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CMHC PULSE

Cardio Metabolic Health Congress – Official Blog

Tobacco Assessment and Cessation Tools for Cardiac, Pulmonary and Vascular Rehab

Partner of the Month: AACVPR

For those quitting smoking, change can be very hard. Helping someone quit smoking can save his or her life, but for health care professionals trying to spark that change within their patient, it can be difficult to know exactly how to communicate.

Mayo Clinic Rochester Shawn Leth, M.Ed, CEP, and Kathy Zarling, MS, APRN, CTTS, both of the Mayo Clinic in Rochester, Mn., recently hosted an AACVPR webinar about using motivational interviewing as a tool to help smoking cessation. Health care providers need to understand how to ask the right questions to dig deeper into what their patients need in order to quit using tobacco for good.

“As we all know, smoking cessation is a challenging process for both the smoker and those trying to help them quit,” Leth said. “Motivational interviewing and coaching have been shown to be the most effective method to use during interventions.”

Motivational interviewing can be done in a variety of ways, but the goal remains the same. By partnering with clients in understanding their goals and motivations to quit using tobacco, health care professionals can facilitate a care plan to help them get there. Most importantly, it’s vital for those helping patients to quit be non-judgmental and empathetic in a person’s journey to quit.

While there are many methods to motivational interviewing, Zarling said it’s important to remember that no one way is the best. Health care professionals should feel empowered to use these tools in combination with one another if they find one resonates more with a patient than another does.

“Motivational interviewing is always a dance,” Zarling said. “It’s collaborative, it’s partnership, it’s working directly with the patient and walking alongside them to make that change.”

The OARS Method

There are several different methods to do this. The first is OARS.

  • Open-ended questions
  • Affirmations
  • Reflections
  • Summarize

Upon intake, professionals should ask open-ended questions. Instead of asking “Did you smoke last night?” try asking, “What challenges did you face that made you want to smoke last night?”

Asking these questions results in more robust questions and gives you an opportunity to learn more about your patient. It also helps you dig into whether they’re feeling confident about their cessation attempts. Maybe a person didn’t smoke the previous night, but hearing why they struggled with that can help dig deeper into what they’re facing.

Which leads into affirmations. If a person who is struggling was successful, be sure to recognize what they’ve been able to do, Leth said.

“Don’t we all appreciate being recognized for something we’re working on? Our patients are no different,” she said.

Help a patient reflect on their experiences, their successes and their failures by actively listening. If they feel they’re being heard—and what they’re saying is important to you—they’re more likely to trust. And lastly, summarize these conversations.

The DARN-CATS Method

Like the OARS Method, DARN-CATS is aimed at using change talk to highlight why a person would want to stop using tobacco, and what tools a person needs to get there.

  • Desire to Change
  • Ability to Change
  • Reason to Change
  • Need to Change
  • Commitment
  • Activation
  • Taking Steps

Again, this method is based on a value-based approach that uses non-judgmental questions to help someone quit tobacco.

The first part of DARN-CATs (the DARN) looks at what a patient feels about their tobacco use. It gauges their desire to change, what they need to do to start making those changes, and identifies reasons and needs for smoking cessation. Listening to a patient’s story helps the health care professional to find the patient’s values and goals.

“It’s walking along side our patients—and just a little behind them—so they lead in telling us their stories and telling us what their motivations and goals are,” Zarling said. “It also explores their values, strengths and desires in moving forward their goal of tobacco cessation.”

Once you understand where they’re coming from, you can help them build a plan. CATS helps move that needle forward. What does a patient think they can do to be successful? What are some small steps they can start on their own time when they’re ready to change?

Elicit-Provide-Elicit Method

Like the others, the Elicit-Provide-Elicit Method is predicated on what a patient is experiencing. This method specifically focuses on the patient experience through asking questions and using those answers to determine what information is applicable to the paitent.

Once you understand how a patient feels—and what questions and reservations they have about quitting—a health care professional should ask their patient if it is okay to make recommendations.

“Provide information in a neutral, non-judgmental way by asking permission first, respecting them and asking if it’s okay to intervene,” she said. “We don’t judge the patient, we meet them where they’re at.”

The Five A’s

While motivational interviewing is key to understanding a patient’s needs and desires, when you start moving into actually creating a plan for care. The Five A’s can create a roadmap for health care professionals to follow.

