Pharmacological And Non-Pharmacological Interventions To Address The Unmet Needs Of Men Over 50 Years In Cardiac Rehabilitation Following Myocardial Infarction

Background

Community nursing requires nurses to develop skills needed for promoting the health of the priority groups. The nurses must be skilful in reaching the audiences with unmet health needs and understanding intervention that is appropriate, accessible and relevant to them. The aim of the project is to identify the unmet health needs of men over 50 years in cardiac rehabilitation following myocardial infarction in Australia and propose a cost effective health promoting activity or program for them. The rationale for the selected target audience is the need of effective care since they have undergone invasive coronary procedures and highly stressed with poor quality life (Redfern et al., 2014). Therefore, knowing the health related preferences will help in developing less expensive and more effective care in this community. 

Pharmacological and non-pharmacological interventions to address the unmet needs of men over 50 years in cardiac rehabilitation following myocardial infarction

To identify the unmet needs of the men over 50 years in cardiac rehabilitation following myocardial infarction literature review is performed using PRISMA tool (Moher et al., 2015). The literature articles will be selected from the year 2008-2017. The inclusion criterion for the article selection includes their publishing in English and dealing with the cardiac rehabilitations particularly the target audiences and the research being conducted in Australia. The articles must include community nursing and needs that are not addressed. The exclusion criteria include articles that are published beyond the time period selected and published in other foreign languages. Articles that are dealing with men in the cardiac rehabilitations in other countries and emphasising on particular care plan or relationship with the caregivers are excluded. Three main databases were used for searching the articles which are PUBMED, Cochrane library and MEDLINE. The key terms used for search of the articles are myocardial infarction, men in cardiac rehabilitation, clinical care status, health assessment, unmet needs, men’s perspectives, and narratives of men over 50 years.

According to Smolderen et al. (2010) the cardiac rehabilitation services provided to the target audience in remote areas of Australia is not structured. Due to which most men although have understood the recommendations such as importance of smoking cessations or quitting alcohol were not able to implement the desired change inspite of counselling. The participants differed in understanding the intensity and frequency of the physical exercise required by them. It means that the caregivers were unable to address the emotional concerns of the target group. This is evident of lack of proper counselling to the patients. Hence the unmet need is the lack proper education or provision of health education which is integral to participate in health promoting activity. These results were supported by the study of Davidson et al., (2008) who found that there was no initiative by the caregivers to address the fear of heart attack among the patients who have been stabilised after the cardiac event. The fear continue to persist even after several counselling sessions.

Identifying Unmet Health Needs

The study executed by Jneid (2016) showed that the older men failed to receive adequate assistance on the activities of daily living. The needs of assistance were reported but in vain. These in turn led to anxiety and stress. The fear of fall prevented them from participating in physical activities. Hence, the unmet need is addressing the patient’s fear and fulfilling the need of complete physical assistance. Knudsen et al. (2014) analysed the narratives of the men in cardiac rehabilitation following myocardial infarction. The results showed that they failed to acknowledge the need for incorporating positive lifestyle changes. These men failed to keep up with the daily routine of exercise and diet. However, these were not a case with all the men. Dietary change was difficulty for men who had sedentary lifestyle before myocardial infarction. Some of the patients narrated that they felt guilty on being unable to manage lifestyle changes. The narratives showed that they were not motivated by the caregivers to overcome the shame and guilt or feeling of insecurity.

According to Kureshi et al. (2016) some men did not achieve the state of reconciliation that they would not have another cardiac event. This was experienced although they have not deviated from the stated recommendation in the cardiac rehabilitation. The reason was they were following the caregiver’s instructions just because they felt it was necessary and not because they enjoyed it. They considered following the care giver’s plan was just a burden (Jneid, 2016). Hence, the need to adopt the healthy lifestyle changes whole-heartedly was not addressed. Gupta et al., (2012) acknowledged other psychological factor that is social isolation. The caregivers do not consider the family environment of older men who have survived cardiac event, which is an integral aid to survival. Men who were near to retirement or in non-working groups were need of improvement in social connection. Having high social connectedness is imperative to overcome illness.

From the literature review, it can be concluded that the medical model of health care has made significant health improvements however; resolving the clinical aspects of men who survived from the heart failure ignores the impact on the quality of life highly in regards to emotional status. The unmet needs in short can be stated as unable to overcome health insecurity, difficulty maintaining healthy lifestyle changes, fear of fall and inability to participate in physical activities. In conclusion, the unmet needs belong to emotional context which in the target audience where found to be unresolved by counselling sessions. Thus, there is a need of developing a health promoting program which includes elements that stimulates changes in the context of physical health, mental health, and social connectedness.

