Poor Compliance:

JULY 01, 2003
Greta M. Pelegrin, PharmD

Treatment regimens are only effective if the patient is willing to follow the plan. Compliance, the extent to which a patient adheres to a treatment regimen, primarily involves following the medication instructions, but it also can include lifestyle modifications, as well as keeping follow-up medical appointments?in general, it means overall participation in the treatment plan. Noncompliance may lead to relapse, aggravation of the disease state, hospitalization, escalating health care costs, and even death. In patients suffering from emotional disorders, noncompli-ance may result in serious setbacks to the progress they have already achieved on a regimen, whereas patients on antihyper-tensive medication may increase the risk of stroke and cardiovascular disease. Pharmacists can have a major impact on compliance rates. This article outlines the reasons behind noncompli-ance and provides 4 strategies for improving compliance.

Reasons for Noncompliance
Noncompliance may be difficult to detect or address. Elderly patients and teenagers have higher rates of noncom-pliance than other segments of the population. Generally speaking, patients often lack enough information about their disease state or medication; they may have physical or functional impairments such as poor eyesight; or barriers may exist relating to attitude, such as personal values and culture. Factors leading to noncompliance are numerous (Table), and some of the major reasons for patient noncompliance are outlined here.

Adverse Effects
It is understandably difficult for patients to follow a treatment that produces discomfort. Certain adverse effects associated with a class of drugs must be dealt with on a case-by-case basis. Many side effects subside with continued use of the medication, but it may take time for a patient to overcome this barrier. Compliance also may be impaired if a patient is not warned, ahead of time, of the potential side effects associated with a drug. For instance, a patient with a major depressive episode may be willing to tolerate the side effects of antidepres-sant medication if he or she is assured of obtaining relief in the long run. Therefore, patient confidence is reinforced if the patient is cognizant of the potential side effects.

Lack of Knowledge About the Drug
A high risk of noncompliance exists for patients who do not fully understand how a medication will improve their health, as opposed to patients who are familiar with the mechanism of action of the drug and can visualize the long-term effects of compliance. It is essential that patients understand how a treatment regimen will impact their disease. Yet, too often the patient lacks sufficient knowledge to take the plan seriously.

Cognitive Impairments
Many elderly patients have cognitive impairments that may affect their ability to understand or follow recommendations regarding their medications. Because older adults often are on multiple medications to treat their illnesses, cognitive confusion may result in a higher risk for adverse drug reactions or hospitalization due to noncompliance.

Complex Drug Regimens and/or Multiple Dosing
Not surprisingly, compliance has been shown to drop as the number of medications taken daily increases. The elderly population is at a high risk of noncompliance because polypharmacy is quite common in this age group. If a medication regimen is too complex?requiring that the drug be taken with food, at night, or within hours of vitamins or antacids?the patient may be confused and may not fully comply. Furthermore, if a medication is dosed more than once or twice daily, certain doses may be missed, resulting in sub-therapeutic effects. Identifying ways to simplify the regimen?such as using 2 drugs in a combination pill or once-a-day dosing versus multiple dosing?can improve compliance.

Solutions to Noncompliance
Although there is no simple solution to the problem of poor compliance, certain strategies can be implemented. They must be patient-specific, and they require that the health care provider take a little extra time with a patient. These strategies include the following techniques.

1.Simplifying the Medication Regimen
The simpler the regimen is, the higher the rate of compliance is. If a confusing dosage regimen is the cause of noncompliance, therapeutic alternatives (eg, once-a-day dosing) should be considered to ensure that the patient will adhere to the treatment plan.

2.Educating the Patient About the Disease
Patients need to be properly educated in a clear and concise way about their disease states and the need for treatment. Persons with hypertension, for example, will be more likely to comply if they understand the risks of high blood pressure?especially important because they generally feel fine.

3.Explaining Potential Side Effects and What to Expect
If side effects are not addressed initially, patients commonly will eventually stop taking the medication. Pharmacists should discuss with patients not only the potential side effects associated with a drug, but the importance of consulting with their physician if an adverse effect becomes intolerable, so that an alternative drug may be substituted. Points to cover with patients to improve compliance include the following:

  • How the medication works
  • How the medication is dosed
  • Major adverse effects
  • What to do in the event of an adverse effect
  • How the treatment will be followed or monitored

4. Encouraging the Use of Patient Reminder Aids
Another reason why many patients fail to take their medication is that they simply forget. For those patients who have difficulty remembering, cues or reminder aids may be helpful. For instance, patients can integrate taking their medication into their daily routine of getting up, brushing teeth, eating, and so on. Patients also may place colored stickers on a calendar once they have taken a pill. Some patients do well with a pillbox with a compartment for each day of the week. Other memory devices include inexpensive wristwatches with alarms and pill bottles with alarms in the cap that record the exact time the bottle was last opened. Electronic vial tops also are available that provide signals corresponding to a dosing schedule. If the cap is not removed on schedule, the device will beep and flash.

Identifying and measuring compliance can be difficult, but several useful strategies can help improve compliance. Patients should be trained in monitoring their own treatment plan, and pharmacists are in an ideal position to tackle lack of compliance through building a trusting relationship with their patients. The better the pharmacist understands patients and their disease states, the more willing patients will be to accept recommendations. Pharmacists are uniquely positioned to deal with some of the compliance barriers encountered and thereby optimize therapeutic benefits.


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