PATIENT MEDICATION ADHERENCE

What you need to learn? Definition of patient medication adherence Consequences of patient non adherence Types of non adherence Causes for non adherence How to measure medication non adherence Methods to improve adherence

Patient medication compliance/adherence (الامتثال / الالتزام) Usually refers to whether patients take their medications as prescribed Main factor that determines treatment success Compliance-obeys to take medicine on physician advice Adherence: physician-patient collaboration (تعاون) “The extent to which a person’s behavior corresponds to the agreed recommendations from a health care provider”

Types of non adherence: Primary : prescription written by physician but not filled/dispensed Secondary: patient decide to stop taking medicine without physicians advice Tertiary-medications are not taken as prescribed. Intentional (مقصود )-patient decides not to take medication Unintentional (مقصود... )- patient may be careless or forgotten doctors advice

Consequences (العواقب) of non compliance: increased mortality low quality of life disease progression hospital admissions increased medical and non medical cost waste of medication

Medication adherence is very important in: Chronic diseases Diseases where serum drug concentration should be maintained-antiepileptics Diseases which affects the health of public Replacement therapy-insulin

Reasons for noncompliance There is usually no single reason for medication nonadherence-multifactorial. WHO divides it to five:

Therapy related factors Complexity of medication regimen- number of drugs, dosage frequency Type of dosage form- large oral, MDI Previous treatment failures- heart problems Duration of therapy- tuberculosis, RA Occurrence of side effects – aspirin ulcer Problems with handling of medicines- child resistant, transportation

Patient related factors Physical impairments Cognitive (المعرفي ) Vision Hearing Psychological/Behavioral Anger, stress, anxiety Low self efficacy(انخفاض الكفاءة الذاتية ) Substance abuse (تعاطي المخدرات )

Condition-Related Factors Asymptomatic chronic diseases High blood pressure High cholesterol Osteoporosis (هشاشة العظام) Mental health disorders- denial of illness Mood disorders Depression Bipolar Dementia Psychosis

Health System-Related Factors Quality of provider-patient relationship- lack of confidence Level & quality of communication-inadequate patient information Access to healthcare Physical Cost Ease of scheduling appointments- ability to get medicines

Social/Economic-Related Factors Low literacy (محو الأمية منخفضة ) Lack of health insurance Cost of medications Burdensome work schedules Poor social support- family problems Cultural beliefs and attitudes incorrect information from other sources

Methods for measuring adherence: Direct methods directly observed therapy- TB measurement of level of medicine/metabolite in blood -antiepileptics Indirect methods Patient questionnaires/self reports Pill counts Patient diaries Electronic monitors Clinical outcomes

Measures to improve medication adherence Education of the health care workers Labeling and packaging Oral/written instructions/audio-visual materials to patients/ family members Provide proper information about their illness and treatment and address misconceptions (المفاهيم الخاطئة ) Tailoring (الخياطة )the regimen to patients convenience-match it with normal daily routine

Sustained release (الافراز المتواصل )and long acting medication decreases the frequency Transdermal and depot preparations improve compliance Simplification of medication regimen-based on the patient characteristics Review the prescription –reduce frequency and multiple drug therapy where possible-fixed combinations/polypills

Communicating with the patient-counselling Address the key information about the drugs (what, why, when, how, and how long) Inform the common side effects and those that patient should necessarily know Medication adherence improving aids(medication diaries, pillbox, medication calendar, alarms, telephone/mail,unit dose dispensing )

Pillbox

Pill dispenser

Epill

Blister pack

Improve patient-pharmacist-physician relationship Regular pharmacist follow-ups &maintain patient contact

Coping with illness التعامل مع المرض

There are different factors affecting coping with illness as stress (إجهاد), motivation(حافز) and personality disorders.(اضطرابات الشخصية) The pharmacist is in good situation to increase the coping of patients with illness

STRESS Around 85% of illnesses are psychosomatic (نفسي ). Stress is a combination mental, physical and emotional symptom affecting most of the body system.

Causes of stress Environmental factors: surrounding people, work family problems, partners, divorce, unbalanced life, unexpected events, changed values, frustration (إحباط). Personal factors: super sensitivity, jealous, selfishness, personality disorders. Chronic diseases: multiple diseases. Multiple factors : combination of all of these

Signs and symptoms of stress 1. Physical: Headache, fatigue, dyspepsia, nausea, vomiting, heartburn,cold skin, hairfall,sweating, decreased appetite, over breathing,palpitation,cramps,excessive yawning 2. Mental: Confusion, decreased concentration, poor memory, poor self image, Improper perception, anxiety, Insomnia, polysomnia, increasing feeling of isolation, nightmares.

3. Emotional: depression, irritability, nervousness, moody, lacks of interest. Habits: Inability to relax, drinking more tea,coffee, alcohol, smoking more cigarettes.

Treatment of stress Biofeedback Change of environmental factors. Multivitamins, trace elements, minerals. Exploring problems to others. Medicinal herbs: valerian