Continuous ambulatory peritoneal dialysis: Psychological factors

LILIAN GONSALVES-EBRAHIM, M.D. A. DALE GULLEDGE, M.D.

scon MIGA, R.N.

Continuous ambulatory peritoneal dialysis: Psychological factors Although time-consuming and a tedious task for the patient, continuous ambulatory peritoneal dialysis offers the prospect of greater independence, and enables the patient to take an active role in his or her own treatment. Little has been published on examination of those psychological factors indicative of a patient's future success in accommodating to and complying with this demanding procedure. Based on our work with 46 patients, we define key factors for consideration, namely, mood, ability to test reality, cognitive function, body image, previous ability to handle crises, tolerance for environmental stress, personality structure, and acceptance of the treatment by relatives.

ABSTRACT:

Patients with end-stage renal disease (ESRD) face an array of stresses. They must adjust to physiologic changes, discomfort, a strict diet, and restrictions in fluid intake. They are intermittently uremic and prone to complications such as secondary hyperparathyroidism. They are chronically anemic. When hemodialysis or peritoneal dialysis is utilized to treat chronic renal failure, the procedure can give rise to psychological stresses, such as increased dependence on the dialysis

machine and the renal team, loss of ability to gratify biologic or psychological drives, restricted social life, changes in occupation or plans, and loss of autonomy.u Continuous ambulatory peritoneal dialysis (CAPO) has recently become available to patients suffering from ESRD. This procedure was first applied in clinical practice in 1975.3 Moncrief and Popovich described it as follows:

continuous presence (24 hours a day, seven days a week) of peritoneal dialysis solution in the peritoneal cavity except for periods of drainage and instillation of fresh solution five times per day. After each drainage and fresh instillation, the patient is disconnected from all tubing. The chronic indwelling peritoneal catheter is capped and the patient is free to participate in his usual daily activities. Essentially, CAPD represents a portable, self-dialysis technique. It trades relatively long dialysis sessions three days a week for five 30to 45-minute interruptions of daily activities everyday.3

We have now accumulated experience with an unusually large sample of patients on CAPO, in particular in regard to assessment of psychological factors. We should note that our conclusions at this stage are impressionistic. Objective studies are needed to assess more precisely psychological features and those attributes possibly predictive of satisfactory use of CAPO.

Very simply, this technique uses the

From the Department of Psychiatry at the Cleveland Clinic. Reprint requests to Dr. Gonsalves-Ebrahim there, 9500 Euclid A ve, Cleveland, OH 44106.

Selection of patients Over a two-year period, the renal service of the Cleveland Clinic PSYCHOSOMATICS

evaluated 46 patients for possible CAPO. Their ages ranged from 18 months to 72 years with a mean of 43.5 years. All but the very youngest were referred to the psychiatric department for an evaluation as part of the routine workup. A social worker interviewed the families or relatives in regard to their financial and functional capabilities, communication and support, comprehension of illness and dialysis, and prior adjustment to stresses. No formal psychological tests were administered to any patient. Instead, information assembled from a careful history, the mentalstatus examination, and the family interviews was discussed with the renal team in considering why a patient would or would not be likely to comply satisfactorily with the requirements of CAPO. Approval for CAPO derived from combined input from the primary physician, liaison psychiatrist, nurses, social worker, nutritionist, physician assistant, and dialysis technicians. On approval of the candidate for the procedure, a peritoneal catheter was inserted, and the patient started training for four to eight days. Following this, the CAPO instructor continued to check with the patient at home via the telephone. The patient made outpatient visits weekly for the first three weeks, and then monthly for the tubing change. The 46 patients manifested a variety of medical problems, comprising 18 cases of diabetes, nine of chronic glomerulonephritis, six of end-stage renal disease of unknown origin, six of polycystic kidney disease, and seven of other disorders. The most common mode of treatment prior to CAPD was intermittent peritoneal dialysis (27

cases), followed by hemodialysis (14 cases), and no previous treatment (five cases). The majority of our patients chose CAPO as a treatment procedure for reasons of independence and freedom to travel. Five had had problems with the fistula or machine. Twenty-three patients are currently being followed at our hospital. Among the other 23, five discontinued CAPO. one was deemed unsuitable for CAPO, four were transferred to other dialysis centers for follow-up, four obtained kidney transplants, and nine died. Three of the five discontinuing CAPO were advised to do so by