  • Ask patients about tobacco use every visit
  • Advise all patients who use tobacco to quit
  • Access the patient’s willingness to quit
  • Assist the quit attempt with counseling and/or medication
  • Arrange a follow up

Using motivational interviewing at each step of the process during this time is beneficial for not only the patient, but the health care professional as well. It can help you ask the right questions, help reinforce with the patient their own personal goals for quitting and allow everyone to get on the same page.

During those follow-up conversations—whether they’re in person or not—health care professionals should continue using motivational interviewing to build confidence in a patient.

“Change takes time,” Leth said. “It’s not going to happen overnight.”

Want to learn more about motivational interviewing? Leth and Zarling’s full webinar will be available on AACVPR’s website.

The Impact of Major Depressive Disorder on Cardiometabolic Disease Risk

Driven by a widespread change in lifestyle factors, such as dietary patterns and physical activity levels, as well as heightened stress levels, the global prevalence of cardiometabolic disease continues to rise. A burgeoning body of evidence suggests the potential impact of mental health factors, specifically the presence of major depressive disorder (MDD) on the development of cardiometabolic conditions. Affecting an estimated 322 million people, MDD has a high comorbidity rate with other medical disorders and in particular, type 2 diabetes. Although the mechanisms underlying the potential causal associations between the two are unknown, both cardiometabolic disease and major depressive disorder place a significant burden on population health.

Past observational studies have reported an association between MDD and an increased risk for type 2 diabetes, caused by biological alterations – such as elevated counter-regulatory hormone release and activity – as well as poor lifestyle factors, including smoking and alcohol consumption. Research has shown that brain regions involved in mood regulation also control metabolism, hypothalamic-pituitary-adrenal (HPA) axis, inflammatory responses, and autonomic nervous system (ANS) thus, controlling heart rate and blood pressure. These factors may influence the relationship between MDD and certain cardiometabolic conditions, however, evidence remains limited.

Adding to the growing body of evidence, a recent bidirectional Mendelian randomization study published in Diabetologia aimed to assess the causal relationships between major depressive disorder, type 2 diabetes, coronary artery disease, and heart failure to further elucidate the connections.

MDD and Cardiometabolic Disease

A team of researchers utilized the Mendelian randomization method – used for assessing causal inference of exposures on outcomes based on genetic variants as instrumental variables for exposures – to diminish chances of residual confounding and eliminate reverse causality due to the fixed nature of genetic variants regardless of disease progression or development.

In conducting their investigation, researchers extracted summary-level data for MDD, T2D, CAD, and heart failure from corresponding large genome-wide association studies; they used 96 single-nucleotide polymorphisms (SNPs) for MDD, 202 SNPs for type 2 diabetes, 44 SNPs for CAD, and 12 SNPs for heart failure. To perform their main analyses, the random-effects inverse-variance weighted method used.

Impact of MDD on Cardiometabolic Risk

Overall, the study’s authors found that the genetic liability to MDD was significantly associated with type 2 diabetes and coronary artery disease; they also found a suggestive association between MDD and heart failure. In examining the causal relationship, the research team found limited evidence in support of the causal effects of cardiometabolic disease on MDD risk, indicating that the presence of these conditions may not increase the likelihood of major depressive disorder.

However, meta-analyses did prove that the presence of MDD had an impact on type 2 diabetes development with the potential to increase risk by up to 60%. Additionally, the team found evidence of MDD having a causal association with the risk of CAD and HF. As diabetes and CAD have been known risk factors for HF and CAD may explain over 60% of heart failure cases, the relationship between major depressive disorder and heart failure may possibly be mediated via type 2 diabetes and coronary artery disease.

The latest findings further validate previous evidence that MDD is a potential risk factor for both type 2 diabetes and CAD, however, additional research needs to be conducted to determine whether MDD is causally related to heart failure. Future studies are likely to continue investigating the correlation to determine the significance of the impact of MDD on cardiometabolic health as well as to assess potential therapeutic interventions.

Due to the high disease burden related to causal association, the study’s authors recommend “that MDD prevention, management, and treatment should be enhanced for type 2 diabetes prevention.” Implications for the clinical practice may include more targeted strategies for the prevention and treatment of cardiometabolic diseases in the future with an increased focus on the mental health of patients.