Pharmacological and Non-Pharmacological Interventions

The health promotion program proposed is applicable for men in cardiac rehabilitation who are afraid of involving in physical activities and are unable to quit smoking or alcohol (whichever applicable) despite knowing its importance. Since their concerns are not met by advocating or merely counselling them about the importance of these services or activities there is a need of developing alternate program that is cost efficient and easy to implement by the cardiac rehabilitation centre. The program must be easy to provoke positive change without any counselling sessions, which is an age old technique but fails to address insecurities in some cases.

A comprehensive health promotion program for the identified unmet needs which is mostly in the category of mental health must include non-pharmacological intervention (till the emotional needs are addressed) followed by pharmacological interventions. These include-

Phase I-

1. Develop schedule that involve less physical activities for men afraid of fall or fragile enough to participate in exercises. Instead replace with alternatives such as meditation and yoga
2. Massage therapy as a part of naturopathy
3. Naturopathic interventions for smoking cessation

Phase II-

Pharmacotherapy and initiation of intense exercise program, Nutritional therapy and lifestyle management after meeting emotional needs.

Nurses need to acquire degree in holistic nursing, certifications and training resources. Only licensed nurses should be allowed to practice the holistic modalities. The skills required by the community nurses in dealing with men after myocardial infarction are patient centered care, sensitivity, cross communication skills training and skills to educate or advocate the patient on health promoting activities. Most importantly the nurses must be highly trained to address the emotional concerns of the patient who are acquainted with the benefits of lifestyle management and dietary changes and those unable to quit addictions (Nathenson, 2012). Nurse’s need intense training in lifestyle counselling, as not addressing the emotional securities is the significant unmet need found.

The health programs proposed is cost effective as the patients do not have to involve in any activity that includes risk of physical harm or create stress and anxiety. Once the patients is well acquainted or used with the elements in the health program proposed it is easy for them to manage their lifestyle on their own  without depending on other person (Melchart et al., 2016).

Incorporating the elements of naturopathy is highly effective in treating serious illnesses in less time and addresses all the health aspects of health that is spiritual, social, physical and mental health. Therefore, addressing the above identified unmet mental health needs will eventually address other health aspects without investing time and money in different interventions. Replacing the physical activities such as exercises or walking with meditation and yoga have been found effective in minimising the risk of heart attack (Okonta, 2012). It was found with multiple benefits in several trials conducted in American and African men since this is mind-body technique. Gupta (2016) showed 48% reduction in risk of heart attack among participants when compared to those who did not meditate. It reduces emotional insecurities, stress and anger. It also helps to cope up with withdrawal symptoms in men addicted to smoking and alcohol.

Health Promotion Program

However, it must be practiced as a part of care in addition to medication, pharmacological therapies and lifestyle management as completely relying on meditation is not yet advocated by various scientific studies. It can address the needs unmet by the counselling sessions. It helps men with sedentary habits to accept positive health and lifestyle changes whole-heartedly (Braun et al., 2014). Thus, a patient may be more confident in participating in pharmacotherapy and physical activities (if not in need of physical assistance for daily activities). Involvement in meditation, yoga and massage therapy may help patient return to work which will enhance the social connection and to great extent reduce the emotional concerns. This can be followed by prevalent services in cardiac rehabilitation for men such as exercise and pharmacotherapy and dietary changes which have been proved effective ages back (Lavie et al., 2009).

Massage therapy is an excellent form of “passive exercise” in naturopathy by which nurses can engage men who do not want to participate in exercises. It is highly stimulating and invigorating when done on bare body. It includes soft tissue manipulation to meet the physical, physiological, and psychological needs. The target tissues for this therapy are ligaments, muscles, tendons, connective tissue. It helps in vasodilatation of arteries, soothing effect on muscles, stimulates heart and strengthens the rate of contraction, reduces trait anxiety and depression, improves blood pressure, eliminates fibrosis and stimulation of parasympathetic nerves releases endorphins and serotonin (Franklin et al., 2014).

Naturopathy uses acupuncture, nutrition, counselling (advocacy and education) and clinical hypnosis both of which have been proven effective in reducing or quitting smoking and alcohol in Australia. It helped reduce physical dependency and mental addiction. The nutritional therapy is essential in preventing future cardiac events as “food is the only medicine” according to naturopathy (Robson, 2014). The diet therapy of naturopathy involve “soothing diet (fruits and salad), eliminative diet (vegetable soups), constructive diet (wholesome flour), and alkaline diet that purifies body. Having diet rich in vitamin E, vitamin C, L-carnitine are beneficial in treatment of acute myocardial infarction and is found successful by numerous clinical trials (Shafiq et al., 2016). These interventions help modify risk factors for future cardiac events. These also involve nutritional counselling that has been successful in preventing and managing obesity, hypertension, diabetes, and others. These methods are more successful in meeting the needs unmet by mere counselling. These methods have been proven effective for avoiding relapse (Muramoto et al., 2016).

Community Nursing Skills

The non-pharmacological interventions will increase the adherence of the men to the pharmacological interventions. The combination of both types of interventions is advantageous for men with low socioeconomic status. For these group non-pharmacological methods addresses unmet needs to great extent. These reduces economic burden as secondary preventive services are expensive. 

