The Importance of Setting Patient Expectations

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The Importance of Setting Patient Expectations

• Gail Hartley, MSN, RNP, MSCN
• Neurology Consultants
• Arcadia, California

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Major Topics

• Adherence issues
• Assisting with commitment to therapy
• Considerations for therapy selection
• Monitoring therapy and adherence
• Assessing efficacy

3
Main Reasons for Stopping DMTs

• Progression of disease
• Lack of improvement
• Fever, flu-like symptoms, joint pain
• Perceived lack of efficacy

T. Vollmer O. Hadjimichael, AAN, 1999.
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Unrealistic Expectations

• Disease modifying therapies
• Symptomatic medications
• Alternative therapies
• Investigational treatments
• Physical therapy

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The Role of the Nurse in MS

• Therapeutic relationship enhancing self care
• Comprehensive assessment and treatment plan
• and reassessment
• Provide education and support
• Promote and monitor adherence to treatment plan
• Promote hope
• Referrals for additional specialty care and
  community resources

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Commitment to Treatment

• What do you and your patient need
• to know?

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Comprehensive Patient Assessment

• Preassessment and reassessment
• Level of current knowledge facts and fiction
• Readiness to learn anxiety, depression,
  cognition
• Learning style
• Family support
• Acceptance vs. Adaptation

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Patient Education

• General information about MS
• Symptoms of disease
• Definition of relapse and treatment
• Information about treatment options for
  management of disease
• Treatment of symptoms

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Therapy Selection

• Treatment rationale
• Current recommendations for treatment of early
  disease
• Expectations of treatment

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What Factors Influence Treatment Choices?
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Adherence to Immunomodulator Therapy in MS US
Patient Survey

• Proportion of Patients Adhering to Therapy
• IFN beta 1b 30.6
• IFN beta 1a 58.6
• Glatiramer Acetate 78.4

T. Vollmer and O. Hadjimichael AAN 1999
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Patient Completion in Long Term Studies
Year 4 Year 6 Year 8 Copaxone 61 57 Be
taseron 45 Rebif 74 48
Johnson KP et al. Mult Scler. 20006255-266 Johns
on KP. Poster Presentation at AAN, Denver 2002
IFN? Study Group, Neurology Jul 1995, vol 45
1277-1285 PRISM Study Group, Neurology Jun 2001,
56 1628-1636 Kappos ECTRIMS/ACTRIMS 2002
Baltimore, Poster P334
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Disease Characteristics

• Type of MS
• Disease duration
• MRI burden of disease
• Clinical indicators relapse rate, severity,
  recovery, and disability
• Coyle, 2002

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Medication Characteristics

• Efficacy
• Side effect profile
• Injection frequency
• Injection technique
• Convenience
• Coyle, 2002

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Patient Characteristics

• Personal preferences
• Lifestyle
• Ability to perform injection/Fear
• Level of disability
• Concomitant medical conditions

• Patient perception of MS
• Lack of knowledge or value of treatment
• Cognitive deficits
• Lack of social support
• Financial restrictions
• Prior experience with DMTs
• Adapted from Coyle, 2002

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Barriers to Treatment

• Communication problems
• Knowledge deficits
• Physical or cognitive impairments
• Social or cultural variables
• Financial considerations
• Emotional or psychiatric disorders

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Monitoring Treatment and Adherence

• Injection technique, rotation
• Side effects and management
• Maintaining consistency of treatment
• Assess risks/reasons for non-adherence
• Reevaluation of patient expectations for
  treatment
• Additional education refresh reinforce

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Monitoring Treatment

• Laboratory monitoring of patients on IFNs
• CBC, LFT
• No consensus on frequency
• More frequent with higher dose IFN
• Unnecessary with Copaxone
• No current consensus on frequency of MRI

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Assessing Treatment Efficacy

• Clinical reduction in relapse rate
• Reduction in relapse severity
• Evaluation of MRI markers
• Sustained functional status
• Improved quality of life

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Nursing Strategies to Promote Realistic
Expectations

• Establish trusting relationship
• Assessment and reassessment of patient
  understanding
• Provide education and correct misconceptions
• Involve family in education sessions
• Involve patient in treatment decision making
• Enhancing self-efficacy (Fraser, 2001 2003)
• Utilize hopeful approach