Quality of Life and Venous Ulcers Mr Adam Howard Consultant Vascular and Laparoscopic Surgeon
Introduction Care focused on wound management alone neglects the diverse needs of the patient with venous leg ulceration
Pain The experience of pain from leg ulceration was found to be the MOST significant and consistently reported symptom of all studies reviewed irrespective of design Health-related quality of life and chronic leg ulceration: part 2. Green & Jester, Wound Care March 2010 Males complained more than women Phillips et al J Am Acad Derm1994 Pain was worse with lower ABPI Cullum 1995 Pain was reported from RCT data (n=387) to have the most significant impact on HRQoL of ulcer sufferers, with 12-21% reporting severe pain. Quality of life of people with with venous leg ulcers: A comparison of discriminative and responsive characteristics of two generic and disease specific instruments. Iglesias et al, Quality of Life Research 2005;14:1705-18
Swelling, Discharge & Odour Leg swelling associated with pain, impaired mobility and ulcer discharge Malodourous leg ulcers have negative effect on social life, anxiety and depression 60% had exudate that smelt or stained (Hareendran 2005)
Mobility and Daily Living Difficulty with activities of day to day living Associated with ulcer itself, pain or its treatment (Hyland 1994, Chase 2000) Mobility was a deficit for all (Franks and Moffat 1998) Problems with exudate 75%, odour 56%, insomnia 65% (Palfreyman 2008)
Vitality Improvements in patients energy levels with treatment, measured with Nottingham Health Profile (NHP) Franks and Moffat 2001, Hunt et al 1986
Social Functioning & Isolation Improvements in social functioning with treatment (Charles 2004) Patients become socially isolated whether healed or not, especially young males (Franks et al 2006, Franks and Moffatt 1998) Patients restrict their own social activity to prevent damage to leg or risk recurrence (Hyland et al 1994) Social life restricted by pain, odour, inability to dress appropriately and appearance of bandages (Hareendran et al 2005)
Psychological Functioning Pessimism, body image and negative emotions improved with ulcer healing (Charles 2004) Depression, dysphoria, anxiety, crying associated with pain and improved with healing (Hyland 1994, Palfreymen 2008)
Recommendations for Nurses and Doctors Practice Effectively assess and manage pain, especially during wound dressing changes/bandaging* Effective strategies to manage wound exudate and odour* Adoption of care pathways e.g. RCN 2006 Develop collaborative practitioner-patient relationship Patient education* Educate staff* Patient focus during nurse-patient consultations* *Juxta Cures may have beneficial effects
HRQoL Measurement Tools Researchers recommend combined use of generic and disease-specific tools for more complete view of effects of leg ulceration on patients Further research needed for care to be effective and directed to disease specific needs of patients - not just ulcer healing Smith et al 2000, Price and Harding 2004, Palfreyman 2008
Generic HRQoL Tools Short Form 36-item (SF-36) Health Survey is well validated and reliable generic measure used worldwide Summary of QoL Multiple conditions 36 questions in 8 domains Physical and mental status scales Ware and Sherbourne, Medical Care 1992;30:473-83 SF-12, Nottingham Health Profile, EuroQOL 5 Dimensions.
Disease Specific HRQoL Tools Specific measure of QoL focuses on the primary condition When combined with generic measure provide accurate overall assessment Examples: Charing Cross Venous Ulcer Questionnaire, 2000 McGill Pain Questionnaire, VAS for Pain Modified Skindex FLQA (Freiburger Questionnaire) 1997 TLQ CVI (Tubingen Questionnaire) 1998 VEINES QOL/Sym (Venous Insufficiency Epidemiological and Economic Study) 2003 CWIS (Cardiff Wound Impact Schedule) 2000 Hyland 1994
Key Points Chronic venous leg ulcers cause significant decline in quality of life Natural history of chronic leg ulcers: 40% before age of 50 years long periods of ulceration interspersed with relatively short ulcer free periods Often nurse and doctor lead care focus on ulcer healing. Majority of research indicates patients need holistic assessment of needs to improve patients quality of life