Kidney Disease and Mental Health | Comprehensive Case Management Certification and LCSW CEUs

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@AllCEUS.com Counselortoolbox. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of therapy notes by just using the promo code CEU when you sign up for a free trial at therapynotes.com I'd like to welcome everybody to today's presentation on addressing issues in chronic kidney disease, otherwise known as nephrology social work. I am Dr. Donnelly Snipes and I will be your host. Today we're going to identify the causes of kidney failure, explore the consequences of kidney failure, the impact of mood or concurrent health issues on morbidity and mortality, identify common issues people with chronic kidney disease may experience, and explore interventions to increase treatment compliance. Now, that being said, I realize that a lot of us don't work in a setting typically where we may be working or we the primary presenting issue is one of chronic kidney disease. But as you will learn, it's a lot more common than you might think. Think. And as clinicians, we may be interacting with people who do have chronic kidney disease. It hasn't progressed to the stage where they're needing dialysis or a transplant or what have you, but it is a chronic condition that they're dealing with. One in seven or 30 million American adults have chronic kidney disease and one in three at increased risk. So just let that sit sink in a little bit. Next time you go to a staff meeting, count up how many people are there. If there's 21 people, that means three people in that room may have chronic kidney disease. That is a staggering number. And chronic kidney disease is not something that only impacts older people or only impacts drug users. Chronic kidney disease can be caused by a variety of factors. Early detection can help prevent the progression of kidney disease to kidney failure. As clinicians, we may be doing a biopsychosocial assessment, and when we're doing that assessment, we may become aware of symptoms that may indicate kidney malfunction, if you will, that if we refer somebody to their primary care physician to get their values checked out, then they may be able to identify kidney disease early before it progresses any further. Interestingly, heart disease is the major cause of death for all people with chronic kidney disorder. Now, if you think about kidneys as filtering waste and helping you go to the bathroom, they do a whole lot more. Your adrenal glands are on your kidneys. So when the kidneys start to malfunction, people's blood pressure often goes up and it's difficult to control their blood pressure. This can lead to stroke or heart disease. Hypertension. High blood pressure causes chronic kidney disease, and chronic kidney disease causes hypertension. There is a bidirectional relationship between the two of them. Therefore, if somebody has high blood pressure and you're seeing them for anxiety, maybe then it's important to help them understand the risks of high blood pressure and why. It's important to make sure that they're monitoring it and keeping it under control. And that can also serve as a motivating factor for reducing their stress and anxiety. And also, if you're working with someone who already tells you that they know they've got stage one or stage two kidney disease, it's important to reinforce with them how important it is to keep their blood pressure under control. And since they already have, if they already have kidney chronic kidney disease, it's even more important for them to regularly monitor it. We're going to talk about this in a few minutes. But one of the issues that the Kidney foundation brings up is that a lot of physicians will minimize kidney disease when it's in stage one or stage two because the person is not having to seek out dialysis or get on a transplant list or whatever. A lot of times the physician's recommendations can seem like suggestions. You know, you may want to try to start doing this instead of listen, dude, if you don't make some changes too sweet, you're going to be headed down the path towards dialysis. And it's really important that you not take this opportunity to slow or halt the progression for granted. High risk groups. People that are high at high risk for chronic kidney disease include people with diabetes, hypertension, and a family history of kidney failure. You're going to find out about this doing the biopsychosocial assessment. If you find out about it, it's worthwhile to at least mention to people that this may be an issue. And you're going to learn later on about the effect of chronic kidney disease on nutrition, on neurotransmitter balance, and on mood. Therefore, if you're seeing somebody in your office who has clinical depression and they're at risk, they have high blood pressure, it's definitely worth ruling out kidney dysfunction as well, because no amount of SSRIs is going to fix the kidney dysfunction. If there's something going on there that also needs an intervention. African Americans, because they have a higher rate of diabetes and high blood pressure, are at higher risk for chronic kidney disease, as well as people who are Hispanic, Pacific Islanders, American Indians, and seniors. When we get older, our body naturally starts wearing out, if you will, and our ability to clear toxins from our body starts decreasing and kidney function starts to go down a little bit anyway, just because those kidneys have been around for 70 or 80 years and, you know, even a car is considered antique after 25, I think. But we do want to pay attention to the fact that if you work with a senior population, and I use that term Senior pretty broadly, 65 and over, definitely, but even, you know, younger can be affected by chronic kidney disease. The progression of chronic kidney disease can be stopped or at least significantly slowed. But the literature seems to indicate that if you can stop it before stage four, which is where you start having to go into dialysis because your kidneys just ain't working anymore, then it can often be stopped and the person can live a very long, healthy life. Think about somebody who has diabetes. Diabetes does not necessarily have to progress to. To the point where somebody has to