Editor’s Note: The authors offer more details about improving medication adherence in an interview with NN&I. 

Abstract

Medication compliance among individuals with hypertension symbolizes a growing concern within the medical community. It is said that roughly 50% of hypertensive patients in the United States do not comply with their medication regimen.1 Uncontrolled hypertension in turn can lead to kidney failure and other complications. Because compliance to medication regimens is complex and difficult to ascertain, solutions to this problem must be multifactorial.

Introduction

A recent national health and nutrition examination survey claimed that 29-31% of adults in the United States have uncontrolled hypertension.1 Controlled hypertension is defined as a systolic of 140 mmHg and diastolic of 90 mmHg.2 One critical reason for minimal patient compliance of medication is due to an absence of strong relation- ships between patients and their physicians.3 Conversely, an analysis of hypertension concluded that adherence to medication does not entirely correlate with uncontrolled blood pressure.4

Finding reasons for non-adherence among ESRD patients

Some of the typical factors affecting medication compliance include numerous patient-correlated influences that are non-specific to treatment schedules.

  • Patients can suffer from memory problems (i.e., forget- ting to take medication),5 or the inability to understand the impact of treatment versus non-treatment.
  • Clinical depression is diagnosed in 19 million patients each year in the United States, influencing their energy to make and sustain change. It can leave a feeling of hopelessness while encouraging thoughts and emotions that impact adherence.6
    Some patients may feel embarrassed to take medications in front of others, and therefore do not take it at all.
  • There may be a lack of self-motivation to take medication. Feeling support from their peers to comply with medication increases self-motivation to adhere.8 Also, fear tends to promote initial adherence; often, however, sustainability does not follow.
  • Functional illiteracy can prevent an understanding of how to take the medication, and there may be an unwillingness to gain knowledge, especially in elderly patients.9
  • There can be poor communications with clinicians. A strong relationship between the physician and patient can lead to a willingness to divulge all health-related information.10 Dishonesty and forgetfulness are correlated with weak relationships among physicians and patients. Many patients will not tell their physician if they have stopped or interrupted their regimen.11
  • Prescribed medications may be refused or not taken in accordance with physician orders.
  • Medications that are perceived as triggering side effects such as nausea, vomiting, drowsiness, cramping, and dizziness tend to have an increased issue of compliance.12
  • Financially, not every patient is covered completely by their health insurance, so patients may not fill prescriptions or skip dose due to costs.
  • Treating an illness like hypertension requires motivation to integrate daily medication into the day’s routine. This may also includes intensive dieting and exercise according to a physician’s desirability.13 More often than not, the difficulty is not unwillingness; it is the lack of perseverance to retain that desirable lifestyle.

Improving adherence with strong beliefs about health

The perceived hazard of illness discussed above is pertinent to both medication and lifestyle adherence. However, the succeeding health theories are chiefly relevant to making positive lifestyle changes.

Risk perceptions regarding treatment

Many patients are skeptical about treatment (i.e., dialysis and specific medications) because of what they hear through others. Less than 5% of patients on dialysis regain kidney function and do become dialysis dependent.14

Perceived benefits of treatment

Clear communication of improvement with patients is crucial and leads to improve compliance. Showing convalescence also motivates the patient to continue adhering to a medication schedule, and shows effective communication with the clinical team.

Patient concerns about medications

Often times, patients are concerned with the number of medications they are taking (i.e., ‘I feel like too many medications are hurting me more than helping me’). Even deeper, sometimes misunderstandings cause patients to question whether or not to continue medications (i.e., ‘When my labs are where they should be, can I stop taking the medications?’). Finally, personal belief such as their ‘dependency on drugs’ also gives a negative approach to adherence.

