Clinical Populations

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Clinical Populations Cardiac Rehabilitation

• KINE 2000
• Psychology of Physical Activity

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Overview

• Exercise Therapy in clinical populations
• Psychosocial factors associated with heart
  disease
• Cardiac rehabilitation
• Home-based

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Exercise Therapy

• Set of procedures aimed at facilitating improved
  physical mental functioning
• Exercise can be an inexpensive, time-efficient
  adjunct to traditional psychological therapy
• Less side effects,
• with other positive health effects (e.g.,
  cardiovascular, weight management)

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Benefits of PA as Tx for Mental Health Problems

• Self-administration
• Convenience
• Low Cost
• Minimal Side Effects
• Social Acceptability
• Ancillary physical benefits decreased health
  problems

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Psychiatric Populations Treated

• Clinical Depression Anxiety
• Developmental Disabilities
• Schizophrenia
• Pain Disorders
• Substance abuse disorders
• Alcohol
• Smoking

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Psychological Benefits of Exercise

• Clinically Depressed Patients
• Aerobic and anaerobic reduce depression
• More depressed individuals benefit most
• Just as beneficial as psychotherapy drug
  therapy
• Long term exercise regime more effective than
  short term programs
• Children and Elderly
• Exercise habits by parents influences children
  and affects their perception of their competence
  and goal orientation
• Exercise in elderly slows decline of cognitive
  functions
• Disabled Individuals

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Guidelines for Exercise Therapy

• A precise diagnosis of the psychological problem
  is needed
• Exercise should be used as an adjunct to other
  forms of therapy
• Individualize the exercise program (duration,
  intensity, freq)
• A variety of aerobic activities appear to produce
  best effects

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Clinical Practice

• Explore clients exercise and medical history
• Examine clients physical ability and motivation
• Explain the benefits of exercise
• Make exercise enjoyable, practical, functional
  (e.g., cycling to work)
• Evaluate clients support system
• Teach self-regulation strategies to plan for
  barriers to adherence
• Evaluate progress
• Provide useful feedback

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Heart Disease
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Burden of Cardiovascular Disease (CVD)

• CVD is the leading cause of morbidity and
  mortality in Canada, and the developed world
• 1 in 4 Canadians have some form of CVD
• 3 in 4 Ontarians 18 -74 have gt 1 major CV risk
  factor
• CVD is expensive 5.5 billion or 2 GNP in
  Ontario
• Aging population Burden of heart disease and
  stroke will increase by 77 by 2026

Heart and Stroke Foundation of Canada (1999). The
changing face of heart disease and stroke in
Canada 2000, 1-107, Ottawa.
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Heart Disease Risk Factors

• High blood pressure (aka Hypertension)
• Family history
• Cigarette smoking
• High LDL and total cholesterol levels
• Physical inactivity
• Diabetes
• Obesity
• Stress

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Behavioural Risk Factors

• Exercise Cdn ?more physically inactive
• (56.9) than ?(48.6 NPHS 98/99)
• Obesity increases with age, higher among men
  than women
• CCHS ? 41 overweight 27 obese
• Central adiposity apple vs. pear

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• Smoking stronger risk factor for AMI in
  middle-aged women than men, women who use OCs
• Incidence of smoking among young ??
• Smoking highest in Quebec Atlantic provinces

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Vulnerable Sub-groups

• Socio-economic status less education more likely
  to show early signs of atherosclerosis
• Lower SES have higher rates of smoking, ?BP, high
  fat diet, DM, inactivity, obesity
• Low SES less angiography, higher mortality
  (Alter, 1999)
• Mediated by social isolation, coping style,
  health behaviour, job strain, anger / hostility?

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Vulnerable Sub-Groups

• Ethnicity / Culture South Asian highest rates of
  CVD among Canadians
• Higher morbidity and mortality (Bhopal, 2002)
• Insulin resistance, physical inactivity, obesity

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Psychosocial Issues in CVD

• If you are working with heart patients, what
  should you be on the lookout for??

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Primary Prev Possible Etiological Role for

• Type A /hostility
• Depression
• Anxiety
• Psychosocial work characteristics high demands,
  low control
• Social Support

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Hostility

• Do you often find it difficult to fall asleep or
  difficult to stay asleep because you are upset
  about something a person has done? 
• Do you believe that most people are not honest or
  are not willing to help others? 
• Do you become irritated when driving or swear at
  others? 
• Does your partner, when riding with you, ever
  tell you to cool or calm down? 
• Do you often have a feeling that your partner is
  competing against you or is too critical of your
  inadequacies? 
• Does the car-driving errors of other drivers, the
  indifference of store clerks, or the tardiness of
  mail delivery upset you significantly?  

