phase. In fact without intervention a patient may return often to the crisis phase.

During the crisis phase patients must mobilize support, learn to manage discomfort, preserve a sense of identity and begin to learn how to deal with suffering. The diagnosis is associated with unstable emotions. The best approach for the psychologist during this period is to engage in crisis intervention with the patient and the family. Educational efforts or lifestyle change tends not to take during the crisis.

During the post-crisis or stabilization period the patient may very well try to return to pre-illness patterns and failure in that may lead to a return to the crisis phase. The basis goal in this period is to restructure life patterns and perceptions so they can move on with the illness as part of their life. Sharoff (2004) identifies a phase called alienation during which there is a high level of anxiety and anger that expresses itself in bitterness. However, not all patients seem to go through such a phase.

During the consolidation or resolution phase the patient must learn to manage limitations and find meaning. They must develop a new sense of self that is acceptable in spite of the illness and must develop a philosophy of life.

In the final phase of integration or synthesis the patient must meld the old self with the new self and yet as Fennell (2003) says: “…to experience a complete life in which illness is only one aspect…”  The person must unify the illness with a healthy identity.

In that context what is the goal of our intervention? According to Len Sperry (2006) “…the goal of Biopsychosocial therapy is to achieve integration of the chronic condition as part of a healthy sense of self…the highest level of wellness possible while living with a progressively degenerative or life-threatening illness.”

One of the most frequent reasons for failure and frustration in combining Behavioral Medicine with psychotherapy is bad timing and poor teamwork. By considering the phases of chronic illness we can improve our timing and by recognizing the importance of all three domains we can improve our teamwork.

In no area of healthcare are the skills of psychologists needed more than in the area of chronic disease. Psychology can play a major role in addressing the crisis in healthcare costs, that will become steadily worse in the decades to come. Only when medicine recognizes the role of emotional and cognitive factors can we improve the services to a sufficient extent that there is less demand for the most expensive services.

Psychological issues cannot be ignored in planning care for acute or chronic illness. Defining the manner in which psychological factors may be affecting a given medical condition is essential. Psychological factors can influence the illness in one of the following ways:

• A close temporal relationship between the development, exacerbation or delayed recovery from the medical condition.
• Psychological factors that interfere with the treatment of the medical condition.
• Psychological factors constitute an additional health risk for the individual.
• Stress-related physiological responses precipitate or exacerbate symptoms of the medical condition. (DSM-IV-TR)

According to Smith and Nicassio (1995) psychological factors may have direct, indirect or moderating influence:

• Direct effects refer to relationships in which some psychological factor is reliably associated with predicted changes in health outcomes. For example, the psychological factor anxiety has direct and predictable impact on muscular tension.
• Indirect effects involve more complex relationships in which psychological factor A has influence on medical condition C but only through mediation of B. The mediating factors may be physiological or behavioral. For example daily stress can lead to increased anxiety which can lead to peripheral vasoconstriction and thus a rise in blood pressure. Or avoidance can lead to poor compliance with anti-inflammatory drugs and thus increased joint inflammation.
• Moderator effects are factors that alter the relationship between a causal factor and a health outcome. For example low levels of social support may increase the frequency of adverse health consequences under stress and high support can moderate the effects of high stress levels.

Adherence is the Achilles heel of medical practice. The system operates under the delusion that if the god-like doctor makes a health related command that people will follow it. Adherence is defined as the extent to which a person’s action or behavior coincides with advice or instructions from a healthcare provider intended to prevent, monitor or ameliorate a disorder. In the 1980s the active term was compliance. However, many practitioners felt such a term endorsed or at least accepted the autocratic approach to medical practice which was part of the problem and not the solution.

According to Alan Christensen (2004) in Patient Adherence to Medical Treatment Regimens in the general health system 50% of patients do not take medication properly. The more complex the regimen and the longer duration of treatment the greater the non-adherence. As patients grow older complexity increases and the length of treatment increases and thus non-adherence may become an even greater problem. Christensen (2004) cites research that indicates the range of non-adherence can range between 20%and 80%. Adherence is best with acute care regimens with rates of non-adherence ranging from 20% to 40%. Rates for chronic illness is 30% to 60%, with  preventive regimes rates the poorest, ranging from 50% to 80% non-adherence.

The three major areas for intervention to promote adherence are:

·        Medication

·        Diet

·        Exercise

Approaches may vary but one key method is education. Written materials about the regimens are common and more recently online interactive education can be found for a variety of diseases.

Social and familial support for adherence is a common issue. Educating the patient without educating the family may be less productive because they will continue to share ideas that may lead to non-adherence.

The most promising method of intervention is Motivational Interviewing which tends to take a collaborative approach and which proceeds according to the readiness and perceptions of the patient rather than the medical staff.

One of the most common problems in adherence is depression. The impact of depression in distorting the perception of the patient and in reducing motivation is a factor which must be addressed. Often when depression lifts adherence follows.

References

Cummings, N.A., O’Donohue, W.T. & Naylor, E.V. Psychological Approaches to Chronic Disease Management, 2005, Cortext Press: Reno, Nevada.

Fennel, P.A. Managing Chronic Illness: Using the Four Phase Treatment Approach, 2003, John Wiley & Sons, Inc.

Sharoff, K. Coping Skills Therapy for Managing Chronic and Terminal Illness, 2004, Springer Publishing Company, Inc.

Sperry, L. Psychological Treatment of Chronic Illness: The Biopsychosocial Therapy Approach, 2006, American Psychological Association.