have a pump installed or other interventions. There are ways to halt the progression that provides people with a lot of hope and motivation to do things early on. We do want to continually emphasize the importance of nipping this in the bud, if you will. 30 to 40% people with diabetes also have kidney disease, which they estimate is greater than 2% of the adult population. People with diabetes and chronic kidney disease are more prone to infections and anemia, increasing their vulnerability to acute complications. If you're working with somebody in mental health, one of the things that we know is that mental health issues can keep people from engaging in health and wellness behaviors. You know, they may not be eating as well, they may not be sleeping as well, they may be drinking or smoking or doing other things that can contribute to the advancement of chronic kidney disease. We want to make sure that we're aware of that, that when we do our biopsychosocial assessment, we are considering the impact of diabetes on the potential development of chronic kidney disease. High blood pressure, as we already talked about, causes kidney disease, Glomerulonephritis. I tried practicing that before this class, and I clearly did not get the hang of saying it is a group of diseases that cause inflammation and damage to the kidneys filtering units. That's the nephritis there. Anytime you see itis, that means inflammation. Inherited diseases such as polycystic kidney disease can cause chronic disease. So it could be something. Genetic malformations that occur when a baby is in utero can cause chronic kidney disease. So you may have somebody who, the minute they breathe air, they already have kidneys that are not functioning at 100%. Lupus and other autoimmune diseases can affect the kidneys. Other things that you may see and are really kind of common obstructions caused by problems like kidney stones. If you're working with somebody who has chronic kidney stones, then they are at higher risk for kidney disease. Tumors on the kidneys or anywhere in that urinary tract system can cause a problem if it starts causing a blockage and causing waste to back up and an enlarged prostate gland in men. Also, repeated urinary tract infections. Some of the clients that I've worked with in substance abuse treatment have, because of their reduced immunity and sometimes because of their choices while they were out there actively using, have a history of significant severe and frequent urinary tract infections. Does that mean they're going to get chronic kidney disease? No, but it does mean that they are higher risk because these infections can cause kidney kidney disease. It's worth having them get the panel done. And there's a blood test and a urine test. It's really easy to do. It's not like they have to go in for an MRI or anything. It better safe than sorry. Might as well evaluate that particular biological cause of some of their mood issues and make sure that that's not a current problem. Symptoms. These are the things that we're going to look for when we're doing our assessment. The first four are common to a lot of your mood disorders. Does that mean they have chronic kidney disease? No, not necessarily. However, we do want to pay attention. If they've also got some of these other symptoms, something might be going on. They feel more tired and have less energy than they did a month ago. They have trouble concentrating, a poor appetite, trouble sleeping. Like I said, those are your common mood disorder symptoms as well, though it may just be a mood disorder. If they have low back pain, that can be an indicator. Because your kidneys are in your lower back area, does that mean that it's necessarily always their kidneys? No. You know, I was doing squats the other day and I did a little bit too much weight and now my low back hurts like crazy. It could be something like that or bending over wrong and picking up your kid. There are a lot of ways to hurt your low back. But if we're starting to put all these Symptoms together and you see multiple symptoms coming up. Can't hurt to have the urine test done if they have muscle cramping at night or swollen feet and ankles or puffiness around their eyes in the morning. So all this is, you know, fluid sort of related. The kidneys help regulate potassium levels. When your kidneys are not functioning, your potassium levels can get kind of wonky, which can lead to muscle cramping, the swollen feet and ankles and puffiness around your eyes is fluid retention. And if the kidneys can't clear the fluids, then it's got to go somewhere. Dry, itchy skin. That was one I hadn't known about before. The need to urinate more often, especially at night, Blood in the urine, nausea and high blood pressure. A lot of times people will come in and we're doing our assessment and they haven't ever been diagnosed with high blood pressure before, but they may start complaining about, you know, starting to have recurrent frequent headaches or a constant dull headache, blurred vision, seeing floaties in front of their eyes, or having a pounding in their ears or in their chest. These can be signs of high blood pressure. Can't hurt to go down to the local drugstore and use one of those little cuff machines just to see where their blood pressure is at. If they have never had high blood pressure before, they probably don't have a cuff at home. So they can just go down to, you know, cvs, Walgreens, Walmart, wherever, and use one of those little cuff machines to identify or to assess what their blood pressure is. If chronic kidney disease progresses, it can progress to end stage renal disease. And that's the point in which the kidneys can't filter waste and excess fluid from the body. They're just, they're shutting down. Dialysis mechanically removes waste when the body is no longer able to do so. And it takes three to four hours per session, three days a week. So that's 12 hours just in the session, not counting travel to and from and sitting in the waiting room and all that other stuff. It is a huge time imposition or commitment, however you want to look at it. In hemodialysis, there are two different kinds of dialysis. In hemodialysis, blood travels through a tube and is filtered by an artificial kidney in