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Secondary Prevention Prognostic role.

• Depression 2-3fold increase in mortality
  (Frasure-Smith)
• Anxiety
• Work Characteristics
• Social Support / Isolation

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Depression

• Independent risk factor for heart disease
  (Cochrane Collaborative Review)
• Prevalence after coronary event ranges from
  15-23 (Lavie et al., 1999)
• Decreases likelihood of adhering to lifestyle
  changes
• Leads to poorer recovery (Arnold, 1997 Carney,
  Freedland, Jaffe, 1990 Frasure-Smith et al.,
  1993 1999 Ziegelstein et al., 2000)
• Women experience more depression than men, 21
  (Ai et al., 1997 Bosworth, 2000 Hamilton et
  al., 1993 Halm et al., 2000 Lavie et al., 1999)

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Anxiety

• Early and intense response to MI
• Investigated less often than depression (Abbey
  Stewart, 2000)
• Women at greater risk (Brezinka et al., 1998
  Frasure-Smith et al., 1999 Halm et al., 2000
  Schuster Waldron, 1991)
• Predictive of recurrent coronary events (Eaker et
  al., 1992 Frasure-Smith et al., 1999)
• Anxiety could compromise performance of
  activities in CR but anxiety could be reduced
  through education and support in CR

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Social Support Recovery

• Emotional sustenance, informational guidance,
  tangible assistance
• Gender differences (Ahto et al., 1997 Conn et
  al., 1991 Halm et al., 1999 Eaker, 1998
  Orth-Gomer, 2000)
• women more often widowed
• lack of spousal support related to lower program
  compliance rates in women (Halm et al., 1999)
• Source physician referral, encouragement from
  adult children (Lieberman, Meana, Stewart,
  1998)

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Why Secondary Prevention?

• Health risks continue after cardiac event
  therefore, secondary preventive efforts are
  important
• Risk of recurrence is 47 in the first year

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What is Cardiac Rehabilitation?

• World Health Organization definition
• the sum of activity required to ensure cardiac
  patients the best possible physical, mental and
  social conditions so that they may, by their own
  effort, regain as normal as possible a place in
  the community and lead an active life.

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Cardiac Care and Heart Health Program at TWH

• Team members
• Dietitian
• Registered nurse
• Kinesiologist
• Nurse practitioner
• Pharmacist
• Psychologist
• Cardiologist
• 6 languages

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Cardiac Rehabilitation (CR)

• Outpatient CR has two major components over 4-6
  months
• Exercise training (avg. 2x / wk.)
• Education and counseling
• medications, nutrition, maintenance of health
  behaviour change, smoking cessation, support,
  stress reduction, depression

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Rehabilitation Includes

• Exercise
• Physiological and psychological benefits
• Weight management
• Smoking cessation
• Lipid and BP management including evidence-based
  medications (titrated) dietary changes
• Stress management
• Vocational Counselling

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Beneficial Effects of CR

• A multifactoral Cardiac Rehabilitation (CR)
  program can reduce mortality by 25 compared to
  usual MD care (Carhart Ades, 1998)
• CR reduces use of interventional procedures
• CR reduces blood lipid (cholesterol) levels,
• improves psychosocial well-being,
• aids in stress reduction,
• reduces cigarette smoking,
• improves exercise tolerance,
• and reduces need for, and cost of
  re-hospitalization

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• Exercise is the key component but
• 50 drop-out rate within first 6 months
• For those who continue benefits include
• Improved self concept, perceived health,
  involvement in social activities, return to work.
• Those who stop are more likely to
• Smoke, have poorer cardiac function, have higher
  body weight, be more sedentary, experience
  greater anxiety and depression.

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CR in Ontario

• Uptake
• 16 CR programs in Ontario
• 16,033 referrals to CR in Ontario in 2002
• 11, 883 intakes

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Referral and Uptake

• Physician guidelines for referral show few real
  contraindications to participation in stable
  patients (AACVPR CACR)
• But only 15-20 use CR
• Should be referred regardless of age, gender, or
  whether they have arthritis or depression

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Referral and Participation in Ontario

• Of the estimated 100,000 people living with CVD
  in Ontario, the current system serves lt20 of the
  population eligible for CR
• even fewer from marginalized populations (i.e.,
  women, low SES, ethnocultural diversity)
• Most American, Australian, UK, and Canadian data
  show lower referral of women to cardiac rehab,
  and subsequently lower uptake
• MOHLTC funded the Cardiac Care Network (CCN) to
  assess process of providing CR in Ontario

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Gender and Secondary Prev of CVD

