Recognize, head off common compliance issues

The patient factor

It was a routine telemanagement call to keep an elderly male patient on the right track with his CHF treatment. He informed the nurse that he had just flushed all his medications down the toilet.

"He said, I’m done. I don’t want to do this anymore,’" recalls Karen Stemmer, MSN, RN, clinical care coordinator at the University of Michigan’s Heart Failure and Transplantation Management Center in Ann Arbor.

She had to call back the next day to talk to the patient about the serious symptoms he was beginning to experience. When he realized that they would get worse and affect the quality of his life, he learned he really needed to follow his doctor’s instructions.

Nurses say that patients who become frustrated often take matters into their own hands. This is particularly common with older people. However, few announce their noncompliance and tell you the moment they have deviated from their treatment plan. Most clues are subtle. But experts say the hints are there if you know what to look for and what to ask.

"There’s usually a reason they are not compliant and you can get them to fess up," Stemmer says. "You just have to work with them."

Aside from the telephone, another place she works with patients is in a weekly hour-long class her facility holds for all CHF patients. It’s a good place to revisit and relearn the important features of their treatment. Stemmer says she is always looking for chances to remind patients about their weight, diet, or medication.

Doctors can look for ways to aid compliance as well. Here are some suggestions on how to recognize and handle situations where patients often stop following your instructions:

Christine K. O’Neil, PharmD, associate professor of clinical pharmacy at Duquesne University in Pittsburgh, says if you’re not thinking about patient compliance, you should be. On average, half the patients receiving medication and instructions don’t follow the doctor’s words to the letter. Often patients do not understand the nature of chronic illness. "[Chronic illness] tends to have the worst non-compliance rates," she says, "because the treatment doesn’t make them feel better." Patients may not realize that they are taking medication to prevent their condition from becoming worse, she says. "The patients aren’t thinking that far ahead."

Patients need to understand their condition and what specifically the medication is doing to control heart failure, says David Roffman, PharmD, BCPS, associate professor at University of Maryland’s school of pharmacy and a therapeutic consultant in the cardiac care unit at the University of Maryland’s Medical System, both in Baltimore.

"This is my heart pill’ isn’t really good enough to enhance motivation," he says. "If they know that their ACE inhibitor helps them live longer, then that will help with compliance," he says, adding, "If they know they are preventing a stroke or MI, they have a little more impetus to take the stuff."

The bottom line: Make sure patients know you are prescribing specific drugs for practical reasons. For example, tell patients that some improve exercise capability. Others prevent them from accumulating fluid that causes the shortness of breath and legs to swell, he says. "Very few patients have that level of knowledge." (See related article on starting a telemanagement system, p. 4.)

Understanding the elderly patient

A quick assessment of the patient’s faculties can tell you a lot about what compliance issues can arise. Making sure a patient can hear you, see clearly, read instructions, remember what to do and pay for medicine can handle a great deal of compliance issues.

"Make sure they can hear instructions," says Katy Scherger, RN, a geriatric nurse practitioner at the University of North Texas Health Science Center in Fort Worth. The patient who is smiling and nodding may not be able to hear you but is too embarrassed to say so, she says. Ask a question. Make sure you are being heard.

Also, remember that as patients age, they experience yellowing in their eyes, Scherger says. That makes it difficult if you refer to pills by their usual colors, since the patient may see them in different shades. This is especially common in seeing white pills as yellow or telling the difference between blue and green ones.

Try to avoid sources of frustration as well. (And yes, it will mean less frustration for you, too.) A patient may not be able to open a childproof bottle because of arthritis. Easy-opening lids are helpful for households with no small children. Also, something as simple as keeping a magnifying glass with medicine can help patients read instructions on the jars and the information from the pharmacy. It also can give patients a better look at the products themselves. Even the way the medication is prescribed can help, too.

"Once-a-day drugs are really the choice here," Roffman says. "There’s enough out there to choose from," he says, but notes there may be an exception with some diuretics.

A doctor may not have enough time to help the patient develop a medication strategy, but someone from the office should help tailor a routine that works.

"Set up a system," Roffman says. "Keep medicine in a specific place that [patients] will go to every morning, so it’s visible."

Here is where compliance devices can help. There are pill boxes that can be filled with a week’s or even a month’s worth of pills. Some even have built-in alarms. In addition, there are beepers and paging services that can remind patients to take their medicine when the time arrives.

"Gadgets are useful if patients are willing to use them," says O’Neil. Pill boxes are OK if people remember to fill them, she says. Here is another area where arthritis may be a hindrance, since patients may remember to do it but physically be unable to open the little doors to put the medication inside.

"A lot of my patients use shot glasses and peanut butter lids," she says. One gentleman who was very organized started using a pill box but was unable to fill it because of his arthritis. He switched to using different peanut butter lids for three different times of the day. At the end of the day, he filled the three lids again.

Roffman says the benefit of using the marked pill boxes for each day or for each time of the day is that once they are filled, patients know they took the medicine if the particular day or hour box is empty. This is helpful for patients who have trouble remembering if they took a specific dose. "That’s something you can’t tell just by looking at the bottles," he says.

"It helps to keep a wallet card," says Hildegarde J. Berdine, PharmD, a clinical assistant professor at Duquesne. Patients should write down all medications, times to take them and any other instructions, she says. They should bring the wallet card to all doctor’s appointments so they can update it whenever something changes.

O’Neil notes that a compliance aid is a very individual tool and an office staff may be able to help the patients find a device that is easy for them to afford and use.

Consider patients’ finances

A doctor may not think about whether a patient can afford a prescription or even a scale to weigh every day. But nurses say compliance often comes down to having enough money to follow what the doctor says to do.

"We may keep wondering why a patient’s blood pressure is so high," says Sherger. "Come to find out he couldn’t afford the prescription so he never got it at all." It’s a good idea to ask if patients have a drug plan, she says, or even to come right out and ask if they can afford to pay for the medicine. Since so many people in this age group are on fixed incomes, compliance may be a casualty when it’s a matter of buying medicine or food.

And while you consider your patients’ budget, retail pharmacist Lynette R. Bradley says you can learn a lot about the socio-economics that can destroy compliance. The doctoral candidate is studying how literacy levels in Baltimore’s urban areas affect how well patients follow medical instructions.

"I noticed a lot of retail pharmacies give out information, but people throw it away," she says. The problem is that most of it is written at an 11th grade level. Materials written at the fifth grade literacy level were much more helpful, she says, especially if the patient is directed to go talk with the pharmacist after the appointment.

A doctor can make that meeting most effective by making sure patients know a bit about their particular condition so the pharmacist can give specific advice and information. Also, keeping a good stock of sample medications can help, too, she says, in cases where physicians can accumulate enough to keep patients in supply between visits or to supplement what the patients can afford themselves.

There are other compliance issues that are particular to women. Besides their greater age and severity of disease, women are three times more likely to develop coughing as a side effect of ACE-inhibitor therapy, says Amparo C. Villablanca, MD, director of the Women’s Cardiovascular Health Program and Clinic at the University of California, Davis, School of Medicine and Medical Center.

The greater chance of cough does not mean doctors should be reluctant to treat female patients with these medications, however. "It’s a nuisance," she says, suggesting doctors tell women to be on the lookout for the side effect and be ready with a substitute therapy such as angiotensin-two receptor antagonists or drug combinations if coughing becomes a problem.