Faculty Peer Reviewed
I distinctly remember being 9 years old, sitting in my doctor’s office after a cold left me struggling for breath, doubled over and wheezing, when he told me that I had asthma. At first I didn’t believe the diagnosis, despite the fact that the albuterol inhaler he had given me was like a breath of life after running suicides on the soccer field. I wasn’t sick or weak! My father insisted I needed to “build my breath up,” and I believed, as he did, that enough running would cure me of all my ills. I remember, more distinctly still, looking disdainfully at the steroid inhaler the doctor had given me, with its clunky plastic “spacer,” a device designed for babies who couldn’t take the medication properly. I took the inhaled corticosteroid (ICS) only sporadically until giving up on it completely. While I had conceded that the albuterol helped, the concept that I needed to take a medication daily was too much to bear, and although the results of taking albuterol were apparent, this other inhaler provided no relief of symptoms, and after a week of solid use, my attacks still came. What good was the thing?
Regular use of inhaled anti-inflammatory agents plus bronchodilators is the mainstay of asthma treatment and can provide excellent control of symptoms with few side effects. Unfortunately, most asthmatic patients fail to take their medications as prescribed, with compliance rates as low as 30%. The reasons for such high non-compliance rates are complex and varied. Buston and Wood found, in a 2000 study that asked adolescents to describe their reasons for non-compliance, that 50% of those questioned attributed their non-compliance to forgetfulness. They reported that changes in daily routines, such as vacations, holidays, and weekends made them less likely to remember to take their daily medication. The perceived ineffectiveness of the medication also caused adolescents to miss doses, as they felt fine. Denial, difficulty using the inhaler, inconvenience, embarrassment, and fear of side effects were all noted to contribute to poor compliance among adolescents. Children who suffered the negative consequences of poor compliance, such as hospitalization, and those whose parents were most persistent in reminding their children to take their medication, were more likely to comply with their medication regimens.
Children may be guilty of invincibility and forgetfulness, but adults are no more compliant than their younger counterparts when it comes to medication compliance, and for many similar reasons. Adults are just as likely as children to misunderstand or forget their disease management, they hold similar fears of medication side effects and dependence, and they are often unable to properly take their medications. Even those with severe illness misuse their medications. Only 50% of patients on nebulizer or oxygen therapy properly follow their treatment plans.
The proper management of chronic diseases requires an honest partnership between the doctor and patient, but patients are reluctant to disclose their non-compliant behaviors and doctors have a difficult time exposing improper medication use. A good doctor-patient relationship begins with rapport building. Nonverbal behaviors, such as leaning forward to reduce social distance and active listening to indicate attention, coupled with praise of compliance and encouragement, can send a powerful message to newly diagnosed patients that their doctor is a partner in treatment and not an adversary. The 11-item asthma-specific version of the Beliefs About Medicine Questionnaire can identify patient doubts and concerns about medications so that physicians can identify poor adherence and their patients’ personal barriers to treatment and can then properly tailor treatments that will lead to better compliance.
Fifty percent of adults and children fail to use metered-dose and dry-powder inhalers properly. Many have trouble timing inhalation with medication release, and spacers are bulky and inconvenient. Patients should be asked to demonstrate inhaler use at each visit and instructed on proper technique. Devices that check inhalation rates can assist patients at home. However, after instruction, 50% of adults continue to use inhalers improperly. In such cases oral agents should be strongly considered. Tailoring therapies to the individual patient is a must. The use of combined inhalers or oral medications, repeated attempts at training, easy-to-use inhalers, and dry powder inhalers for children and the elderly can improve compliance substantially.
I’m not exactly sure what factors led to my noncompliance as a young patient. I experienced embarrassment at the diagnosis, I felt distant from my white-haired PCP, and I failed to understand the concept of chronic disease treatment and the use of my long-acting corticosteroid inhaler. My father certainly nagged me about using the thing enough, but it never sank in until I ended up hospitalized at 16, frightened that something as insignificant as asthma could have such a serious consequence. A 1994 study conducted by Yeung and colleagues demonstrated the observer effect beautifully. The simple act of knowing they were being monitored led patients to be more compliant with their asthma medications . Perhaps it is that simple. Once you have explained the diagnosis; once you have gone over the medications, their uses, benefits, and side effects; once you have seen the technique and adjusted the dosing; let your patients know that you are tracking their progress. Perhaps if my doctor had asked, I would have express my doubts about the need for an ICS and I could have avoided years of dangerous poor disease control.
Kristen Mattei is a 4th year medical student at NYU School of Medicine
Peer reviewed by Linda Rogers, MD, Pulmonary Medicine, NYU Langone Medical Center
Image courtesy of Wikimedia Commons
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