Beyond Motivation

March 28, 2014

Nancy Hansen Merbitz, PhD

Clinical Assistant Professor

Department of PM&R

University of Michigan

The planners, editors and faculty of this activity have no relevant financial relationships to

disclose.

Learning ObjectivesAt the conclusion of this course participants will be able to:

Describe a variety of medically-related causal factors that can overlap and have cumulative effects on behavior, emotions, thoughts and cognitive abilities

Distinguish that medical and psychological factors are not “either-or”

Identify that a patient’s ability to follow through with goal-directed behavior arises from the highest levels of brain function and can easily be disrupted by factors separate from the person’s baseline personality & desire to get better

To obtain credit you must:

– Be present for the entire session

– Complete an evaluation form

– Return the evaluation form to staff

Certificate will be sent to you by e-mail.

Rush designates this live activity for 1 (one) AMA PRA Category 1 Credit™

Rush University Medical Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Rush University (OH-390, 8/25/2014) is an approved provider of continuing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Rush University designates this live activity for one (1) Continuing Education contact hour(s).

Rush University is an approved provider for physical therapy, occupational therapy, respiratory therapy, social work, nutrition, speech-audiology, and psychology by the Illinois Department of Professional Regulation. Rush University designates this live activity for one (1) Continuing Education credit(s).

Many rehab inpatients come from critical care

Growing evidence of persisting cognitive impairments after critical illness (e.g. ARDS, sepsis)

Pandharipande, P. P., et al. "Long-term cognitive impairment after critical illness." New England Journal of Medicine369.14 (2013): 1306-1316.

Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA 2010; 304(16): 1787-1794.

Many rehab inpatients come from critical care…

Growing evidence of persisting emotional impairment after critical illness (e.g. depression; anxiety, PTSD)

Davydow, Dimitry S., et al. "Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review." Psychosomatic medicine 70.4 (2008): 512-519.

De Miranda S, Pochard F, Chaize M, et al: Postintensive care unit psychological burden in patients with chronic obstructive pulmonary disease and informal caregivers: A multicenter study. Crit Care Med 2011; 39:112-118.

Impact of prior critical care

These experiences have lingering effects on their participation in rehabilitation.

Arousal, alertness

Trust

Mood, emotional regulation

Cognition: Orientation and new learning abilities

This may give rise to questions about their motivation for rehab.

How do we think about “motivation”?

There is a human tendency to lapse into tautology regarding explanations of behavior:

“If the patient did something, he was motivated to do it. If he didn’t do something, he was unmotivated to do it.”

Interestingly, we are less likely to explain our OWN behavior in this way.

A consistent finding from Social Psychology research re our perceptions of less-than-optimal behavior is:

the “Fundamental Attribution Error”.

The Fundamental Attribution Error

When I do something (or fail to do something), it’s due to circumstantial factors, such as “I was tired. I was stressed by others. I have too much going on. I didn’t get enough sleep.”

The Fundamental Attribution Error

When someone else does something (or fails to do something), it is because of his or her motivation.

i.e. various internal factors such as mood, fear, lack of determination, avoidance, poor work ethic, etc.

These may or may not be relevant in a particular case, but the point is, we infer these internal psych factors re: OTHERS’ behavior more than we do re: our own behavior.

Of course our patients do come to us with many psychological factors influencing their behavior.

Their previous personal history converges with their current struggles with dependence and vulnerability,

and most of this takes place in connection with a team of people, formerly strangers, who in many respects become more intimate than family.

This is powerful stuff, which has a great impact on behavior during rehabilitation and beyond.

But today I want to point you toward some factors that are closer to the traditional medical bailiwick, but which can present as problems of “motivation”.

Main ideas for today: #1

The effects of medical conditions, medications, hospitalization, pain, and sleep deprivation on brain functioning can fall far short of “delirium”,

presenting instead as problems with energy, mood, new learning and recall, emotional self-regulation and maturity of coping.

As one pt put it, “It’s like I’m going to therapies with my brain tied behind my back.”

#2

Acute rehabilitation provides a unique, extended opportunity to observe behavior (broadly defined to include learning, moving, interacting with others, expressing emotions) in an environment that is both challenging and supportive.

#3

Viewing problems of behavior as problems in “motivation” may cause us to miss opportunities to improve what we are doing and get better outcomes.

It may lead to overtreatment with psychotropic medications.

