Behavioral contracting to improve dietary compliance in chronic renal dialysis patients

OCXX-7908/81/010063-05 $02.00/O !? 1981 Pergamon Pres Ltd.

J. Behav. Thu. & Exp. Psychrut. Vol. 12, No. 1, pp. 63-67. 1981 Printed in Great Britam.

BEHAVIORAL COMPLIANCE TERENCE Veterans

CONTRACTING IN CHRONIC

M. KEANE, Administration

DONALD

TO IMPROVE DIETARY

RENAL DIALYSIS

M. PRUE and FRANK

Medical Center and University

PATIENTS

L. COLLINS,

of Mississippi

JR.*

Medical Center

Summary-End stage renal disease is the most severe stage of kidney failure. Hemodialysis or kidney transplants are required to insure patient survival. When dialysis treatment is used, patients experience dietary restrictions and consequently must limit fluid and food intake to compensate for the lack of kidney functioning. Two case studies are presented to demonstrate the effectiveness of behavioral procedures in improving compliance to dietary restrictions in chronic fluid overloaders. A contracting procedure between medical staff and the patients, and contingent staff praise for meeting weight standards, led to lower intersession weight gain. Continuous follow-up assessment indicated long term maintenance of treatment effects for these patients.

matically evaluate treatment of the dialysis patient for fluid overloading. There are two noteworthly exceptions. Hart (1979) reported the establishment of a token economy program on a dialysis unit to promote dietary compliance in outpatient subjects. Subjects received tokens for reporting to sessions within 5% of their dry weight. Tokens could be exchanged for shorter dialysis sessions, canteen booklets or hot meals. Over a 7 week period (three baseline, four treatment) 10 volunteer renal patients showed a decrease in their intersession weight gain. However, there were no follow-up data reported and consequently it is difficult to determine the longterm efficacy of this intervention. Furthermore, subjects in the Hart study were not chronic fluid overloaders. Barnes (1976) described the inpatient treatment of a renal patient with a history of chronic fluid overload. In this study the introduction of a token economy program decreased fluid weight gain while the patient remained hospitalized. In addition, Barnes (1976) reported 6 month follow-up data that indicated continued decreases in weight gain.

Chronic renal failure is the inability of the kidneys to adequately cleanse the blood of waste and other foreign matter. Recent advances in the artificial cleansing of the blood, hemodialysis, have greatly improved the prognosis for this disease. For the patient, dialysis treatments mean a radical change in life style to accommodate the thrice weekly dialysis sessions and the dietary restrictions placed on the patient. Specifically, the dietary restrictions for these patients include reduced fluid, potassium and sodium intake. Failure to comply with the dietary and fluid intake restrictions can lead to fluid overloading which can result in pulmonary edema and increased hypertension. Previous research efforts have been directed toward identification of the personality characteristics of successful and unsuccessful compliers to the dialysis process (Burke, 1979; KaplanDeNour and Czaczkes, 1972). In addition, a number of studies have outlined the psychosocial problems of the dialysis patient (Cole, Stelzer, Bayersdorfer, 1979; Flannery, 1979). However, there have been few reports in the literature which delineate, conduct and syste-

*Frank L. Collins is now at West Virginia University, Morgantown, West Virginia. Requests for reprints should be addressed to Terence M. Keane, Director: Behavioral Medical Center, 1500 E. Woodrow Wilson, Jackson, Mississippi 39216, U.S.A. 63

Consultation

Program,

V. A.

64

TERENCE

M. KEANE. DONALD

M. PRUE and FRANK L. COLLINS,

Unfortunately, these data were confounded by training in home dialysis which occurred after hospitalization but before follow-up. The present study examined the long-term effects of behavioral techniques with two patients with extensive histories of fluid overloading. The interventions were implemented by the dialysis staff with the clinical psychologist operating on a consultative basis to the Kidney Disease Unit. CASE 1 Method Subject. Nora was a 54 yr old, obese (wt = 76 kg, ht = 165 cm) black female with a 9 yr history of renal problems. Nora’s kidney failure was associated with a long history of uncontrolled hypertension. The patient’s chart documented an extensive history of noncompliance to her dietary regimen. Dependent variable. Intersession weight gain, an indirect but highly correlated measure of dietary compliance, was the variable of direct medical interest. Dry weight was routinel) obtained prior to and following each dialysis session. Intersession weight gain was computed by subtracting the patient’s post-dialysis weight from pre-dialysis weight at the next session. Weight gain had been routinely gathered by the kidney treatment unit and Terved as baseline measurement.