For evaluating the intended outcomes of the proposed health program the caregivers in cardiac rehabilitation must perform evaluation after the intervention have begun during mid of the interventions. Regular monitoring helps to implement remedial measures and maintain accountability to the expected results from the programme. Data collection (qualitative and quantitative) from the caregivers and the care users involved in modifying health risk activities will be used in the evaluation process to coordinate the activities of the program. It includes ensuring that the caregivers are implementing the protocol correctly for the target audience and integration of policy related to the program in the cardiac rehabilitation centres. Lastly, based on the annual reports it can be assessed if the desired changes have been achieved (Grembowski, 2015). There are several benefits of the proposed health program. The elements of the program are evidenced based options and its benefits are shown in peer reviewed medical research. Therefore, it is sure to be successful as the elements of naturopathy addresses the needs unmet by routine methods in cardiac rehabilitations.

References

Braun, L., Stanguts, C., Spitzer, O., Hose, L., Gunawan, M., Kure, C. E., … & Rosenfeldt, F. (2014). A wellness program for cardiac surgery improves clinical outcomes. Advances in Integrative Medicine, 1(1), 32-37.

Davidson, P. M., Cockburn, J., & Newton, P. J. (2008). Unmet needs following hospitalization with heart failure: implications for clinical assessment and program planning. Journal of Cardiovascular Nursing, 23(6), 541-546.

Franklin, N. C., Ali, M. M., Robinson, A. T., Norkeviciute, E., & Phillips, S. A. (2014). Massage therapy restores peripheral vascular function after exertion. Archives of physical medicine and rehabilitation, 95(6), 1127-1134.

Grembowski, D. (2015). The practice of health program evaluation. Sage Publications.

Gupta, S. (2016). Relaxation Value of Meditation in Coronary Heart Disease Patients. Health Psychology, 1, 234.

Gupta, S., Das, S., Sahewalla, R., Gupta, D., Gupta, I., Prakash, R., … & Rastogi, R. (2012). A study on quality of life in patients following myocardial infarction.

Jneid, H. (2016). Cardiac Rehabilitation After Myocardial Infarction: Unmet Needs and Future Directions. Jama cardiology, 1(9), 978-979.

Knudsen, M. V., Laustsen, S., Petersen, A. K., & Angel, S. (2014). Lifestyle after cardiac rehabilitation: did the message come across, and was it feasible? An analysis of patients’ narratives. Health, 6(19), 2641.

Kureshi, F., Kennedy, K. F., Jones, P. G., Thomas, R. J., Arnold, S. V., Sharma, P., … & Nallamothu, B. K. (2016). Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction. Jama cardiology, 1(9), 980-988.

Lavie, C. J., Thomas, R. J., Squires, R. W., Allison, T. G., & Milani, R. V. (2009, April). Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease. In Mayo Clinic Proceedings (Vol. 84, No. 4, pp. 373-383). Elsevier.

Melchart, D., Eustachi, A., Wellenhofer-Li, Y., Doerfler, W., & Bohnes, E. (2016). Individual Health Management-a comprehensive lifestyle counselling programme for health promotion, disease prevention and patient education. Forschende Komplementärmedizin/Research in Complementary Medicine, 23(1), 30-35.

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., … & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), 1.

Muramoto, M. L., Howerter, A., Eaves, E. R., Hall, J. R., Buller, D. B., & Gordon, J. S. (2016). Online Tobacco Cessation Training and Competency Assessment for Complementary and Alternative Medicine (CAM) Practitioners: Protocol for the CAM Reach Web Study. JMIR research protocols, 5(1).

Nathenson, P. (2012). Application of holistic nursing in the rehabilitation setting. Rehabilitation Nursing, 37(3), 114-118.

Okonta, N. R. (2012). Does yoga therapy reduce blood pressure in patients with hypertension?: an integrative review. Holistic nursing practice, 26(3), 137-141.

Redfern, J., Hyun, K., Chew, D. P., Astley, C., Chow, C., Aliprandi-Costa, B., … & Nallaiah, K. (2014). Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand. Heart, heartjnl-2013.

Robson, D. (2014). Positive effects of the Mediterranean diet in the prevention and management of cardiovascular disease: a literature review. Journal of the Australian Traditional-Medicine Society, 20(3), 200.

Shafiq, A., Jayaram, N., Gosch, K. L., Spertus, J. A., Buchanan, D. M., Decker, C., … & Arnold, S. V. (2016). The Association Between Complementary and Alternative Medicine and Health Status Following Acute Myocardial Infarction. Clinical cardiology, 39(8), 440-445.

Smolderen, K. G., Spertus, J. A., Nallamothu, B. K., Krumholz, H. M., Tang, F., Ross, J. S., … & Chan, P. S. (2010). Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. Jama, 303(14), 1392-1400.