center. Hemodialysis is done three times per week in a clinic setting. It can be done at home. In peritoneal dialysis, a solution is administered through a catheter in the abdomen and is later removed. Peritoneal dialysis and home hemodialysis can be done at a time and a location chosen by the patient. Not everybody is comfortable setting up home dialysis. It may be more than they can handle cognitively or emotionally. If it can be done at home, then obviously that saves a little bit of time for the person and provides a little bit more comfort for them because they can be in their own easy chair or wherever. The functions of a nephrology social worker include psychosocial evaluation and treatment planning Counseling and conferences with patients, families and support networks Discharge planning Group work including psychoeducation self help, emotional support, whatever you would normally do Groups on information and referral Facilitation of community agency referrals Team care Planning and collaboration Advocacy on the patient's behalf within the setting and the appropriate local, state and federal agencies and programs Patient and family education. A nephrology social worker has a lot to do and it's not necessarily required or whatever word you want to use to wait until somebody is in stage, the end of stage three or stage four before a social worker is involved. It is really very helpful if a social worker or a case manager or a clinician gets involved early in the process. As soon as chronic kidney disease is identified, even if it's only stage one, it is really important to educate the person and the family and make plans for lifestyle changes that may thwart the progression of the chronic kidney disease and to address emotional and psychosocial issues surrounding getting a diagnosis of chronic kidney disease. It's really scary when you hear chronic kidney disease. A lot of people think oh my gosh, dialysis. And for a lot of people, if they get early intervention, it doesn't have to get to that point. Problems addressed that we may see in people who have chronic kidney disease, adjustment to the chronic illness and treatment as they relate to quality of life. People who have chronic kidney disease may not be able to do some of the things that they used to do. Maybe they used to go out for happy hour three, three days a week. That's probably not going to be the best choice anymore. When they are in stage one through three, they are not going to dialysis. So there is less less change in their activities and friendships. However, they may get tired more easily. Those 8 mile hikes or 20 mile bike rides may be out of the question now and there may be some restrictions on their activity because intense exercise can put a lot of strain on the kidneys. It's going to be important to help the person talk openly with their primary care provider or their kidney provider to know what Their restrictions are and what they can and can't do. Once they progress to the stage of dialysis, then that's, as I said earlier, at least 12 hours a week. Probably more involved in setting up, going through dialysis, you know, cleaning up after dialysis, all that kind of stuff. That's a lot of time. And as the kidney disease progresses, the symptoms of fatigue and malaise and difficulty sleeping and pain, those will start increasing, which can also prevent people from engaging in things that they used to really enjoy doing. There are some basic functional issues, if you will, that people who are going through dialysis in clinic may need to have help with getting assistance with transportation. Not everybody can drive themselves, either because it's too far away or they don't have a license or they are on medications that make it difficult to drive. There's a lot of reasons why someone wouldn't be able to drive themselves. Childcare needs. If they're doing in clinic dialysis and they have, you know, three children at home that are not in school, maybe they're, you know, really young children, then they may need somewhere for their children to be while they are getting their dialysis. As I've mentioned multiple times, fatigue is something that we can help them look at. We can help them look at their quality of sleep and make sure that's happening, but also help them learn how to pace themselves now, because with this disease, they are potentially going to get fatigued easily. Does that mean they can't exercise anymore or they can't garden anymore, whatever? No. But what we do want to look at is what kind of modifications may we need to help this person identify so the fatigue doesn't prevent them from engaging in meaningful life activities. Interestingly, age, employment and finances were significant predictions of adjustment issues and treatment compliance. People who were older in their age as well as younger in their age tended to have worse adjustment, but especially the people, interestingly enough, who were younger. People who are older kind of expect their bodies to start, you know, having problems here and there. But if you have a child or a know young adult get a diagnosis of chronic kidney disease, that can throw them for the loop. Employment levels are also predictors. Those who are unemployed start thinking, oh my gosh, how am I going to pay for this? What am I going to do? Those who are employed start thinking, oh my gosh, how am I going to get this time off from work so I can go to dialysis, etc. Remembering. And I'm kind of trying to go back and forth between stage one, two and three and Then stage four and five, people who are employed and in stage one, two and three are going to have some fatigue issues and some other issues. Go on to the JAN network, the job accommodation network, and identify reasonable accommodations or work with a rehabilitation counselor to identify reasonable accommodations for them to be able to maintain employment despite starting to get more fatigued and potentially having a lower immune system. And finances are also predictors of adjustment issues. If people don't have enough money, or if they're worried that they're going to lose their job, and then they're not going to be able to pay their house, their mortgage, or their childcare, whatever it is, then they're going to have a lot of extra