Criterion. Nora was given two criteria for intersession weight gains: 2.5 kg for Monday sessions and 1.5 kg for Wednesday and Friday sessions. These weights were determined by the medical staff on the basis of number of days between dialysis sessions and were deemed as acceptable intersession weight gains for this particular patient. Treutment. A behavioral treatment program was implemented with Nora following the baseline calculation of weight gain for a nine week (29 session) period. The treatment (25 sessions) included (a) staff praise and social interactions contingent upon meeting criterion, (b) patient graphing of intersesrion weight gain and (c) a behavioral contract between

JR.

Nora and the nursing supervisor. The contract stipulated that Nora would be scheduled for morning dialysis sessions contingent upon meeting her weight criterion for 10 of 12 consecutive sessions. Staff changes following week nine of the first treatment phase led to a natural return to baseline conditions. More specifically, the primary care nurse, who controlled many aspects of treatment, was transferred to another unit. This coincided with a change in the psychologist working on the case. Thus, the treatment program was totally withdrawn within a period of three sessions. The second baseline period (32 sessions) did not involve any contingencies for the patient, however, she still retained the morning dialysis sessions. A treatment program was again instituted for this patient. This time maintenance of the morning schedule was dependent upon meeting the criterion weight gain for 10 of the 12 sessions. Thus in operant terms, this second treatment approach emphasized response cost or punishment procedures. Results Figure 1 presents intersession weight gain for Case 1 for consecutive dialysis sessions. During Baseline 1, Nora attained her criterion weight 79% of the time with a mean intersession weight gain of 2.15 kg. When the contract was implemented, the patient reached criterion at a rate of 88%, with a mean intersession weight gain of 1.42 kg. This change was statistically significant, t(52) = 3.01, p < 0.01. Returning to baseline, the patient reached criterion only 74% of the time with a mean weight gain of 1.96 kg. Reinstituting the contract resulted in a 91% success rate at a mean weight gain equal to 1.45 kg. Again this change was statistically significant, t(66) = 4.06,p
CONTRACTlNG 793%

Under

goal

88%

Under

goal

WITH DIALYSIS 74

PATIENTS

I% Under goal

906%

65 Under

goal

6

0 BASELINE

CONTRACT

BASELINE

CONTRACT

. = NEW PRIMARY CARE NURSE Fig.

1. Intersession

weight gain in kilograms

history of renal problems secondary to diabetes and hypertension. The patient had been on hemodialysis for the previous 4 months and during that time his intersession weight gain was typically uncontrolled. This patient we also scheduled for three weekly dialysis sessions. Dependent variable. As with Case 1, the dependent measure of interest for this patient was intersession weight gain. Dry weight was procured immediately before and after all dialysis sessions. Criterion. A criterion of 3 kg weight gain for Wednesday and Friday sessions and 3.5 kg for Monday sessions was determined by the medical staff in light of the patient’s history of noncompliance. Treatment. An interview with the patient revealed that despite a knowledge of how to control fluid intake, the patient had not been compliant with fluid restrictions. Thus, an attempt was made to identify consequences that could be manipulated to increase dietary compliance. Discussions with the dialysis staff revealed that meal content was a potentially powerful reinforcer for Billy Bob. Since the patient consumed breakfast at the Medical Center, it was possible to offer the patient highly palatable foods in return for reaching

for Case 1 (Nora).

criterion. Specifically, the patient reported a preference for salt, hot cakes, bacon, toast and jelly. A meal contingency was initiated following the identification of preferred foods. Criterion weight gain was followed by a preferred breakfast and the use of salt at breakfast and lunch. Failure to meet criterion yielded a satisfactory breakfast of eggs, grits, toast and juice with no salt or coffee provided for either breakfast or lunch. In addition, staff members were instructed and encouraged to praise and socialize with the patient (e.g. sitting and talking with patient) on each day that he met criterion, or to minimize social interactions when he failed to reach criterion. As with the previous patient, the staff was completely responsible for conducting this treatment program and psychologists consulted daily on treatment for 14 weeks (42 sessions). After this time, psychology gradually reduced contact except for infrequent checks with the staff on the program (17 weeks, 52 sessions).

