Pharmacotherapy and chronicity: factors and guidelines for good medication adherence
The European Society for Patient Adherence, Compliance and Persistence (ESPACOMP) defines the term "medication adherence" as the process in which the patient takes the medication as prescribed.
Lack of adherence to chronic treatments has become a universal and real problem that affects the effectiveness of these treatments, which is a major public health problem. In figures, the World Health Organisation (WHO) estimates that one out of every two patients with chronic pathologies is not adherent to their treatment; a similar figure (48.3%) to that presented in a Spanish study carried out in 2014 on polymedicated people over the age of 65.
Not taking medication properly can have certain consequences such as a reduction in quality of life and life expectancy, ineffectiveness of treatment and worse control of the disease, which translates into greater complications and clinical worsening, an increase in medical consultations, hospitalisations and complementary tests, with the consequent negative impact on health expenditure.
In general, adherence tends to be highest at the start of treatment and in those of short duration, but tends to decrease in prolonged treatment, as well as in polymedicated patients or in groups where it is more difficult to monitor treatment. This lack of adherence may be intentional, when there is a clear desire on the part of the patient not to take the medication, or unintentional, related to the loss of memory or autonomy of the patient, the complexity of the treatment, the lack of creation of daily routines and habits, the severity of the pathology, etc.
We are talking about a complex and multifactorial process, mainly conditioned by factors related to the patient, the treatment and the healthcare environment.
In the first of these, the gender gap should be highlighted. They show greater adherence to treatment. Other aspects to be taken into account in relation to the patient would be: the presence of mental problems, the level of training/education (the lower the level, the less adherence), the lack of knowledge of the disease and/or of confidence in the benefit of the treatment, the loss of independence for the development of daily life activities, the presence of multiple comorbidities, alcoholism, etc.
Among the factors related to the treatment, aspects such as the complexity of the treatment, polytherapy, multiple daily doses, use of an inadequate pharmaceutical form (difficulty in breaking up tablets, lack of suitability in swallowing problems, etc.), cost, the appearance of adverse effects, etc., should be noted.
Finally, in the section on the healthcare environment, the doctor-patient and/or carer relationship should be highlighted, as well as other aspects related to the health system (medical consultation times, many prescribers, inadequate follow-up, etc.) The quality of the communication and healthcare received, the empathy or capacity to motivate on the part of the healthcare professional have an impact on the patient's behaviour.
Although there are currently various methodological approaches to determine adherence to treatment (Morisky-Green questionnaires / ARMS-e, medication counts, electronic devices or pharmacy records), in interventions with older people with a multi-pathological and chronic condition, the monitoring process becomes more complex. In cases like this, a combination of several methods is needed for evaluation, with the following guidelines available to improve adherence to treatment:
- Comprehensive geriatric evaluation.
- Empowerment: making the patient a participant in their treatment.
- Optimisation, simplification of pharmacotherapy, therapeutic adaptation to the need for shared decision-making with the patient and/or carer.
- Use of devices to remind patients to take their medication.
- Promotion of communication skills and knowledge of health professionals.
- Periodic assessment of adherence.
- Integration of health services, through greater communication between primary care and hospitals.
In short, it is necessary for the strategies proposed to be multidisciplinary, with longitudinal and individualised monitoring, and educational, and that they promote the reduction of pharmacotherapeutic complexity, ensuring at all times another aspect that seems fundamental, such as communication between patient/carer and healthcare professionals.
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