stress. All of these things can contribute to people's grief, shock, anger, and adjustment issues. The perception of an illness, rather than the actual symptoms themselves best account for adaptation to chronic kidney disease. If somebody gets chronic kidney disease and they have the perception that, okay, this is something that has happened, it's not something I wanted, but there are things I can do to slow the progression. If they feel empowered, if they feel hopeful, then they are going to adjust a lot better than if they get this diagnosis and they don't understand what's going on and they just automatically start teleporting to dialysis and kidney transplant. We want to help them, using cognitive behavioral strategies, have a realistic perception of their illness and the stage that they're at. That's really increasing a lot of health literacy surrounding chronic kidney disease. We also need to help them prevent concurrent issues. Chronic kidney disease is regarded as a non traditional risk factor for stroke. Severe sleep apnea, chronic inflammation and malnutrition. We're going to talk about why some of those are problematic in a minute. But let's just start with stroke. When people have strokes, then the brain is deprived of oxygen for a certain period of time, which we know is correlated with cognitive dysfunction. Sleep apnea keeps people from getting enough sleep, and we know that's connected to depressive symptoms as well as fog and difficulty concentrating. But during sleep apnea, they actually stop breathing for short periods of time. That can increase their risk of stroke and it can also again, increase cognitive dysfunction because of a lack of oxygen access. Chronic inflammation has been linked to the development of depression in multiple studies, which we know that if they've got chronic inflammation and kidney disease, their outcomes are significantly worse if they also develop depression on top of it. We want to help them address their inflammation. And malnutrition is a side effect of chronic kidney disease. Neuropsychiatric conditions, including depression, anxiety disorders and chronic and cognitive impairment are prevalent in patients with chronic kidney disease. And a lot of times it's caused by the chronic kidney disease. The most common hypothesis is based on the occurrence of cerebrovascular diseases. Anything that prevents the brain from getting enough oxygen and accumulated toxins in adult patients with chronic kidney disease. Basically, chronic kidney disease can make the brain's environment less hospitable for functioning. Inflammation is a common feature in brain and kidney lesions. When somebody has kidney cysts or kidney diseases, this increase in inflammatory cytokines contributes to the development of depression. As inflammation goes up, depression also goes up. We want to help them figure out how to manage that as best as possible. Another interesting fact is that adults with chronic kidney disease exhibit alterations in tryptophan metabolism. Tryptophan is the amino acid, which is a protein that has to be broken down into in order to make serotonin. And serotonin is broken down to make melatonin. You have to get tryptophan from your diet. Therefore, since tryptophan metabolism is disrupted in people with chronic kidney disease, you can see where we're going with this. They may not have adequate amounts of serotonin, which can contribute to depression and anxiety, and they may not have adequate amounts of melatonin or which can disrupt sleep, which intensifies depression and anxiety. Alterations in tryptophan metabolism have been associated with various neurological and psychological disorders, including depression, anxiety and a decline in cognitive functioning. Suicide rates are 10 to 400% times higher in people with chronic kidney disease. Wow, that's a big number. That's a big range too. It's important to pay attention to our clients level of hope and optimism and suicidality, especially if they have concurrent chronic conditions. Mood, they have found, is a superior predictor of the physical and mental components of health related quality of life in patients compared to the number and severity of physical symptoms. People who may have, you know, 12 symptoms and be handling it, be very resilient and coping well and perceive themselves to have a really good health related quality of life, whereas somebody else may have 12 symptoms or four symptoms. Let's go with that. They may have four symptoms, but be depressed and angry and resentful and hopeless, they are going to perceive their health related quality of life as much worse. We want to look at mood more than we do the number of symptoms somebody has, how are they coping with it? What is their level of hardiness and resiliency? We want to highlight the importance of assessing negative emotional states to Reduce the impact of chronic kidney disease on health related quality of life. This is more, these are more interventions we can do that are cognitive in nature as well as psychosocial in nature. What can we do? What is it that is making you feel unhappy right now? You know, what are you angry about? What are you depressed about? What are you hopeless about? And let's start targeting those sorts of things to help you improve your mood. We can also look at other aspects of somebody's mood. When somebody's depressed, a lot of times they're experiencing a lot of fatigue. Okay, well if they are experiencing fatigue, maybe they want to focus on that. Maybe they would just really love to have more energy. They could deal with all this if they could get through the day without having to take a nap. Okay, let's talk about how that might be able to happen. We're going to have to work with the rest of the team to make that happen because we're not doctors or kidney specialists. But we can help the person figure out ways to feel empowered and hopeful. Depression and poor quality of life affect adherence to rigid dietary restrictions and medication regimens. If you go online and you look at the dietary restrictions, for somebody who, especially people who have advanced chronic kidney disease, there's a lot of stuff they can't eat. I was looking through, I was like, I don't know what I would eat. Therefore, a lot of