MyAction Couple: Primary Prevention Case Study. Teresa Mackay, Rhian Houghton, Tim Grove

Transcription

1 MyAction Couple: Primary Prevention Case Study Teresa Mackay, Rhian Houghton, Tim Grove

2 Reason for Referral and Patient Demographics Referral Mr Smith Referred by GP High CVD 34.5% QRISK Hypertension (155/92) Hypercholesterolaemia Ex smoker stopped 5 months ago Positive Family History Demographics 63yr old Male British White Married 1 Grown up child Temporarily unemployed Living in an area of deprivation

3 Past Medical History No previous CVD history Hypertension GP treated Hypercholesterolemia (treated)

4 Clinical InitialAssessment (Aug 13) He felt well with no complaints of chest pain, shortness of breath palpitations or dizziness. No side effect experienced from medication Blood Pressure: 155/92mmHg 151/92mmHg Pulse / ECG: 70 bpm regular/sinus rhythm Bloods: TC: 5.2 LDL:3.21 HDL:1.28 TG:1.56 TC:HDL:4.06 F/G 5.6 HbA1C 37mmol/mol Current Meds Bendroflumethiazide 5mg od (2 years) Amlodipine 5mg od (1 year) Simvastatin 40mg od NRT patches HAD A = 5 D = 4

5 Partner Treated Hypertension Obesity Raised HbA1c Treated Hypercholesterolaemia 65 year old lady British White Wife of patient 1 Grown up child Works Part time Looks after family

6 Past Medical History Hypertension Hypercholesterolaemia Asthma

7 Clinical Initial Assessment Mrs Smith She felt well with no complaints of chest pain, shortness of breath palpitations or dizziness. Experienced a cough from ACE inhibitor in the past Blood Pressure: 133/73mmHg 121/79mmHg Pulse / ECG: 72 bpm regular/sinus rhythm Bloods: TC: 3.3 LDL:1.61 HDL:1.18 TG:1.13 TC:HDL:2.80 F/G 6.2 HbA1C 51mmol/mol Current Meds Bendroflumethiazide 5mg od (2 years) Irbesartan 300mg od (18 months) Simvastatin 20mg od HAD A = 7 D = 11

8 Dietetic Assessment

9 Dietary Assessment IA (Mr Smith) Ht 1.83m Wt BMI WC Med score 8 Stage of change 97.4kg 29kg/m² 109cm Action Mr Smith had already started to make dietary changes: Avoiding high fat foods like cheese & crisps. Limiting sweet snacks At IA he had already lost 6kg in 2 months. Agreed goals: Had a discussion about portion control of his evening meal. Continue to monitor weight loss- aim for 0.5kg per week

10 Pulses, Beans, Legumes Pasta, Bread Fruit and Vegetables Mediterranean Diet Nuts, Seeds, Olive Oil Alcohol Fish Low Saturated Fat

11 Mediterranean Score

12 Ht 1.595m Wt BMI WC Med score 6 Stage of change Dietary Assessment IA 101.5kg 40kg/m² 118cm (Mrs Smith) Preparation Mrs Smith influenced by her husband had started to think about making dietary changes to help her lose weight. Identified some issues around emotional eating. Goals/Advice Limit savoury snacks like crisps to once per week. Avoid frying foods such as bacon & eggs Limit cheese to a match box size portion (25g) Reduce portion size of evening meal

13 Physical Activity Assessment

14 Physical Activity Assessment 7 Day PA recall diary Functional limitations profile Pedometer steps/day Chester Step Test (fitness test) Stage of change

15 Physical Activity Initial Assessment Mr & Mrs Smith Measurement Patient Partner 7 Day PA Diary (meeting PA guidelines Y/N) Pedometer steps/day 6,200 4,500 Functional limitations Profile Cardiorespiratory Fitness (MET max) Stage of Change Cont Cont N N Goals Increase structured exercise & PA levels Increase fitness Mrs Smith Weight loss

16 Risk Factors Following Our IA Mr Smith Hypertension Hyperlipidaemia (not treated to target) Positive Family History BMI 29 Low active/low cardiorespiratory fitness

17 Risk Factors Following IA Raised BMI 40kg/m² Mrs Smith Emotional eating Psychologist Raised HbA1c Low active/low cardiorespiratory fitness

