Download Non-adherence to treatment

Non-adherence to treatment
Clinical Coaching
Brief Advice
Behaviour Change Councelling
Motivational Interviewing
Topics
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Non-adherence to treatment
Motivation
Clinical Coaching
Brief Advice
Behaviour Change Councelling
Motivational Interviewing
Adherence to treatment
Adherence vs. compliance to treatment
• Adherence: active involvement of the patient
in treatment processes
• Compliance: patients simply follow doctor´s
orders
• Better adherence = better clinical outcomes
Non-adherence to treatment
30% of
patients
• Taking too little (drug or excercise too little, etc..)
• Taking too much
• Not taking at the prescribed intervals (or excercising too or
less frequently as required)
• Taking other medication without the knowledge of the
prescribing medical professional
• Not taking the treatment for the prescribed duration
Examples?
Clinical example: Course of psychotic disorders and the
prescribed duration of the treatment
C
C
Early
warning
signs
1st.
attack
Remission
Early
warning
signs
1st.
relapse
Antipsychotics (neuroleptic medication) for psychotic
disorders:
Recommendation for the relapse prevention
• After 1-st episode: 1-2 years
• After 2nd episode: 5 years
• Three and more episodes: life-long treatment
Reality?
Psychotic disorders:Treatment nonadherence
nonadherence
(%)
76%
69%
40%
33%
25%
10 days
discharge
6 months
12 months
Perkins, 2002; Kamali et al., 2006, Lam et al, 2002; Weiden et al., 1997
24 months
Why?
Psychological factors:
Depression;
Attitude, beliefs,
perceived benefits
Disease factors:
No or few or mild symptoms
Fluctuating course
Lack or no insight
MD´s factors
Ability to communicate
and provide information
Treatment factors:
Complex regimen
Side effects
Psychosocial factors:
poor support
Healthcare factors:
Poor availability,
Long waiting time
Case: Jirka
Promoting adherence
• Discuss the patient´s beliefs, concerns, and intentions relating to
treatment
• Where possible customize the regimen in accordance with the patient´s
wishes
• Simplify the regimen
• Provide simple, clear instructions for taking medication
• Elicit the patient´s feelings about his ability to follow the regimen and
discuss stratgegies for enhancing adherence
• Consider the use of medication-taking systems including electronic
reminders
• Emphasize the value of prescribed regimen and the importance of
adherence for producing the best treatment outcomes
• Obtain any necessary help from family members, friends, etc.
Promoting adherence
• Monitor adherence. Watch for the mardkers of nonadherence
such as missed appointments, missed refills, and a lack of
response to medication
• Express approval of adherence and encourage continued
adherence.
• Ask the patient about nonadherence and barriers to
adherence in an understanding, non confrontational way
• If adherence appears unlikely, prescribe medication with lon
half-lives, depot (extended release) or transdermal
medication
How to do it???
Adherence and nonadherence:
Patient´s attitude not
symptom!
How to influence
patient´s attitude?
What do they
have
in common ?
Clinical Coaching
Doctor educates to the
patient´s needs
doctor
searches for inner motives for
change,
addresses ambivalence
respects wishes,
solves problems together
Education
Motivational
Interviewing
doctor
as sparingpartner, shares knowledge,
communicates comprehensibly,
respects patient´s opinion, negotiates
procedure,
offers choice
Barrier-free Access
Intervention Brief Advice (BA)
Time
Setting
Goals
Behaviour Change
Councelling (BCC)
5-15 minutes
Mostly opportunistic
5-30 minutes
Opportunistic or helpseeking
Demonstrate respect,
BA + Establish rapport,
communicate risk,
identify client goals,
provide information,
exchange information,
initiate thinking about choose strategies based
change in problem
on client readiness, build
behaviour (Ask, Assess, motivation for change
Advise, Assist, Arrange)
Practitioner- Active expert – Passive
recipient
recipient
Councelor-active
participant
Motivational
Interviewing (MI)
30-60 minutes
Mostly help-seeking
BA + BCC+ develop
relationship,
resolve ambivalence,
develop discrepancy,
elicit commitment to
change
Leading partner partner
Motivational Interview
How to influence the clients´s
attitude and promote behavioural
change
Motivational Interviewing
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Diet and physical activity change
Smoking cessation
Behavioural and drug addiction councelling
Medication adherence
HIV prevention
Chronic illnesses: diabetes and cardiovascular diseases
Public health problems: preventing infection (ebola!!)
Motivation
What is your
motivation to
study
medicine?
• Motivation is a drive to act
• Motives:
• Biological (to eat, to reproduce): to ensure
homeostasis of an organism
• Psychological and social (to achieve particular
status, need to influence or control others; to
make impression on others..)
Theory of motivation:
Incentive theories
• External factors trigger and regulate
motivation
• Expectations and values
• Knowing more about motives means we can
address the situation more constructively
Theoriy of motivation:
Drive theory
• Drive theories: behaviour to ensure the
stability in bodily functions that is necessary
to survive.
• A lack of equilibrium between our current
state and our needs creates a tension which
we are motivated to reduce
Give an example of a
disorders with strong
motivational component
Give an example of
abnormal extremes of
biological drives.
Motivation to drink alcohol
????
Craving
• Strong motivational effect
• Worsening of cognitive functions
• Physiological symptoms: increase of heart rate and
increase of skin conductance
• The same as stress
Reward System
Basic neurobiological system for survival and reproduction.
A collection of brain structures to regulate and control behavior
by inducing pleasurable effects.
When activated, reinforces behaviors.
dopamine
Primary evolutionary
natural incentives:
air,
water
food,
Sexual partner
Safety
Reward System: Abused by drugs!
Nonnatural
incentives:
Drugs:
Activate the systém
more than natural
podněty and
Change the activity
of the reward systém