people who are depressed or have a poor quality of life, they're just like, screw it, I am going to eat what I want and do what I want. And if that means that I die sooner, I do. We want to help them maybe challenge some of those cognitions and figure out ways to can conform to the rigid dietary restrictions and medication regimens in a way that doesn't as severely negatively impact their life. The most commonly used tool to assess depression and health related quality of life is the Kidney Disease Quality of Life Survey. Go figure. Improvement in the kidney disease quality of life increase the chance of being listed for a kidney transplant which is associated with better outcomes. Obviously this is for people who are in stage four or five. However, this is a really strong motivator if we can help them. See, in order for you to really to be more likely to make it onto this transplant list, we need to get your kidney disease quality of life score up. So what can we do? How can we work together? Because I really want to help you get on this transplant list. Those undergoing hemodialysis showed more depression and worse physical well being, occupational functioning, spiritual fulfillment and more health interference. With work than transplant patients. Well, you know, that kind of makes sense. Once somebody has a transplant, they are on some really intense anti rejection medications. However, they're not having to do the 12 hours a week plus of hemodialysis. And a lot of times, once they have that new kidney, they have this renewed sense of hope. It's like I made it through the worst part. I came out the other end and there's optimism and a sense of being encouraged. We want to help people on hemodialysis see that light at the end of the tunnel and identify anything during the hemodialysis period, during the stage four that we can help them address that can improve their physical well being, occupational functioning and spiritual fulfillment and overall health. Transplant patients, though receiving the immunosuppressor sirolimus, exhibited more cardiac, renal, cognitive and physical limitations than the rest of. Despite the fact that they're on these immunosuppressant drugs, they still seem to have better quality of life than those that are on hemodialysis. We do still want to recognize though, that once they get their transplant, it doesn't mean they're done, they're out of the woods. We do need to recognize that there are side effects to these really intense medications. The dialysis type correlated positively with sleep disturbances and depression scores and negatively with total quality of life. Hemodialysis patients, the ones that have the blood, and it's generally done in the arm and it can be done in the office or at home. Hemodialysis patients experienced more distress than peritoneal dialysis patients. Peritoneal dialysis patients, if you remember, are the ones who get dialysis through their abdomen. One of the reasons they speculate this might be is because there is a fistula that is made without going into great detail right now on a person who is undergoing hemodialysis, that is obvious. You know, you can see it and it's a constant reminder to the person that they are dealing with chronic kidney disease. They the peritoneal dialysis, at least that's under your clothes, so it's not as present and other people really can't see it. It's not like somebody when you're out shopping at the grocery store is going to go, what's going on with your, with your belly because you've got a shirt over it. Other problems include emotional issues and this may not fall into clinical depression. This may be more adjustment issues. But people experience grief, resentment, and feeling overwhelmed when they receive their diagnosis of chronic kidney disease. Most of us we don't want to get some sort of chronic diagnosis or any diagnosis for that matter. There is a grieving process that people have to go through because their life is not going to be exactly the same anymore. There's treatment related fatigue, we already talked about that. We may need to help them address. People may need to rearrange their lives to accommodate treatment and that can be really frustrating. If they have to go to dialysis three days a week and they have to figure out how to work their job around that, you know, that's basically adding a part time job on top of a full time job. And if you have kids and soccer and everything else on top of that, it can feel very overwhelming. There's potential concerns about body image, such as the arteriovenous fistula, which is noticeable and an ever present reminder. Some people, if they get a kidney from a deceased donor, experience grief and sadness at knowing that they've got a part of somebody in them that that person was not able to live. And there's also anxiety about having to learn about the equipment and treatment protocols. And the equipment can be everything from blood pressure monitoring that they have to do multiple times a day to home hemodialysis. There's a wide range of things that people may or may not have to learn how to deal with. There can be problems related to treatment options or setting transfers. Somebody may want home hemodialysis and for some reason they can't have it, or they have been getting in clinic hemodialysis and they are given the go ahead. For home hemodialysis, there needs to be a gradual handoff to make sure the person's comfortable with that setting transfer. Resource needs, including finances, living arrangements, transportation and legal issues may need to be addressed. All of these things we're addressing, yes, they seem to be wraparound issues or ancillary issues, but they all contribute to stress, anxiety and depression if they are not dealt with. And people may need assistance with figuring out how to make decisions regarding advanced directives. And that's always a big issue, especially if you're dealing with a physical chronic condition that may progress to the stage of being fatal. Chronic pain management 60 to 70% of patients with advanced and end stage kidney disease often have chronic pain. Serotonin is one of those neurotransmitters that helps modulate our pain perception. When our serotonin is low, our pain perception or our pain tolerance tends