#4

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Conversely, viewing behavior over time, as a phenomena in itself, may allow us to discover and correct barriers to optimal functioning, medical or environmental.

Rehab patients’ medical and psychological

experiences are intertwined, not either/or

May have had a long hx of medical problems

With many prior setbacks, struggling to cope w/ decline

May have had an unusual disorder that wasn’t diagnosed for years,

while the pt worried about his/her credibility in reporting symptoms.

May have distrust, anxiety w/ Dr and other medical providers

Medical complications frequently

interrupt rehab participation

One study (Siegler et al 1994) found that, of 1075 patients admitted to rehab, 359 (33.4%) had acute medical complications on rehabilitation considered severe enough to interrupt treatment.

Of the 359 patients, 158 (44%) required an unexpected transfer off rehabilitation.

This may include critical care …

Further analyses revealed major risk factors for complications leading to transfer off-unit:

a primary diagnosis of deconditioning or nontraumaticspinal cord injury

severity of initial disability

number of comorbid conditions

(Siegler, Stineman & Maison, 1994)

Sounds like a lot of our patients …

Nevertheless, we know that pts w/ medical comorbidities can make reasonable gains during rehab …

For example, in a retrospective database review of 175 rehabilitation patients with comorbidities,

Lee, Lee, Date, Zeiner (2002) concluded:

“Except for life-threatening medical emergencies, patients may benefit by staying on the acute rehab unit, where both medical management and a comprehensive rehabilitation program are provided with continuity.”

Given the medical complexity of our patients…

What are some things to keep in mind that may present barriers to optimum participation and benefit from rehabilitation?

How can we avoid the Fundamental Attribution Error in our work with patients?

Given the medical complexity of our patients…

Bottom line: If we ascribe behavior solely to psychological/motivational factors, this can lead to over-treatment with psychotropics,

while underestimating the impact of medical complications & current environmental factors.

Because rehabilitation is so demanding of patient’s behavioral capacities, and because it all takes place under close observation over an extended period of time…

The rehabilitation unit is a goldmine of behavioral data to inform us:

not only about the person’s progress

but about the great sensitivity of the human organism to changes in lab values or medication regimens that may not usually be considered as having a clinical impact.

You know this already, but it’s often overlooked or under-rated…

We’ll see in the clinical example later:

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Behavior (and changes in behavior) can be a highly sensitive indicator, even a prodrome, for medical complications AND for response to medical interventions.

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Rehabilitation places large demands on higher level cognition and coping:

A switch from passive mode to active mode

Learning the names and roles of a large team

Learning how to do activities in a different way

Learning equipment. Learning routes in the hosp.

Being around a lot of people (this may be a big change for some)

Being watched and evaluated

Waiting, and being on the unit’s schedule

Functioning adequately while SLEEP DEPRIVED!

A sample of co-morbidities with greater impact on behavior than you might suppose:

Anemia

Hypo and hyperglycemia

Hypo and hyperthyroid

UTIs

COPD

Hyponatremia

Sleep apnea

and the ubiquitous sleep deprivation

plus medication side effects …

Note: the issue is not just delirium…

Side effects and co-morbidities that are far short of causing frank delirium can significantly interfere with higher level psychological and neuropsychological functions that are required for a good response to rehabilitation.

Plus, could it be that non-severe comorbidities and mild side effects have cumulative, unexpected impact on higher functions?

Anemia

The hypoxic condition caused by even mild anemiacan negatively affect physical function, cognitive performance, mood, and quality of life,

as found in a large community sample of individuals aged 65–84 years, comparing persons with mild anemia and a randomly selected sample of non-anemic controls

Mild anemia was defined as a hemoglobin concentration between 10.0 and 11.9 g/dL in women and between 10.0 and 12.9 g/dL in men.

Lucca, Ugo, et al. (2008)

Hypo and hyperglycemia

Hypoglycemia’s impact on cognition is well-recognized. But also can cause or exacerbate depressed mood and

feelings of anxiety and panic

Less well-known are the effects of hyperglycemia, often experienced acutely by our pts even without h/o diabetes, e.g. Sommerfield, Deary and Friar (2004):

During acute hyperglycemia, cognitive function was impaired and mood state deteriorated in a group of people with type 2 diabetes.

Prior experience of delirium

Patients coming from critical care units may be especially likely to have undergone some episode of delirium.