Severely depressed and psychotic patients are not suitable for CAPD. their physicians following several bouts of peritonitis with abdominal adhesions, making an indwelling catheter painful. One patient missed the supportive environment of the hospital and so was restarted on intermittent peritoneal dialysis. The fifth person "felt pregnant and bloated" with much abdominal discomfort during the infusion of dialysate, and thus preferred intermittent dialysis. The patient not accepted into the program was a 35-year-old diabetic mother of two young children. who worked as a part-time printer. On hemodialysis for two years, she desired CAPO to enable her to continue working, and because she thought it would interfere less with being a wife and mother. A psychiatric interview revealed that her 55-year-old second husband was an alcoholic. She would periodically go on drinking binges, ostensibly "to show my husband

how it felt." She was noncompliant with her fluid and dietary restrictions, emotionally shallow, and displayed poor self-care. For these reasons, it was felt that she was quite unreliable and not suitable for CAPO.

Psychological factors Most articles on CAPO deal only with the medical aspects. and information on psychological features is very limited. Based on our work with these 46 patients and on whatever information was available in the literature, we found the following six psychological factors important: mood and ability to test reality, cognitive function, body image. previous ability to handle crises and a fairly good tolerance for environmental stresses, personality structure, and support for and acceptance of the treatment by relatives. Mood and ability to test reality.4 Severely depressed and psychotic patients are not suitable for CAPO because successful adherence to the requirements of this frequent treatment procedure calls for a strong desire for independence, a high degree of determination, and careful attention to self-care. Individuals incapable of understanding their motives and actions should not be entrusted with this self-treatment. Patients should be carefully assessed in these respects. Cognitive (unction. A clear sensorium is necessary to carry out the exchanges at regular time intervals and to follow sterile techniques. Peritonitis is a very common complication of CAPD,5.7 as in the following patient. Case 1 A 54-year-old married man with a long-standing history of ESRD sec-

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References: 1. lacoblon A et a/: Psychophysio/09Y 7:345. Sep 1970.2. Lynch T. Greene Vf: /Ir Coli Phys Surs 4:87-90. Ian 1975. J. lames NM. Montague Af:NZ Meel /81246-248. Mar 12. 1975.4. Taws lR. Brunning I. Arenillas L: / Int Meel Res .J:417-422. 'un 1975. 5. Broadhurst AD. Arendlas L: Curr Meel Res qxn 3:413-416. lui 1975 6. Data on file. HoftmannLa Roche Inc.. Nudey. NI. 7. Kakos A et a/: / Clin PharmaroI17:207-213. Apr 1977. 8. Greenblan 01. Allen MD. Shader RJ: Clin Pharmaco/ Ther 21:355-361. Mar 1977. 9. Monti 1M: Methods find Clin PharTTldrol 3:303-326. May 1981.

