A associação da saúde mental de cuidadores de pacientes com doença renal crônica em diálise com a sobrevida dos pacientes e as perspectivas sobre a morte

Abstract

Introduction: In Brazil, there is an increase in the prevalence of chronic diseases, currently constituting a Public Health problem, as they are a long-term condition and in great demand by health services. Among these, there is chronic kidney disease (CKD), with a progressive increase in the number of people on dialysis, in addition to high rates of mortality and chronic disabilities. The condition of chronic illness brings anguish, stress, fears, anxieties and feelings to the patient that, for its elaboration, the role of the health team and the main family caregiver will be fundamental. It is clear, therefore, that just like the patient, the family is significantly affected by CKD and its treatment, where it will have to adapt to the persistence of a clinical condition that presents instability and uncertainty with permanent care needs, at the cost of great overload in the most diverse aspects of their lives. In this context, in which the family constitutes a risk group for the development of psychological symptoms as well as several chronic diseases, it is essential to assess the level of elaboration of the process of illness experienced in this group, in its most varied aspects so that one can then outline better intervention strategies. The aim of this study was to assess the mental health of chronic kidney patients and their caregivers and their association with quality of life, symptoms of anxiety and depression, symptoms and levels of stress, levels of fatigue and beliefs about death, in addition to their clinical condition. Patients, seeking to observe the association between the variables investigated in the caregiver and the patient and the clinical and laboratory variables of the patient. Patients and Methods: Prospective cohort study in patients with CKD undergoing renal replacement therapy (Hemodialysis / Peritoneal Dialysis) undergoing treatment at HU-CAS / UFJF. Inclusion Criteria: All patients with at least 6 months of hemodialysis treatment and their caregivers, of both sexes, over 18 years of age, who signed the Informed Consent Form (ICF) were evaluated. For the selection of caregivers, we consider this as the person appointed by the patient as the person responsible for the care of their health at home. Variables analyzed: age, sex, color, income, education, marital status, occupation, (according to IBGE), CKD etiology, comorbidities, use of psychiatric drugs, complete blood count, transferrin and ferritin saturation index, calcium, phosphorus, Alkaline Phosphatase, Parathyroid Hormone (PTHi), Creatinine, Urea, Kt/v. Death and depression, anxiety, quality of life, level of stress and fatigue and beliefs about death were also evaluated. Clinical and laboratory data were taken from medical records. Statistical Analysis: The data related to the evaluation of the questionnaires were described as mean ± standard deviation, median (interquartile variation), percentage or frequency according to their characteristics. Subsequently, we divided into two groups those patients who were still being followed up and those who died, and we compared the assessment of depression, quality of life, stress and fatigue and the clinical and laboratory variables of patients at T0 (initial time of study). Subsequently, we compared these same variables between patients versus patients and patients versus caregivers at T1 (second stage of the study). We also evaluated the perspectives on death in a descriptive way and correlated them with sociodemographic and mental health variables. Finally, we performed a survival analysis using the Cox regression model. A 95% confidence interval was considered, with p <0.05, we used the statistical software SPSS 17.0. Results: In the comparison between T0 vs T1 between patients, there was a decrease in anxiety when comparing T0 vs T1 (7.42 ± 5.35 vs 5.14 ± 4.38, p = 0.02). Regarding stress, there was a tendency to decrease total stress (1.25 ± 1.13 vs 0.75 ± 1.0, p = 0.08); this decrease was due to a decrease in psychological symptoms of stress (2.38 ± 1.0 vs 0.95 ± 1.0, p = 0.001). In terms of quality of life, there was a tendency for improvement in social aspects (60.71 ± 32.42 vs 72.32 ± 34.38, p = 0.08). In the comparison between T0 vs T1 among caregivers, there was a decrease in anxiety among caregivers at both times (8.71 ± 3.84 vs 7.52 ± 4.44, p = 0.01). In emotional social support, there was a trend towards improvement (3.0 ± 0.72 vs 3.28 ± 0.83, p = 0.08). In total stress, however, we did not observe a difference, however, with respect to its physical symptoms, we observed a decrease (1.90 ± 0.99 vs 1.33 ± 0.91, p = 0.05) as well as in psychological symptoms (2.0 ± 0.74 vs 1.23 ± 1.13, p = 0.02). In terms of quality of life, there was a tendency to increase vitality (44.52 ± 27.29 vs 54.41 ± 18.69, p = 0.09). When assessing the relationship between the various variables and the perspectives on death, there was a positive association between anxiety and the perception of death 7 (death as failure) (r = 0.53, p = 0.02) and between depression and perception death 1 (death as suffering and loneliness) (r = 0.51 and p = 0.03). There was no correlation between anxiety and depression with the perception of death among patients. Stress showed a positive association in caregivers with the perception of death 6 (death as courage) (r = 0.52, p = 0.03) and the perception of death 1 (r = 0.48, p = 0.05), with no correlation in the group of patients. The perception of social support, however, did not correlate with the perceptions of death in the group of caregivers, but it did negatively correlate in the group of patients with the perception of death 1 (r = -0.71, p = 0.006), with the perception 3 (indifference to death) (r = -0.60, p = 0.02) and with the perception 7 (r = - 0.601, p = 0.02) when related to practical social support. Emotional social support showed a negative association in the group of patients with perception 1 (r = -0.06, p = 0.01) and perception 3 (r = -0.56, p = 0.03). In the analysis of survival, the model adjusted for age, sex, causes of CKD and social support was the one that showed normal residues and showed age and social support as independent risk factors for mortality. That is, when age and sex were adjusted for practical and emotional social support, there was an evident trend (p = 0.06 with CI 0.99-1.23) of age as an important factor in patient mortality, showing that the higher the older, the higher the mortality. When the analysis is adjusted for social support, the age factor also appears as a trend (p = 0.09 with CI 0.99-1.23) for mortality. When the CKD etiology variable was included, aspects of physical and mental health and quality of life showed age with a tendency (p = 0.06 with CI 0.99-1.23) to be a factor related to patient survival. When the analysis is adjusted for social support, the age factor appears as significant (p = 0.02 with CI 1.01-1.32) for mortality and social support starts to have a direct tendency in relation to mortality (p = 0.09 with CI1.01-1.32). Conclusion: CKD and dialysis treatment modalities impact on several aspects of mental health, both for the patient and his family caregiver. Patients and caregivers have similar levels of general mental health and the social support received by the patient is associated with the patient's survival. Considering patient and family caregiver an inseparable dyad in health care, it is evident the need to include mental health care for both as a routine of services in nephrology. Conclusion: Chronic kidney disease and dialysis treatment modalities impact on several aspects of mental health, both for the patient and his family caregiver. Patients and caregivers have similar levels of general mental health and the social support received by the patient is associated with the patient's survival. Considering patient and family caregiver an inseparable dyad in health care, it is evident the need to include mental health care for both as a routine of services in nephrology.