Hyperglycemia: Medication Non-Adherence & Patient Education

NUR2114A Medical-Surgical Nursing I Written Assignment
Hyperglycemia: Medication Non-Adherence & Patient Education

Hyperglycemia. Upon seeing this word, many would instantly think of diabetes. Diabetes is a precipitating factor of hyperglycemia, though it must be acknowledged that coexisting diseases, infections, substance abuses, antipsychotic drugs, and even noncompliance to prescribed medications can result in hyperglycemia as well (Nugent, 2005; Stoner, 2005). Noncompliance, of all mentioned factors, is currently a major issue worldwide, and is generally comprised of the “failure to fill a prescription, taking an incorrect dose, forgetting to take doses, skipping doses, committing errors in dose timing, and stopping the medication prematurely” (Rickles, Wertheimer & Smith, 2010). Why is this occurring? Could the consequences of it really be that detrimental? And if the consequences are fatal, how can non-adherence be “reversed” so that those suffering from the condition will not experience relapses? The answer to these is extremely significant as they aid health professionals in providing holistic and effective care to hyperglycemia sufferers. With effective management, an overall cessation of the multiplication of the condition would be evident on a global scale. This would not only be beneficial for individuals as they are provided with guidance, but would also reduce strains on economic costs (Rickles, Wertheimer & Smith, 2010).
There are three main areas that contribute to non-adherence to medications for hyperglycemia: physician-, medication- and patient-related. Health professionals are the key to the adherence of medication as they diagnose and council the patient on their medication regimen (NCPIE, 2007). Yet, studies have shown that there’s a lack of counseling due to overestimation of the patient’s ability to adhere to the medication and to poor communication between the two parties (NCPIE, 2007). Patients are not properly informed about the medication regime that they are taking – the purpose of it, their side-effects and how to overcome the side-effects – which would result in them feeling uneasy about undergoing proper treatments. In addition, any impairment in the physician-patient relationship would also lead to significant reductions in compliance as trust between both parties has not been established (Winkler, Teuscher, Mueller & Diem, 2002). The medication regimen itself could be a barrier. This could be due to its complexity, as is the case of undergoing insulin therapy for many (Winkler et. al, 2002), or due to the side-effects of the oral medications ingested. Side-effects result in approximately 45% of discontinuations of medical treatment, as shown in a study conducted in 2005 (NCPIE, 2007). Even with the undivided support and guidance from health professionals, noncompliance can still occur because of the individual him or herself or his and her external factors. We are humans, and are thus governed by our mindset, mood and emotions (Hernandez-Ronquillo, Tellez-Zenteno, Garduno-Espinosa, Gonzalez-Acevez, 2003; Ramirez & Lopez, 2008). There will be times when medication time is skipped due to forgetfulness (Roberts, 2009); excuses of having no time; fear of side-effects and of needles and self-injections; and even lack of motivation and control over eating (Hernandez-Ronquillo et. al, 2003; Ramirez & Lopez, 2008). More importantly, however, is the individual’s self-perception of their condition, belief in the effectiveness of treatment and the lack of knowledge of what their condition is (Ramirez & Lopez, 2008). In fact, Ramirez & Lopez (2008) states that the medications are only taken upon the onset of clinical manifestations of the condition, such as trembling, due to the lack of knowledge of his or her condition. An interesting contributor to non-adherence is depression, and it is most evident in missed appointments. Studies have shown that increased depression in the hyperglycemia sufferer is a result of dissatisfaction with healthcare professionals as there is a lack of empathy, communication and care (Gonzalez, Peyrot, McCarl, Collins, Serpa, Mimiaga & Safren, 2008). The individual’s educational level also plays a role as it facilitates in putting the health professional’s instructions into action. Studies have shown that the more educated tend to appreciate and adhere to medical treatments, whereas the illiterate have more potentials of errors as they are unable to distinguish their treatments (Sweileh, Aker & Hamooz, 2004; Deary, Gale, Stewart, Fowkes, Murray, Batty & Price, 2009). External factors that would be of hindrance to effective illness recovery are the cost of medications (which do tend to be very expensive, unless they are heavily subsidized as in the case of Singapore), limited access to health care facilities and heavy work schedules for both the wealthy and the poor (Deary et. al, 2009). The outcome of non-adherence, due to any of the three areas mentioned, can lead to exacerbation of metabolic functions in the body as a result of insulin resistance (IR), which could lead to tissue damage, hypertension, cardiovascular diseases and