18 Set Goals Following our IA Our Aims for achieving goals? Medication awareness Reduce & control BP & TC Repeat HbA1c for Mrs Smith Lifestyle changes: Increase physical activity frequency/intensity Encourage weight loss Encourage healthy eating Optimise Medications: Uptitrate Amlodipine 10mg od Mr Smith Change to Atorvastatin 10mg od

19 MyAction Exercise & Educational Sessions Patient & partner attended 16 community educational and exercise sessions, which included a once per week: Review of the patient & partner goals (home exercise prog, BP & weight check) 1 hour individualised group exercise circuit class 45 minute talk/workshop on the following: CVD risk reduction, smoking cessation, food labelling, stress management, benefits of PA

20 End of Programme Assessment

21 Clinical EOP Assessment (November 2013) IA EOP Presentation No cardiac symptoms No cardiac symptoms Blood Pressure: 155/92mmHg 151/91mmHg 125/77mmHg 128/76mmHg Pulse / ECG: Bloods: TC: LDL: HDL: TG: TC:HDL: 70 bpm regular sinus rhythm on ECG 5.2 FG HbA1c bpm regular on palpation 3.9 FG HbA1C 32 HAD A=5 D=4 A=3 D=3 Current Meds Bendroflumethiazide 5mg od Amlodipine 5mg od Simvastatin 40mg Bendroflumethiazide 5mg od Amlodipine 10mg Simvastatin 40mg Atorvastatin 40mg od

22 End of Programme IA EOP Presentation No cardiac symptoms No cardiac symptoms Blood Pressure: 133/73mmHg 121/79mmHg 128/70mmHg 120/69mmHg Pulse / ECG: 72 bpm regular sinus rhythm on ECG 65 bpm regular on palpation Bloods: TC: 3.3 FG FG 5.6 LDL: 1.61 HbA1c HbA1C 42 HDL: 1.18 TG: 1.13 TC:HDL: 2.80 HAD A=7 D=11 A=5 D=5 Current Meds Bendroflumethiazide 2.5mg od Irbesartan 300mg od Simvastatin 20mg od Bendroflumethiazide 2. 5mg od Irbesartan 300mg od Simvastatin 20mg od

23 Diet EOP Assessment (Mr Smith) Ht 1.83m 1.83m Wt 97.4kg 96.2kg BMI 29kg/m² 28.7kg/m² WC 109cm 108cm Med score 6 8 Stage of change Action Action Mr Smith at EOP had maintained all his previous dietary changes. Goals/advice Identified he could reduce his alcohol intake. Plus still improving portion control of his evening meal.

24 Diet EOP Assessment (Mrs Smith) Ht 1.60m 1.60m Wt 101.5kg 98.1kg BMI 40kg/m² 38.3kg/m² WC 118cm 116cm Med score 6 8 Stage of change Preparation Action Mrs Smith at EOP felt more confident to make dietary changes & the importance of losing weight for her health. Goals/advice Improving portion control of her evening meal & gave her a selection of healthy recipes from the Change for Life website

25 Physical Activity EOP Assessment (Mr Smith) Agreed Goals/Advice Home exercise programme Pedometer diary

26 Physical Activity EOP Assessment (Mrs Smith) Measurement 7 Day PA Diary (Meeting PA Guidelines Y/N) Partner IA EOP No Yes Pedometer 4,500 7,100 Steps/day Functional Limitations Profile Cardiorespiratory Fitness (MET max) Stage of Change Cont Action Agreed Goals/Advice Home exercise Programme Pedometer diary Exercise class at work

27 Long Term Care Referral to Phase IV (Community Centre) Lifestyle Referral Scheme (Leisure Centres) Local Weight Management Programmes (Community Dietitians) Online Services (NHS Choices) 3 Monthly Phone Calls/ s From MyAction Team

28 In Summary 63yr old Male. Referred as 34.5% High CVD (QRISK) & Wife 65 yr old 10.4% risk Improved healthy eating Reduced/ maintained weight/bmi Increased physical fitness Increased physical activity/function Controlled BP to target Controlled TC levels within target Reduced anxiety Increased self confidence Maintained non smoking status

29 The End Any Questions? Thank You For Your Time