to be lower. Even in the earlier stages of chronic kidney disease, if there is a disruption in serotonin levels, you may have someone who is experiencing more chronic pain. As kidney disease progresses, there is more chronic pain as that kidney shuts down. And when toxins start building up in the body, it has a ripple effect on the rest of the organs. Increased drug levels and associated adverse effects may occur due to reduced renal clearance and development of toxicity due to reduced protein binding associated with hypoproteinemia, hypoalbuminemia, or acidemia. We don't need to know all the specifics there. We do need to know that people who are taking medications often and have chronic kidney disease often will need different levels than people who have chronic kidney disease. You also have to consider if they're in dialysis, that the level of the drug in their system, the concentration of the drug in their blood, may be different if they're going through dialysis. So you have to figure out how much dialysis pulls out and compensate for that or the doctor does. Opioids are contraindicated until the pain is in its source state. For a lot of reasons, but partly because opioids can be really hard on the kidneys. Codeine and hydrocodone are specifically not recommended. And you can read more in this article here about pain management if you're really interested. But I found it interesting because codeine, at least when I was a kid, I don't know what it's like now, but cough medicine with codeine was not uncommon to be prescribed for kids. When I was pregnant with my son, I had this persistent cough and the doctor ended up prescribing cough medicine with codeine. Had I had some sort of kidney problems, that wouldn't have been able to happen. But it's important that if people are taking medications, they're aware of their functioning of their kidneys and liver and all that other stuff. Methadone may actually be recommended in cases of severe pain, which doesn't respond to other interventions. Apparently the impact of methadone on the kidneys is less intense or whatever word you want to use, than others. And methadone is not like some of our over the counter opioids that have Tylenol in them. And Tylenol is really hard on your system. Nutritional deficiency complications include high mortality, increased risk of atherosclerosis, inflammation, oxidative stress, anemia, polyneuropathy, encephalopathy, weakness, fragility, muscle cramps, bone disease, depression, or insomnia. Sound like I just told you about the side effects of a drug, doesn't it? We want to be aware of that. Even when we're Working with a client who is in stage one or stage two with chronic kidney disease because we don't want it to progress. Just like we talked about in the class on psychosocial aspects of bariatric surgery, alterations in the digestive system can have pretty far reaching complications in chronic kidney disease. Nutritional deficiencies develop for several reasons, including dietary restrictions. Like I said, there's a lot of stuff on that list that you can't eat anymore. Loss of appetite, medication side effects, impaired intestinal absorption, age, and the use of diuretics or dialysis. All of these things affect your body's ability to break down foods to extract the nutrients and then absorb those nutrients. Specific deficiencies common in patients with chronic kidney disease include vitamin C, which is one of our immunity vitamins, thiamine. When we talked about, again, bariatric surgery, as well as substance abuse, substance induced cognitive issues, we talked about Korsakoff syndrome. A deficiency in thiamine can cause dementia like symptoms. It can cause what they call alcohol related dementia. But they're finding that that syndrome, Korsakoff syndrome, is present in people who've had bariatric surgery, people who are anorexic, and people with chronic kidney disease with. You don't want to assume just because your patient doesn't drink alcohol that their thiamine levels may not be a problem. So if your clients start showing signs of cognitive dysfunction, get their thiamine levels tested. It's going to be really important. Vitamin B6, folic acid, zinc and selenium are also potentially deficient in people with chronic kidney disease. Vitamin B6, folic acid and zinc are necessary for the body to break down tryptophan to make serotonin. You can see where we're going from here. Iron deficiency anemia is also common in patients with chronic kidney disease. If you've worked with patients with iron deficiency anemia or had it yourself, you know that that can also. That can often look like clinical depression. This is another one of those things that you want to rule out if you think there might be a chance that your client has kidney disease. Have that tested. If you think there might be a nutritional component to their mood issues, such as iron deficiency, which can be caused by a lot of things, not just kidney disease, have that tested. It's so easy to do and can provide rapid improvement to clients if they can get their nutritional issues, you know, kind of balanced out so their body has the building blocks it needs to help them feel happy and whatever sleep disturbances were found in 36% of patients with chronic kidney Diseases they speculate partly because of pain, partly because of having to urinate more during the night, and partly because of insufficient melatonin. And it kind of depends on the patient and the level of their kidney disease, what might be causing it if they're not sleeping well. We know that sleep disturbance and inadequate quality sleep contributes to depression and cognitive decline. So we need to intervene here. This is one of those easier things to intervene on compared to some of the cognitive stuff for a lot of people. Among caregivers, people with chronic kidney disease often do not live by themselves. And the term caregivers, I'm using sort of broadly, family members, significant others, whatever term you want to use. Among caregivers, 33% have anxiety or depression caregivers. And this is especially true for people who are in stage four, where they're getting dialysis all the time, or stage five, where they're on the, on the transplant list. Those caregivers report insufficient practical