Jones et al (2001) found that for some, delusional memories persisted and this predicted longer-term, clinically significant anxiety.

Patients who have experienced delirium are more likely to show some degree of long-term cognitive deficit relative to pre-delirium baseline

ARDS: A common pre-rehab admission experience (MANY of our pts)

Hopkins, et al. (2005): Their study, following 74 ADRS pts (w/ no prior neurological disease) for 2 years, found cognitive deficits at hospital DC, 1 yrand 2 yr follow-ups.

ARDS resulted in significant neurocognitive and emotional morbidity and decreased quality of life that persisted at least 2 years after hospital discharge.

They concluded:

The cognitive impairments in the patients with ARDS appear to be under-recognized by ICU and rehabilitation providers.

Education regarding cognitive sequelae after ARDS is needed to enhance referral of patients to rehabilitation, not only for physical debilitation and weakness, but also for cognitive impairments.

Hyponatremia is fairly common in hospitalized patients, especially elderly.

Different published articles describe different levels of hyponatremia associated with symptoms. There can be subtle effects at mild levels of derangement.

Symptoms can be more notable when drop in sodium is rapid versus slow.

In rehab setting we may get a clearer picture of subtle symptoms because of close observation in a demanding environment.

Neurological signs

At different severity levels, there may be:

Mild (125 and 130 mmol/l)

○ anorexia, headache, nausea, vomiting, lethargy.

Moderate (115 and 125 mmol/l)

○ personality change, muscle cramps and weakness, confusion, ataxia.

Severe (<115 mmol/l )

○ drowsiness; seizures, coma

When the cause is SIADH (as was concluded for our Case Example)

SIADH is a clinical manifestation of a wide range of clinical disorders and drug therapies.

Etiology may be medications:

Various literature has pointed to a wide variety of medications, including but not limited to antidepressants, antiseizure medications, quinolones, haloperidol and many others, as well as combinations

(SIADH is also commonly associated with intracranial diseases, particularly traumatic brain injury)

Our patient, Mr. C “An 80+-year-old man with a history of:

coronary artery disease,

chronic systolic heart failure,

type 2 diabetes mellitus,

stage III chronic kidney disease,

hypertension,

hyperlipidemia,

GERD, possible esophageal dysmotility,

depression, and

recent posterior spinal fusion for cervical stenosis.”

He was admitted to Acute Rehab in February from the Neurosurg unit, where his sodium level had fluctuated.

It continued downward after his admit to our unit.

Various measures were taken to correct it, and ultimately these were successful.

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Trend in Sodium Lab Values

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As his sodium went down…

He appeared more lethargic, depressed and anxious.

His minutes of therapy dropped to zero.

Psychotropic remedies were attempted, to no avail, along with ongoing efforts to address his hyponatremia.

He developed swallowing problems as sodium dropped further, and became disoriented.

Discharge to SAR was planned.

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Calendar Days (Sundays numbered)

Therapy Time and Sodium Lab Values Trending Together

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“Tell them I’m not usually like this.

I want to get up. I want to get better.

I’m not lazy. I don’t feel right.”

I just can’t do it.”

Once the etiology of Mr. C’s hyponatremia was determined to be SIADH, he was put on strict fluid restriction plus salt tablets.

Held: diazepam (3/7), and furosemide (3/2 ).

DC’d: citalopram & tamsulosin (3/12).

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Citalo Diaza Trazo Loraz

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Naprox Cipro Furosemide NaCl

Fluidrestrictionremoved

Fluids restricted to500cc

Fluids restricted to 1000cc

Sodium levels rose steadily, and held WNL. Mood, alertness, and minutes of therapy rose as well. Even swallowing improved to “within functional limits”.

Mood, alertness, minutes of therapy and swallowing maintained even as fluid restriction was lifted and furosemide was re-started.

Conclusion was: “SIADH 2/2 medications; likely citalopram, tamsulosin”

He discharged to home with his daughter.

Importance of tracking info related to risk of future delirium

If we have observed acute changes in mental status, this charted information should carry forward for future reference in the pt’s subsequent medical records.

For whatever reason that it occurred, it represents a greater risk for future delirium, which perhaps could be forestalled with closer monitoring of prodromal symptoms.

Questions? Other examples?