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Dalmanet!>(Ilurazepam HCI/Roche) € &dare prescribing. please .consult complete product information. a summary of which follows: Indications: Effective in all types of insomnia characterized by difficulty in Ialling asleep. Irequent nodumal awakenings and/or early morning awakening: in patients with rectirring insomnia or poor sleeping habits: in acute or chromc medical situations requiring resdul sleep. Objective sleep laboratory data have shown effectiveness lor at Ieasl 28 consecutive nights of administrallon. Since insomma is ohen Ifansient and mterminent. prolonged administration is generally not necessary or recommended. Repeated therapy should only be undertaken with a~ priate patient evaluation. Contraindications: Known hyper.;ensitivity to nurazepam HCI; pregnancy. BenzodiazeplfleS may cause fetal damage when administered during pregnancy. Several studies suggest an increased risk 01 congenital mallonnations associated with benzodlazepme use during the first trimester. Warn patients of the potential risks to the Ietus should the possibility of becoming pregnant exist while receiving nurazepam. Instruct patient to disconllnue drug prior to beroming pregnant. Consider the possibility of pregnancy prior to instilullng therapy. WaminSS: Caution patients about possible combined eIIec15 with alcohol and other CNS depressants. An additive effect may occur " akohol is consumed the day 101lowing use lor nightllme sedation. This potenllal may exist lor several days following discontinuation. Caution against hazardous occupations requiring complete mental alertness (e.8.. operating machinery. dnving). Potential impainnent 01 performance 01 such activitIeS may occur the day following Ingestion. Not recommencled for use in persons under 15 years of age. Though physical and psychological dependence have not been reported on recommencled doses. abrupt discontinuation should be avoided with :Jadual tapering of dosage lor those patients on medication lor a prolonged period 01 lime. Use caution in administering to addiction-prone individuals or those who might oncrease dosage. Precautions: In elderly and debilitated patients. it IS recommended that the dosage be limIted to 15 rng to reduce risk of oversedation. dizziness. confusion and/or ataxia. Consider potential additive eflects WIth other hypnotics or CNS depressants. Employ usual precautions in severely depressed patients. or in those with latent depression or suicidaltendeocies. or in those with impaired renal or hepalic Junction. Adverse Reactions: Dizziness. drowsiness. Iightheadedness. ~ng. ataxia and lalling have occurred. particularly in elderly or debilitated patients. Severe sedation. lethargy. disorientation and coma. probably indicative of drug intolerance or overdosage. have been reported. Also reported: headache. heartburn. upset stomach. nausea. vomiting. dianhea. cOnstipation. GI pain. nervousness. talkativeness. apprehension. Irritability. weakness. palpitalions. chest pains. body and joint pains and G, complaints. There have also been rare occurrences of leukcr penia. :Janu!ocytopenia. sweating. nushes. dilfieulty in focusing. blurred vision. burning eyes. faintness. hypotension. shortness of breath. pruritus. sIon rash. dry mouth. biller taste. excessive salivation. anorexia. euphoria. depression. slurred speech. confUSIon. restlessness. hallucinations. and elevated SGOT. SGPT. total and direct bilirubins. and alkaline phosphatase; and paradoxical reactiOflS. e.8.. exdternent. stimulation arid hyperactivity. Douse: Individualize for maximum beneficial effect. Adubs, 30 rng usual dosage; t5 rng may suffice in some pallents. Elderly or debilitated patients, 15 rng recommended initially until response is determined. Supplied: Capsukos containing 15 rng or 30 rng nurazepam HC!.

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Peritoneal dialysis ondary to chronic glomerulonephritis slarted on CAPO in February 1980. after a careful evaluation. Prior to CAPO, he had been on intermittent peritoneal dialysis for three years. He did well on the new procedure for six months, until he developed slurred speech, mild righi-sided weakness, and disorientation. Unable to carryon the fluid exchanges, he was admitted to Ihe hospital with bacterial peritonitis and a mild left cerebral hemisphere thrombotic infarct. Within a few weeks, hospital treatment improved the acute infection and cerebral dysfunction, with minimal residual neurologic symptoms. He went back on CAPO and was functioning well unlil he died a year later.

Body image. Special attention should be given to the patient's attitudes toward the dialysis bag, the noises produced by the fluids, and the sensation of feeling too full following the fluid exchanges. Sexual problems may arise from the patient's thinking that the bag is ugly and undesirable. One patient seemingly ready for CAPD proved unsuitable because of underlying attitudes. Cas. 2 A 46-year-Old mother of two daughlers, who had been diabelic for 21 years, asked to change from intermillent peritoneal dialysis to CAPO to facilitate an independent mode of life. She was successfully trained for the procedure, but discontinued it a month later, because' 'The fluid made me uncomfortable and I looked pregnant." Further questioning revealed that seeming pregnant reminded her of her stillborn son, a trauma with which she had not fUlly come to terms. Also, her husband was more caring of her when she was on the machine. She subsequently returned to intermittent peritoneal dialysis.