even death (Falvo, 2010; Jellinger, 2009). It is thus essential that interventions are in place to prevent these situations from occurring. Nurses play one of the leading roles in the prevention of non-adherence and treatment of hyperglycemia, both inside and outside of the clinical setting (Peimani, Tabatabaei-Malazy & Pajouhi, 2010). The bulk of the interventions that are undergone are patient education for the betterment of self-care management, regardless of age group and cause of hyperglycemia. This aspect of the intervention cannot be dismissed as the control of hyperglycemia does require alterations in lifestyle. Its dismissal would result in relapses of the condition (Redman, 2007). Before education occurs, motivational interviewing (MI) is recommended to be undergone (Mahoney, Ansell, Fleming & Butterworth, 2008). MI is a patient-centered and directive method to explore and resolve any feelings of uneasiness or ambivalence that the patient may have in regards to their condition and medication regimen (Mahoney et. al, 2008). Building trust and showing support and care is crucial at this point as a lack of these could contribute to the non-adherence of treatment (Russell, Daly, Hughes & op’t Hoog, 2003). They are given the opportunity to take part, voice out and make decisions in their treatment (Falvo, 2010), which results in the development of a plan of action that is catered to the needs, lifestyle and living situation of the patient to tackle their condition (Mahoney et. al, 2008). With the information obtained, the patient’s main concerns can be alleviated. Cognitive-behavioral therapy and blood glucose awareness training are implemented (Wild, von Maltzahn, Brohan, Christensen, Clauson & Gonder-Frederick, 2007) to deal with the concerns via focused problem-solving and motivational techniques (Redman, 2007), as well as education on how to prevent and spot for symptoms of hypoglycemia (Heller, 2008), respectively. Trepidation of medications prescribed is addressed during therapy. Patients are re-informed about the types of medications prescribed, their purpose, the dosages to partake per serving and their side-effects (Bangalore, Kamalakkannan, Parkar & Messerli, 2007). This is so that they know what to expect when treatment is under way. Bangalore et. al (2007) found that fix-dose combinations of drugs are more effective in medication adherence. Thus, nurses, being the advocator for the patient, can assist in this area by informing doctors of the possibility of prescribing fixed-dose combinations for the patient to reduce polypharmacy (one vital factor of non-adherence).
Alongside medications is the self-administration of insulin therapy. This is one treatment that the patient must be able to master. Nurses guide by instructing the patient on information such as storage of the insulin, injection techniques, blood glucose monitoring, the complications associated with the therapy and the alternative routes of delivery (Joslin, Kahn & Weir, 2005). All of these must be re-assessed and re-demonstrated to ensure that the proper techniques have been taught to reduce complications. Insulin therapy is the core of the control of hyperglycemia, thus adherence to it will most certainly improve the quality of life of the patient. Depending on the cause of the hyperglycemia, nurses should recommend that daily exercise is undergone as it helps in the prevention of obesity and high blood pressure (Joslin, Kahn & Weir, 2005), and well as increases insulin sensitivity in the body which facilitates the uptake of glucose for cellular metabolism (Balkau, Mhamdi, Oppert, Nolan, Golay, Porcellati, Laakso & Ferrannini, 2008). Now we enter new forms of interventions that have been proved effective or useful in increasing medical adherence, and physical and mental health. Devices such as MEMS (Medication Event Monitoring System) (Kheir, Greer, Yousif, Al-Geed, Al Okkah, Zirie, Sandridge & Zaidan, 2010) and the sensor-augmented insulin pump therapy (Hirsch, Abelseth, Bode, Fischer, Kaufman, Mastrototaro, Parkin, Wolpert & Buckingham, 2008) can be used to asses adherence via compilation of the patient’s medicine histories and to view real-time glucose values to be alerted for impending hypo- or hyperglycemia, respectively. These devices are more technical and thus should only be taught to those that are capable of understanding how to use the device in the correct manner (Cramer, Benedict, Muszbek, Keskinaslan & Khan, 2007). With the advancement of technology, alternatives that integrate with media can be used to improve adherence, such as the use of electronic memory aids, reminders and diaries (van Dulmen, Sluijs, van Dijk, de Ridder, Heerdink & Bensing, 2007). Roberts (2009) and van Dulmen et. al (2007) also suggest the use of sms-es to remind patients to take their medications as this has shown to have been effective, alongside giving educational materials so that the patient can re-listen to and re-read the instructions in them at their own free time. The modes of treatment to increase adherence is only effective if it benefits the patient, thus, it is crucial that these modes are identified and put into practice (Russell, Daly, Hughes & op’t Hoog, 2003).
