Important to follow doctor’s orders

By Dr M. RADZNIWAN A. RASHID

EVERYBODY wants to get better, but how many people actually follow their doctor’s advice and recommendations?

This includes taking medication, following a diet, and/or executing lifestyle changes.

Not following your doctor’s recommendations can have negative consequences not only for the patient but also for the provider, the physician, and the government as well. These include waste of medication, disease progression, reduced functional abilities, a lower quality of life, and increased use of medical resources such as nursing homes, hospital visits and hospital admissions.

Diabetes is not an exception where non-adherence to medication causes detrimental effects to health and gives rise to serious economic consequences.

Diabetes and its complications remain a major concern in healthcare management where many patients have poor glycaemic control. When the control becomes poor, patients are prone to complications such as to the heart, eyes, brain, kidneys and nerves.

They can even die early from heart attack or stroke. A study conducted in Malaysia found that 58% of patients with diabetes had neuropathy or nerve damage, 53% had retinopathy (damage to retina), 8.6% had cardiovascular diseases, 5.6% had stroke, and 1.9% had amputation.

Current recommendations to achieve good sugar or glycaemic control targets, as assessed by HbA1c (glycated haemoglobin) levels, are dependent on age and duration of illness. For instance the appropriate control among elderly diabetes ranges between 7 and 8% of HbA1c. Fortunately, there are medications which can be used to bring down the HbA1c to this target. However despite its proven efficacy, many studies have reported poor medication adherence among diabetic patients.

Hence it is important that steps are taken to ensure all patients adhere to doctor’s recommendations so as to reduce the consequences or complications.

The increasing number of diabetic patients among the 60 and above age group poses a great challenge to healthcare providers as it is not easy to get elderly diabetics to follow the doctor’s recommendations.

Taking many medicines (i.e. “a pill for every ill”) at the same time, termed as “polypharmacy” is one important cause. As we age, the likelihood of having more illnesses would result in having to take multiple medications. It has been reported that almost 20% of elderly in community settings take 10 or more medications.

Some of the reasons which may affect adherence to medications are: the decline in cognitive function such as recognition and memory, as well as physical limitations especially with visual and hearing problems. The lack of information about the illness and treatment plans, complexity of medication regimen, side effects, medication costs, and emotional well being also increase the risk of non-adherence.

Communication is without doubt, a very important aspect to ensure better adherence as poor communication is a major contributor to non-compliance.

Therefore elderly diabetic patients should expect to receive clear communication from their doctors explaining the treatment benefits. Patients on the other hand need to voice their concerns and ask questions if they are unclear on the medication.

Patients are also encouraged to inform their doctors if medications or lifestyle-related recommendations are not adhered to. Expectations or personal goals (such as longer life, reducing symptoms, reducing number of pills to be taken, avoiding adverse effects, reducing costs by using generic rather than “branded” drugs) are best communicated and discussed with your healthcare provider, keeping in mind that decisions agreed upon should be practical and achievable from the patients’ personal point of view.

For example, some elders are more keen to have a good quality of life compared to increasing their lifespan. For example, being able to sit up without support may be better than being bedridden. Repeated medical investigations and procedures are examples which also reduce the quality of life.

Patients can also request their doctors to simplify the medicine regime to promote and facilitate better adherence. For example, using long-acting medications and dosing different drugs at the same time is practical, as is using one medication to treat two conditions when possible.

Doctors also need to “tackle” patients’ family members or carergivers as most of elders rely or depend on family members and trusted caregivers to administer care.

In elderly diabetes, the main concern is not the ability to achieve the desirable HbA1c level but to attain acceptable HbA1c without compromising the patients’ quality of life. This aspect is most often overlooked.

Hence, having a HbA1c that is within an accepatble range without compromising the quality of life (that is without the patient having episodes of hypoglycaemia, or low blood sugar) may be the ultimate goal for the patient.

Support from family members is also important. Those who have good support are more likely to achieve better HbA1c levels compared to those with less family support.

In a nutshell, every individual needs to be treated differently to achieve a better outcome and good medical adherence.

Take home messages:

1. Adherence to medication is very important as it makes your diabetes easier to control and prevents complications.

2. Taking too many medications is a common cause for non-adherence, among others.

3. Make sure you and / or your caregiver read carefully and understand the instructions for medications.

4. Write down the instructions or ask for a copy of written instructions.

5. Write down or record details of any side effects or uneasiness while taking your medicine (side effects /date/time /place). Show this to your doctor on the next visit or immediately if it is too troublesome.

6. Communication is very important. Please talk to you doctors and clarify any doubts.

Dr M. Radzniwan A. Rashid is a senior lecturer in family medicine at the University Kebangsaan Malaysia Medical Centre (UKMMC).

References:

Malaysia clinical practice guideline 4th edition, 2009. MOH/PAK/184.09(GU)

Shalansky SJ, Levy AR, Ignaszewski AP. Self-reported Morisky score for identifying non adherence with cardiovascular medications. Ann Pharmacother. 2004;38(9):1363–1368.

ADVANCE Collaboration Group (2008) Patel A, MacMahon S, Chalmers J, Neal B, et al. (2008) Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 358: 2560–2572. doi: 10.1056/nejmoa0802987

Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, et al. (2000) Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 321: 405–412. doi: 10.1136/bmj.321.7258.405

Huang ES, Liu JY, Moffet HH, John PM, Karter AJ (2011) Glycemic control, complications, and death in older diabetic patients: the diabetes and aging study. Diabetes Care 34: 1329–1336. doi: 10.2337/dc10-2377

Zaini A. Where is Malaysia in the midst of the Asian epidemic of diabetes mellitus? Diabetes Res Clin Pract. 2000;50(Suppl 2): S23–S28

American Diabetes Association (2013) Standards of Medical Care in Diabetes–2013. Diabetes Care (Suppl 1): S11–S66.

Cramer JA (2004) A systematic review of adherence with medications for diabetes. Diabetes Care 27: 1218–1224. doi: 10.2337/diacare.27.5.1218

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