• Women may have poorer outcome the year after a
  coronary event
• could be accounted for by comorbid conditions and
  older age
• Demographics women have fewer psychosocial
  supports, are 10 years older, live alone, more
  likely to be retired than men (Benson, Arthur,
  Rideout, 1997 Cristian, Mandy, Root, 1999
  Shaffer Corish, 1998)
• Women experience more mood disturbance following
  M.I.- depression, anxiety, guilt (Eaker, 1998
  Lavie, 1999 Shaffer Corish, 1998)

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• Most studies on CR and secondary prevention do
  not include women. Only outcome data on
  short-term QOL, functional capacity, risk factors
• However, women who attend rehab show the same or
  greater improvements in functional capacity as
  men (Carhart Ades, 1998 Halm et al., 1999
  Hamm Kavanagh, 2000 OFarrell et al., 2000
  Richardon et al., 2000)
• Improvement is also seen among older women (Ades
  et al., 1999)

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Results of Patients Referred to
Participating in CR
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Who Recommended CR?
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Reasons for Not Attending CR Assessment
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Patient Preferences for On-Site Versus Home-Based
Cardiac Rehabilitation
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Home-based Cardiac Rehabilitation

• Modified program risk stratification, home
  exercise, telephone contact support (Carlson et
  al., 2000)
• Equivalent efficacy to hospital-based CR (Carlson
  et al., 2000)
• A low-cost complement/ alternative to traditional
  CR, with larger catchments, and possibly, early
  integration/long-term maintenance of exercise
  behaviour (Cannistra, 2003)

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Cardiac Care and Heart Health Program at TWH
Event
Referral (MD)
Intake to CCHH
Exercise treadmill test
Intake seminar
Hospital Program
Home Program
Risk Reduction
48 sessions total (2 or 3 session per wk.)
ea. 2 wks for 4 mos.
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Research Question

• What are the preferences and barriers to
  participation in home-based versus hospital-based
  cardiac rehabilitation programs?
• Design Retrospective chart review
  cross-sectional study with mailed
  survey/questionnaire.

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Methods
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No significant difference between participants
and non-participants in age, gender, length of
stay in hospital after event, or length of time
between event and referral to CR.
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Demographics of Participants, N80
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Preferences by Self-Reported Ethnocultural
Background
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What issues factored in decision?
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Benefits and drawbacks of the programs?
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Frequency, Duration and Intensity of Exercise
During and Post-CR

Mean Score

p 0.000 p 0.042
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What Participants Liked Best About the Program

• I found that the staff were excellent in every
  way possible.
• I thought all of it was excellent. It's between
  the education and exercise.
• The exercise program was and is (very) important
  in my life. (The team members) were phenomenal
  people to work with. Very non-judgmental,
  understanding, professional.
• This program works. The staff are great people.
  They get a lot of resources for the patients. The
  cardiologist is a great doctor. He really
  treated us with support and dignity. His staff
  are wonderful people. Keep up the great work.
• At the time I went I was much impressed with 3
  of your staff. The nurse practitioner, the
  dietician and the pharmacist. On a 1 to 1, I was
  encouraged to ask questions. Facts, ideas and
  plans were presented in an easily understandable
  manner.

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Suggestions for improvement

• Call patient at intervals for a brief time to
  check on progress/questions.
• Not enough help with home exercise.
• Limited information on progress. Did initial
  assessment and then little feedback after that,
  other than blood pressure and pulse checks.
• At the beginning I was given a list of
  appointments, some were changed, and this was
  inconvenient.
• Being forced to stop program because of time
  allowed - feeling like I was just starting to get
  into it.

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Conclusions

• Demographics
• Non-white and Non-working (retired or other)
  participants chose the hospital-based program
• Adherence to exercise
• Home-based participants exercised more
  frequently, less duration DURING CR than
  hospital-based. Hospital-based participants
  exercised more frequently and less duration AFTER
  CR than BEFORE.
• Home-based participants may better be able to
  adopt physical activity into daily life

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Recommendations

• Tailor the home-based program to those who work.
  They can fit in physical activity during
  off-hours.
• Doing a great job at reaching non-white cardiac
  patients, considering they are generally
  under-represented at CR programs. Capitalize on
  their preference for the hospital-based program,
  for support and monitoring.
• Make sure patients understand the option of home
  vs. hospital-based programs.
• Monitor and support the home-based program more
  rigorously.

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Find Out More

• Cardiac Care Network
• http//www.ccn.on.ca/
• Cdn Association of Cardiac Rehab
• http//www.cacr.ca/
• Canadian Cardiovascular Society
• http//www.ccs.ca/
• Heart and Stroke Foundation
• www.heartandstroke.ca