Essentially, the aim of education is to improve the patient’s metabolic control, self-care management, and their ability to detect early complications of the condition (Joslin, Kahn & Weir, 2005), or more generally, their well-being and quality of life of the patient. These are all targeted to prevent exacerbations of their condition.
In conclusion, health professionals, the prescribed medications and the patients themselves are all plausible causes for non-adherence to medications. To tackle these, nurses play a significant role by finding the patient’s underlying cause of non-adherence via motivational interview, then trying to gradually reverse their perceptions of the cause through therapies and education about their medication regime, insulin therapy administration and exercise. If beneficial for the patient, new technological aids can be used to assist them further in the journey to the adherence of medications, such as devices, memories aids, diaries and educational materials. Hyperglycemia is a chronic condition but can be prevented and the nurse can assist in doing just this.

References
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Bangalore, S., Kamalakkannan, G., Parkar, S., & Messerli, F.H. (2007). Fixed-dose combinations improve medication compliance: A meta-analysis. The American Journal of Medicine, 120, 713-719. Retrieved from MEDLINE database. Cramer, J.A., Benedict, A., Muszbek, N., Keskinaslan, A., Khan, Z.M. (2007). The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review. The International Journal of Clinical Practice, 62(1), 76-87. Retrieved from Wiley Online Library database. Deary, I.J., Gale, C.R., Stewart, M.C.W., Fowkes, F.G.R., Murray, G.,D., Batty, G.D., & Price, J.F. (2009). Intelligence and persisting with medication for two years: Analysis in a randomized controlled trial. Intelligence, 37, 607-612. Retrieved from CINAHL Plus with Full Text database. Falvo, D.R. (2010). Effective patient education: A guide to increased adherence (4th ed.). United States of America: Jones and Bartlett Publishers, LLC. 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References: Heller, S.,R. (2008). Minimizing hypoglycemia while maintaining glycemic control in diabetes. Diabetes, 57, 3177-3183. Retrieved from PubMed Central database. Jellinger, P.S. (2009). Metabolic consequences of hyperglycemia and insulin resistance. Insulin, 4(1), 2-14. Retrieved from ScienceDirect database. Joslin, E.P., Kahn, C.R., & Weir, G Mahoney, J.J., Ansell, B.J., Fleming, W.K., & Butterworth, S.W. (2008). The unhidden cost of noncompliance. Journal of managed care pharmacy, 14, 1-32. Retrieved from PubMed Central database. NCPIE Nugent, B.W. (2005). Hyperosmolar hyperglycemic state. EmergencyMedicine Clinics of North America, 23, 629-648. Retrieved from ScienceDirect database. Peimani, M., Tabatabaei-Malazy, O., & Pajouhi, M Ramirez, V., & Lopez, W.A. (2008). Noncompliance in patients with type 2 diabetes enrolled in local diabetes education program. Ethnicity & Disease, 18, 85-86. Retrieved from MEDLINE database. Rickles, N.M., Wertheimer, A.I., & Smith, M.C. (2010). Social and behavioral aspects of pharmaceutical care (2nd ed.). United States of America: Jones and Bartlett Publishers, LLC. Redman, B.K Roberts, J. (2009). Patient compliance: New media tools to help patients take their medications. The Journal of the European Medical Writers Association, 18(4), 218-220. Retrieved from Wiley Online Library database. Russell, S., Daly, J., Hughes, E., & op’t Hoog, C. (2003). Nurses and ‘difficult’ patients: negotiating non-compliance. Journal of Advanced Nursing, 43(3), 281-287. Retrieved from ScienceDirect database. Stoner, G.D. (2005). Hyperosmolar hyperglycemic state. American Family Physician, 71(9), 1723-1730. Retrieved from MEDLINE database. Sweileh, W.M., Aker, O., & Hamooz, S. (2004). Rate of compliance among patients with diabetes mellitus and hypertension. An-Najah Univ. J. res. (N. Sc.), 19, 1-12. Retrieved from CINAHL Plus with Full Text database. van Dulmen, S., Sluijs, E., van Dijk, L., de Ridder, D., Heerdink, R., & Bensing, J. (2007). Patient adherence to medical treatment: a review of reviews. BMC Health Services Research, 7, 55. Retrieved from Wiley Online Library database.