Previous ability

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handle crises

and a fairly good tolerance for environmental stresses. The following patient handled crises quite well, at least until repetition of an unusually stressful event affected the choice of treatment. Case 3 A 60-year-Old self-employed man had suffered from diabetes mellitus since age 22. Both he and his wife had coped well, traveled a great deal. and remained successfUlly married. After peritoneal dialysis for six months, he requested CAPO so that he could continue to travel and lead an active life. Nine months later, his right leg was amputated below the knee because of diabetic gangrene. He was initially depressed at the thought of using a walker and a wheelchair. His wife was overwhelmed and would nol leave him alone for fear of an acciden!. They were seen together in therapy, where our role was one of support to allow ventilation of feelings, especially of anger stemming from his progressive loss of independence and reduced ability to handle many responsibilities. His depressive symptoms were Ireated with methylphenidate and desipramine with a good response. The situalion gradually improved and he was able to continue on CAPO for a year, unlil amputation of the other leg below the knee became necessary. Following this surgery, he found it very difficult to ambulate and so returned to intermiltent dialysis.

Personality structure. The treating physician can sometimes utilize personality features toward a successful outcome. Meticulous or even obsessive-compulsive patients do well, with their regular charting of exchanges, blood pressure, and drugs, as well as with thorough care of the catheter. Support for and acceptance ofthe treatment by relatives. Although the patient must assume primary responsibility for handling the treatPSYCHOSOMATICS

ment, a spouse, relative, or other reliable person should be available in case of a crisis. Possible discord or conflict that could affect motivation for or performance of the treatment should be looked for and assessed. Relatives should be forewarned concerning details of the dialysis, and the kinds of supportive services available described to them. In the following case, support from a spouse was generally beneficial in early years, but problems later developed, subsequently moderated, through counseling, during the balance of the patient's life. Case 4 A 34-year-old married man and father of two teenage girls had been diabetic since age 12. He described a "good, solid" marriage and a close family. Over the years he had developed considerable loss of vision secondary to diabetic retinopathy (left eye =

20170, right eye = 20/400). However, the CAPO instructor developed specific methods so the patient could master the technique and perform fluid exchange with some help from his wife. At this point, his wife took on more responsibility and tried to do everything from looking after the family and household to attending nursing school. She subsequently felt overwhelmed, and he became reactively depressed from being unable to continue his previous more independent mode of life. Referral for marital therapy led to useful discussion of issues such as dependence versus independence, control, and feelings associated with dealing with chronic illness. He was able to function on CAPO for a year until he developed peritonitis and subsequently died of generalized septicemia.

Conclusion The increasing role of technology in treatment means that greater attention should be paid to how pa-

tients relate psychologically to the application of what can seem to be overpowering or even fearsome technical means. Appropriate evaluation and selection of candidates for CAPO can enable these chronically ill persons to better control and adapt to the critically necessary 0 procedure of dialysis.

REFERENCES 1. Wright RG. Sand P. Livingston G: PsychOlogi. cal stress during hemodialysis for chronic renal tailure. Ann Intern Medicine 54:61 t-621. t966. 2. Rabinowitz S. Van oer Spuy HIJ: Selection cnferia for dialysis and renal transplant. Am J Psychiatry 135:861-863.1978. 3 Moncrief JW. Popovich RP: CAPO. The Kidney (National Kidney Foundation monthly newslet· ter) 12:9-12.1979. 4. HaNke EA. Rajendran S. Egan Jo: D,alysis. depresSIon and antidepressants J Clin Psy· chiatry 39:759-760.1978. 5. Popovich RP. Moncrief JW. Nolph Ko. et al: CAPO. Ann Intern Med 88:449-456. 1978. 6. Nolph Ko. PopoviCh RP. Moncrief JW: Theoretical and practical implications of CAPO. Nephron 21:117-122.1978. 7. Oreopoulous oG. Robson M. deVeber GA. et al: CAPO: A new era in the treatment of chronic renal failure. Clin Nephro/l1 :125-128. 1979.

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