social support. You know, what do I do? How do I make this happen? How do I juggle my life? Where do I find resources? And only moderate levels of emotional social support. There's a lot to deal with when you're watching your loved one struggle and watching their kidneys start to fail. 14.3% reported being extremely tired pretty much all the time. And about 70% reported that they were unable to engage in all of the activities that they usually performed before the patient's illness. This can contribute to some resentment and other things. Results confirm that the interrelationship between caregiver burden and depression is pretty strong. If we can help people who are, if they're having to take on that caregiver role, if we can help them still maintain some sort of normalcy to their life, it is going to improve their mental health. When they don't feel as burdened and depressed, it's going to likely have positive effects on the patient. Interventions Knowledge is the first thing. Knowledge is power. Knowledge includes understanding how the kidneys function and recognizing symptoms associated with disease progression. With this often increases treatment participation. Once clients understand, okay, this is what it does, this is why, you know, I started having these symptoms, this is what I can do to start feeling better. It's like, well, okay, you know, let's make it happen. We need to educate patients early in their disease process regarding how blood pressure self management may delay complications such as heart disease associated with chronic kidney disease. Remember, heart disease is the number one killer of people with chronic kidney disease. If we help people be aware of and manage their blood pressure and Understand the connection, understand why this is important, because a lot of people are like, well, what does blood pressure have to do with my kidneys? A lot. Help them understand this. Chronic kidney disease literacy, coping with anxiety, prerequisites for self management and rep reciprocity in information provision are all things that help people become more literate in how to manage their disease. A lot of times, participants, clients, whatever you want to call them, fill deficiencies in their knowledge with misconceptions and half truths about causes, symptoms and treatment. That is they went on the Internet and googled it. We want to make sure that they understand what their condition is, what level their issue is and what unique factors apply to them. Anxiety about chronic kidney disease at the time of diagnosis versus the feeling of irrelevance later was often due to the absence of chronic kidney disease symptoms and physician minimization of the seriousness of chronic kidney disease. People initially get that diagnosis and they get really anxious and then they're like, well, I'm not feeling any symptoms and my doctor doesn't seem to be making a big deal about it. So, you know, whatever. It's important that we don't let that happen. We need to help people see that, okay, you may not be feeling it right now, let's keep it that way. Patients often fail to connect lifestyle and cardiovascular disease with chronic kidney disease. Chronic kidney disease literacy and willingness to change are both necessary to accept the pretty dramatic lifestyle changes that are often required even for people in stage one or stage two. Self management skills, including problem solving, decision making, action planning, goal setting, and improving that patient provider partnership. Resource utilization is central to improving adherence to daily self management behaviors. Well, there's so much stuff in there. Self management is really going to be individualized to your client. What they need to know. Some of the general things that they may need to understand is what nutrients are hard on their kidneys like phosphorus, potassium, sodium, so they can start reading food labels and gearing their diet towards what is more beneficial for them. They need to know about sleep hygiene, stress management, how to enhance communication between them and their healthcare providers because sometimes providers can be off putting. It's important for us to help people understand how to self advocate and we want to educate them about their medications, compliance with those medications and disease monitoring. Sometimes people with chronic kidney disease, especially if they've already got high blood pressure issues going on, may have a lot of medications or it may feel overwhelming and cumbersome. We want to help them figure out how to manage all that so they can comply with their treatment plan. And prevent progression. Confidence or self efficacy increases over time and is associated with positive health outcomes. When people have more confidence that what they're doing is going to make a difference, they are more likely to modify some of those risk factors if they see the connection. When they have confidence that what they're doing is going to make a difference, that they kind of goes along with hope. It improves physiological and psychosocial functioning if they don't feel defeated and hopeless. And confidence also contributes to improved self management behaviors and medication adherence. They see a purpose for what they're doing. They see the benefit. They actually experience the benefits for what they're doing. Just as an aside, the promis, which is the Patient Reported Outcome Measurement Information System or promis, measures depression, anxiety, social, peer relationships, pain interference and mobility and is sensitive to the clinical status of people with chronic kidney disease. This is one of the measures that's available at Health Measures. This was a little gem I found when preparing this class. You can use it in order to monitor these things in your client and kind of develop that service plan. Health Measures is a website that has four precise, flexible and comprehensive measurement systems that assess physical, mental and social health symptoms, well being, life satisfaction, and sensory, motor and cognitive functioning. All of these instruments are available to you, my understanding is for free and it has the scoring information. A lot of it is sponsored by the National Institute of Health. So if you're