Inflammatory arthritis, such as rheumatoid arthritis, is common and affects between 0.5% and 1% of the UK population (Abhisheki et al, 2017). It is a life-changing diagnosis and lifelong illness requiring specialist care and complex immunosuppressive therapies. The symptoms of joint pain, joint swelling and fatigue are unpredictable but when active (often known as a flare) impact on a person's general wellbeing. This commentary will focus on the potential impact on mood and work.
Mood
Rheumatoid arthritis (RA) is associated with an increased prevalence of depression and anxiety (Matcham et al, 2013). The level of depression is similar to that experienced by people with diabetes, Parkinson's disease and cancer (Matcham et al, 2013). Psychological distress in inflammatory arthritis can relate to many factors including coping with fluctuating daily symptoms, restriction in social activities, the emotional impact of living with a long-term condition and managing complex medication regimens (Dures et al, 2014). It is important to identify if depression is occurring as, left untreated, it can lead to poorer patient outcomes including increased pain and fatigue, reduced physical ability, withdrawal from normal activities and limited response to drug treatments (Hider et al, 2009; Matcham et al, 2013).
Despite RA impacting on mood, emotional wellbeing does not appear to be routinely assessed in clinical practice. Indeed, a national survey identifying whether psychological support was provided by rheumatology units in England reported provision as being ‘inadequate’ (Dures et al, 2014). A lack of clinic time and rheumatology clinicians not receiving appropriate training in identifying psychological distress were cited as reasons for why psychological provision is lacking. (Dures et al, 2014).
‘It is important to identify if depression is occurring as, left untreated, it can lead to poorer patient outcomes including increased pain and fatigue, reduced physical ability, withdrawal from normal activities and limited response to drug treatments’
The National Institute for Health and Care Excellence (NICE) (2020) guidance recommends that mood is assessed within the context of an annual review clinic for people with RA. Patients attending for an annual review identified the association between their RA and their mood but a fear of stigmatisation and a perception that clinicians prioritise physical health prevented patients seeking help in this area (Machin et al, 2017).
Good communication by the clinician and continuity of care have been identified by patients as being necessary to share how RA is impacting on their emotional wellbeing (Machin et al, 2017). Interventions that can be offered to patients include relaxation, stress management and cognitive coping skills to aid adjustment to living with RA (NICE, 2020).
Patients with RA have expressed a wish for access to psychological support and have identified rheumatology specialist nurses as being able to understand the impact of living with RA and possessing the ability to signpost to appropriate services (Ryan et al, 2013). Some patients with RA have expressed a preference for psychological therapies, wishing to avoid medications due to concerns about interactions with existing drug treatments (Machin et al, 2017).
If you are conducting a consultation with a patient with an inflammatory arthritis, asking the question ‘Is your arthritis affecting your mood?’ will provide the opportunity for the patient to share how they are coping. Patients don't expect rheumatology nurses to be experts in managing mood but they do want nurses to be able to help them seek appropriate support. Don't be afraid of saying ‘I am not an expert in this area but I can put you in touch with services that can help you’.
Work
Having an inflammatory arthritis can impact on a person's ability to work, with the rate of work disability ranging from 23% to 80% (Barnett et al, 2000). Factors that contribute to work disability include joint pain and fatigue, performing a job that requires manual labour, older age and lower levels of education (De Croon et al, 2004). Employment status often changes due to having inflammatory arthritis; employees with poorer mental health and more physical limitations report a greater number of work hours lost (Galloway et al, 2020)
Increased levels of fatigue were related to difficulties coping with physical work and complying with a rigid work schedule (Connolly et al, 2015). The unpredictability of symptoms can make it difficult to remain in occupations that have a fixed starting time especially as joint stiffness can be heightened in the morning. Occupations that enable employees to be flexible with their working times increase the ability to cope, with individuals often able to work around their symptoms. Patients with continual pain, fatigue, functional disability and high levels of disease activity often have to leave the workforce (McWilliams et al, 2014). Factors identified by patients that would increase the likelihood of remaining in employment included increased flexibility from the employer regarding the hours they work and urgent access to the rheumatology team when their condition became active (National Rheumatoid Arthritis Society, 2017). Any improvement in activity impairment leads to less work productivity loss (Xavier et al, 2019). This further reinforces the need for early treatment to achieve remission and a reduction in inflammation.
Having a nursing consultation provides the opportunity to discuss whether the inflammatory arthritis is impacting on any aspect of the patient's work role. With the patient's permission the nurse can talk to the employer to discuss ways of making work more manageable. This may include explaining the necessity of regular short breaks to prevent joint stiffness, minimising repetitive actions on the joints, providing a working splint for someone with wrist pain and discussing the possibility of flexible working hours. Goal setting can also be used to help patients focus on how to manage fatigue levels throughout the working day and during days off.
Rheumatology services will have different resources to offer patients and this may include access to a local vocational rehabilitation service, which can provide information about modifying the work environment or the possibility of retraining opportunities. Other services may have occupational therapists who can provide expertise around work-related issues.
When caring for people with inflammatory arthritis, it is important to identify what their priorities are and what aspects they would welcome support with. By being aware of the potential impact on mood and work, nurses can discuss these issues in clinic and provide support and advice and signpost to other resources including patient organisations when necessary.