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10. Address Adherence and Life Style Modifications

Poor adherence can limit the effectiveness of therapies. In asymptomatic conditions such as hyperlipidemia, this can be especially problematic. Long-term adherence to drug therapy for chronic conditions is estimated to be only about 50%. Adherence in clinical trials is often much higher, due to multiple factors including patient selection, close monitoring and educational efforts of medical staff.

Some factors associated with poor adherence are number of drugs, complexity and frequency of drug administration, adverse side effects, asymptomatic conditions, cost and psychosocial problems.

The first step is to identify potential adherence. Some signs of non-adherence include missed visits, inability to reach by phone, medication refill history, rescheduling of appointments, complaints about office visits, impatience during visits, failure to achieve therapeutic goals, and change in health care provider(s).

Suggested ways to improve adherence include asking about compliance in a non-threatening way at each visit; simplification of the drug regimen (frequency and complexity); reminder systems; drug-count devices; pill minders; involvement of family or friends; a health care team approach including nurses, dietitians, pharmacists and educators, in addition to physicians; written instructions; and educating the patient about the medications, including potential adverse effects, importance of therapy, realistic goals, necessity of lifelong treatment, and importance of continued attention to non-pharmacologic therapy (i.e., diet, exercise).

Additionally, the doctor-patient relationship can play a key role in improving compliance, in part through the physician's efforts to understand the patient's perspective on compliance.


Assess the patient's knowledge of his/her medication and medical condition:

"Can you explain why you are taking this medication?"
 
"How do you take your medication (with food or on an empty stomach; in the morning or the evening)?"
 
Assess the patient's medication administration process:


"Many patients have difficulty remembering to take their medication.  From what you recall, have you ever had trouble remembering to take your medications?"

"How do you remember to take your medication each day?  Do you use a reminder device such as a pillbox or alarm?"
 
Assess the patient's barriers to adherence: 


"What is the most difficult task for you in reaching your cholesterol goal?"

"Are you comfortable with your ability to follow the treatment plan that we have designed for you?"


"Are you experiencing any unusual symptoms that you fear may be due to your medication?"
"Is the cost of your medications interfering with your treatment?"
 
For more information on adherence please refer to Appendix D, "NCEP Recommendations on Strategies to Improve Adherence."

(Insull, 1997 [R]; Morris, 1993 [R]; Nichols-English, 2000 [R]; Riesen, 2004 [R])

Lifestyle Modifications

With the patient, review key lifestyle changes and set priorities and goals. Reinforce lifestyle modifications as described in Annotation #2, "Initiate Lifestyle Modification."