in a private practice or in a small clinic that can't afford some of those really expensive tools, you definitely check out this website. But I digress. Mood and health related quality of life are significant predictors of outcomes in people with chronic kidney disease. We know that chronic kidney disease can cause biological or physiological alterations that can negatively impact mood. But we also know that mood can negatively impact, you know, health related quality of life. Finances, employment and social support are significant predictors of mood and quality of life. Let's trace that backwards. Finances, employment and social support. If we have those under control in general and the person's happy and comfortable with where things are at, they're likely to have a better mood. If they're likely to have a better mood, that's going to lead to a higher health related quality of life and and better outcomes. So score clinicians working with people with chronic kidney disease should identify and address perceived obstacles to health related quality of life. So you're fatigued more often and you can't play with your dog as much. Whatever the obstacles they see or the barriers they see to doing what they want, the barriers or obstacles to Their rich and meaningful life, so to speak. Let's look at those and see how we can mitigate those obstacles. So you can still do the things that you love doing. You may just not be able to do them as intensely. If you are a marathon runner, you may only be able to walk 5 miles now instead of running 24 or whatever it is. We want to enhance client and significant other knowledge about chronic kidney disease. Even if they're in stage one or two and their significant other hasn't taken on a caregiver role yet. We want all of the people in the family to understand what this is, what modifications may be necessary so everybody's on board and can provide support and encouragement and understand why the patient has to do some of the things they have to do. We want to empower people to take active steps towards disease prevention and self management by increasing their health literacy and reducing their treatment related anxiety. Help them address that early on anxiety and if they get to the point where they're in stage four and they're going to have to have dialysis, help them reduce the anxiety related to that and the potential complications. Finally, we want to highlight successes to increase their efficacy. Sometimes we don't see the successes when they're really small and we're just, we're living them. We want to help people highlight those successes to see that, okay, you made these changes and yes, you still can't run a marathon, but look, you were able to go out and walk for an hour last week and help them start seeing that, you know, maybe three out of the last seven days they had more energy than they did the past week and start working that up. So you have seven out of seven days. There are a lot of things we can do to help people that have chronic kidney disease. An awareness of what contributes to it is really important. But as I said at the beginning, as mental health clinicians, if somebody comes into our office and starts talking about things that may, it may indicate symptoms of chronic kidney disease. Can't hurt to have it tested. A lot of times this isn't necessarily something that is tested for in a general physical, but people can certainly ask for it to be done because two of the three things that are measured come from a simple urine screen and how much protein is in the urine and something else. And then the other one comes from blood. And I know when I go get my physical they always draw more than enough blood to, you know, run any test they could possibly want. If somebody is at risk for some reason, then hopefully their insurance would also Cover it. In response to Pat's question about sugar numbers, I have no idea of the effect of chronic kidney disease on people's sugar levels when they have diabetes. I would think it would alter their sugar numbers. And Matt, in response to your comment, I would love it if more people were trained to always consider physiological causes or contributors to mood and cognitive issues first. Most programs that I'm aware of, including the one that I graduated from, don't even touch on physiological causes. And yes, I know in the DSM it always says it can't be better explained by a general medical condition, but most of us, at least back in the day when I went through graduate school, we weren't even told that there may be other contributors that hadn't been diagnosed. I would love it. It would just make my year if more people really started encouraging their clients to get a physical. If they're coming in and they've got anxiety or depression or cognitive decline in some way, shape or form, go to the doctor, get a physical, have them, you know, test your, your blood pressure, listen to your heart, make sure that there's nothing, as I say, easy, but nothing physiological that can be addressed, which may provide rapid improvement. We also know that alterations in sex hormone levels, estrogen or testosterone can contribute to mood issues when we also know that thyroid hormone levels can contribute to mood issues. But there's a lot of stuff that a medical doctor can test for, screen for, rule out in order to help us hone in on what may be contributing to somebody's current level of distress. And Angela pointed out that there's a huge increase in suicidality in people who have chronic kidney disease. And I will have that dovetail on what I said before about the fact that most mental health clinicians, the programs that we went through, really didn't talk about any, any of the medical issues. Now social workers have, you know, somewhat of a different curriculum. Rehabilitation counselors we did have medical aspects, but a strict CACREP approved mental health counseling program often doesn't touch on a lot of the medical issues. So that may go unnoticed or unmentioned. Alrighty everybody. Thank you for being here today and I will see you on Thursday. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com all podcastce that's allce.com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to Allce. Com sponsor. Thank you.