Motivating ESRD patients to make changes

State of change

The patients’ inability to adapt to change, or not having the willingness to change, can be an obstacle to medication adherence. This discussion is in correspondence with the State of Changes model15 [see Table 1]. Some of the elements of the State of Changes include time, i.e., when the medication is first prescribed, patients may adhere properly; however, over time, the consistency and sustainability reduces.16

Tactics for increasing adherence in ESRD patients

In essence, clinicians can merge efficiency and the knowledge of the above factors into routine patient visits with- out greatly adding to the amount of time spent with each patient. To help reduce the likelihood of non-adherence, the dialysis team should address matters concerning adherence at the time for writing prescriptions or reviewing forthcoming lifestyle alterations and appointments. Give realistic short-term goals for the patient to achieve and feel more motivated.

Other steps can include:

  • Provide solid communication and bedside manner to develop trust. Clinicians should recognize positive traits that the patient has, and utilize it for their benefit in getting healthy. Furthermore, address fallacies concerning the illness, side effects of each medication, and fortify positive beliefs about treatment.
  • Apply motivational interviewing techniques where possible. This gives the patient a sense of empowerment and responsibility to get better. Moreover, it assists in illustrating value of consistently adhering to medication regimens.
  • Identify and address general barriers to adherence. Formal valuation of broad barriers do not need to be conducted with every patient; however, the caregiver should evaluate suspected cognitive deficiency with a mental status investigation and question psychopathology, including mood, coping, sleep, and appetite disturbance. Caregivers should always assess inspiration for treatment by asking why they want to undergo treatment, while encouraging them to have personal as well as medical reasons for treatment.
  • Urge the patient to acquire community support for treatment. When making lifestyle changes, family and friends can aid with praise and motivation during the action stage, and with stimulus control and reinforcement during the maintenance stage17 [see Table 2].
  • Search for support groups for others making similar changes (i.e., Alcoholics Anonymous), as they can be helpful in reinforcing positive health motivations and activities, and in providing good role models.
  • Frequent follow-up can be helpful—phone calls, letters, or e-mail from nurses or other clinic staff can advance adherence considerably by responding to patient questions, supervising and addressing patient-initiated cessation of treatment, and reinforcing motivation for persistent engagement in medical treatment or lifestyle change.

PatientManagement-table2

Identify and address non-adherence

In a follow up, compliance of medications needs to be addressed, implementing the following techniques. Let this topic be all about the patient at home.

  • Inquire about any side effects connected with or without adherence.
  • Let the patient see that you are there to support them in their journey to get healthier.
  • Address non-adherence from the patient’s perspective (i.e. ‘Your labs are good because you are on this medication.’)
  • Ask questions such as, ‘Have you been following your medication schedule?’ or ‘Do you need any refilled prescriptions?’

Dealing with ceaseless non- adherence

Non-adherence is wearisome for both the clinician and the patient; this can hinder the relationship over time. While taking note of patient concerns, the clinician may give light to symptom remissions, as well as improving laboratory marks. Moreover, the caregiver should address how this can affect their relationship with the patient; if necessary, the caregiver could give unambiguous conditions to meet if they anticipate continuing treatment. Conversely, clinicians should be aware and understand that meaningful change takes time.

Summary and suggestions

Adherence to medications pre- scribed by the physician is associated with better clinical outcomes. Patient factors that may be involved with adherence include cognitive impairment, psychopathology, the patient’s motivation for treatment and change, and the patient’s health literacy. Other factors are under the umbrella of patient follow-ups and patient to physician relationships. Aspects specific to medication compliance include medication side effects, the obstacle of the medication regimen, the worries of medication adherence (i.e., inconvenience, cost, and obligatory changes in lifestyle), and patient opinions about medication convalescence. Factors specific to lifestyle adherence include the patient’s willingness to make changes, the burdens of lifestyle changes, patient theories regarding lifestyle changes, and the obtainability of peer support for lifestyle changes.

Clinicians can work to grow the probability of adherence proactively by explaining the foundation for treatment in language the patient can comprehend, utilizing motivational interviewing methods, detecting and addressing hypothetical difficulties to adherence, and collaborating on the strategy of treatment. Clinicians should identify non-adherence and its causes by inquiring questions about adherence, and by asking about medication side effects and the burdens of lifestyle changes. Clinicians should try to address issues by working from the patient’s perspective. An excellent clinician-patient relationship is key.

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