Results Figure 2 displays Billy Bob’s intersession weight gain during baseline, treatment phase 1 with regular psychology contact, and treatment

TERENCE

M. KEANE,

BaselIne

I-ig. 2. Intersetrion

DONALD Phase

M. PRUE and FRANK

I

Phase 89 %

weight gain in kilograms

phase 2 with reduced psychology contact (approximately one contact per month). During baseline the patient reached criterion at a rate of 47% with an average intersession weight gain of 3.6 kg. During treatment phase 1 Billy Bob attained the criterion weight gain 71% of the time with a mean weight gain of 2.7 kg. This change in intersession weight gain reached statistical significance, 1(54) = 2.97, p < 0.01. It is noteworthy that when psychology withdrew its regular contact, the patient’s compliance continued to improve. Weight gain averaged 2.4 kg and the patient met criterion for 89% of the sessions in treatment phase 2. Comparing these figures to those obtained during baseline, the changes between phases were statistically significant, f(65) = 5.64, p < 0.001.

DISCUSSION Behavioral contracting between the dialysis patient and the staff of the treatment unit effectively reduced intersession weight gain with two chronic fluid overloaders. Each patient in these case studies received different contingencies to improve the degree of compliance to their respective dietary restrictions. However, both cases were viewed by the staff as

L. COLLINS,

for Ca\e

JR

2

2 (Billy Bob)

incorrigible and unresponsive to all previous educative interventions. The treatment programs arranged naturally occurring consequences to be contingent upon the desired level of weight gain for each patient. At this time it is impossible to determine if the social reinforcers (praise and conversations) or the tangible reinforcers (i.e. access to early sessions and preferred meals) were responsible for the observed changes. However, it is optimistic to know that patients with long histories of chronic fluid overload can be managed successfully if the contingencies are appropriately established. For some patients the potential for future illness and complications is too far removed to exert control over their daily routine. The present study demonstrates that these patients will respond to more immediate consequences. For Case 1 data are presented for 40 weeks while for Case 2 the data are presented for 37 weeks. The treatment program continued intact following data collection. More importantly, the programs did not require the presence of the psychologist beyond the initial training of the staff and intermittently providing praise for the staff for a job well done. The use of intersession weight gain as the

CONTRACTING

WITH DIALYSIS

sole measure of compliance can be problematic. Since it is an indirect measure of compliance, it is difficult to determine reliably the source of the problem when the patient does not reach criterion. Although procedurally difficult, other more direct measures (e.g. amount of fluid, type of food, etc.) might provide useful clinical information for further interventions. One obvious discrepancy in the two cases reported here is the criterion weight gain for each patient. These divergent criteria depend upon the patients’ weight, their idiosyncratic fluid loss, and their baseline rates of intersession weight gain. These criteria were determined by the medical staff in conjunction with psychologists and deemed acceptable with minimal risk for complications secondary to fluid gain. The cases presented here demonstrate the successful use of a behavioral consultation program to renal dialysis units. Systematic

PATIENTS

61

replication and extension of these treatments with more sophisticated experimental paradigms would provide useful and needed information. In particular, the effectiveness of social versus tangible rewards merits future consideration.

REFERENCES Barnes M. R. (1976) Token economy control of fluid overload in a patient receiving hemodialysis, J. Behav. Ther. & Exp. Psychiat. 1,305306. Burke H. R. (1979) Renal patients and their MMPl profiles, J. Psycho/. 101.229-236. Cole B. H., Stelzer S. and Bayersdorfer M. U. (1979) Development of a psychosocial program on a dialysis unit, Prof. Psychol. 200-206. Flannery J. G. (1979) Adaptation to chronic renal failure, Psychosomalics 19,784-787. Hart R. R. (1979) Utilization of token economy within a chronic dialysis unit, J. Consult. C/in. Psychol. 47, 646-648. Kaplan-DeNour A. and Czaczkes J. W. (1972) Personality factors in chronic hemodialysis patients causing noncompliance with medical regimen, Psychosom. Med. 34,333-344.