Thanks, and you can contact me at nmerbitz@med.umich.edu

Bibliography (not all were cited) Anderson RJ, Chung HM, Kluge R & Schrier RW. Hyponatremia: a prospective analysis of its

epidemiology and the pathogenetic role of vasopressin. Annals of Internal Medicine 1985 102 164–168.

Cox, Daniel J., et al. "Relationships between hyperglycemia and cognitive performance among adults with type 1 and type 2 diabetes." Diabetes Care 28.1 (2005): 71-77.

Davydow, Dimitry S., et al. "Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review." Psychosomatic medicine 70.4 (2008): 512-519.

De Miranda S, Pochard F, Chaize M, et al: Postintensive care unit psychological burden in patients with chronic obstructive pulmonary disease and informal caregivers: A multicenter study. CritCare Med 2011; 39:112-118.

Duppils, G. S. and Wikblad, K. (2004), Delirium: behavioural changes before and during the prodromal phase. Journal of Clinical Nursing13: 609–616. doi: 10.1111/j.1365-2702.2004.00898.

Gankam Kengne F, Andres C, Sattar L, Melot C & Decaux G. Mild hyponatremia and risk of fracture in the ambulatory elderly. Quarterly Journal of Medicine 2008 101 583–588.

Gonder-Frederick, Linda A., et al. "Cognitive Function Is Disrupted by Both Hypo-and Hyperglycemia in School-AgedChildren With Type 1 Diabetes: A Field Study." Diabetes Care32.6 (2009): 1001-1006.

Hopkins, R, Jackson et al. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. American journal of respiratory and critical care medicine 171.4 (2005): 340-347.

Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney Jr LM. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669–76

Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA 2010; 304(16): 1787-1794.

Jackson JC, Hart RP, Gordon SM, Shintani A, Truman B, May L, Ely EW. Six-month neuropsychological outcome of medical intensive care unit patients. Crit Care Med 2003;31:1226–1234.

Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions, and development of acute posttraumatic stress disorder-related symptoms after intensive care. Crit Care Med. 2001 Mar;29(3):573-80.

Lew HL, Lee E, Date ES, Zeiner H: Influence of medical comorbidities and complications on FIM™ change and length of stay during inpatient rehabilitation. Am J Phys Med Rehabil2002;81:830–837.

Lucca, Ugo, et al. "Association of mild anemia with cognitive, functional, mood and quality of life outcomes in the elderly: the “Health and Anemia” study." PLoS One 3.4 (2008): e1920.

Lundstrom M, Edlund A, Lundstrom G, Gustafson Y. Reorganization of nursing and medical care to reduce the incidence of postoperative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci 1999; 13: 193–200.

Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001; 49: 516–22.

McNicoll, L., Pisani, M.A., Ely, E.W., Gifford, D., & Inouye, S. K. (2005). Detection of delirium in the intensive care unit: Comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. Journal of the American Geriatrics Society, 53, 495–500.

Olofsson B, Lundström M, Borssén B, Nyberg L, Gustafson Y. Delirium is associated with poor rehabilitation outcome in elderly patients treated for femoral neck fractures. Scandinavian Journal Of Caring Sciences [serial online]. June 2005;19(2):119-127.

Pandharipande, P. P., et al. "Long-term cognitive impairment after critical illness." New England Journal of Medicine 369.14 (2013): 1306-1316.

Renneboog B, Musch W, Vandemergel X, Manto MU & Decaux G. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. American Journal of Medicine 2006 119 71e1–71e8.

Robinson, T. N., & Eiseman, B. (2008). Postoperative delirium in elderly: Diagnosis and management. Clinical nterventions in Aging, 3, 351–355.

Siegler, Eugenia L., Margaret G. Stineman, and Greg Maislin. "Development of complications during rehabilitation." Archives of internal medicine 154.19 (1994): 2185.

Thomas, R. I., Cameron, D. J., & Fahs, M. C. (1988). A prospective study of delirium and prolonged hospital stay: Exploratory study. Archives of General Psychiatry, 45, 937–940.

Torpy, J. M., Burke, A. E., & Glass, R. M. (2008). Delirium. Journal of the American Medical Association, 300(4), 2936.

Truman, B., & Ely, E. W. (2003). Monitoring delirium in critically ill patients. Using the confusion assessment method for the intensive care unit. Critical Care Nurse, 23, 25–38.

Woo MH, Smythe MA. Association of SIADH with selective serotonin reuptake inhibitors. Ann Pharmacother. 1997;31:108–10