Adherence. Introduction. How Do You Treat Non-Compliant Patients with DFUs? How Do You Treat Non-Compliant Patients with DFUs?

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1 Hw D Yu Treat Nn-Cmpliant Hw D Yu Treat Nn-Cmpliant Gary M. Rthenberg, DPM, CDE, CWS The University f Michigan Medical Schl Clinical Assistant Prfessr Department f Internal Medicine Metablism, Endcrinlgy and Diabetes Divisin UCSF Vascular Sympsium April 8, 2017 N relevant financial relatinships related t this presentatin Intrductin Adherence Prblem patients Difficult patients Trublemakers Negative patient judgment ften challenging and frustrating fr clinicians Cmpliance prvider cntrl ver the patient Prvider centered paradigm Submissin t authrity Cercin Unidirectinal Adherence patient chice Based n the infrmatin prvided The degree t which a persn fllws the caregiver s advice, in terms f taking medicatin, bserving a diet, r realizing a change in lifestyle Nn-adherence can be the intentinal result f a ratinal decisin based n persnal beliefs related t the disease and its treatment 1

2 The Imprtance f Adherence Prfile f Nn-adherent Patient Accrding t the WHO, nnadherence rate is 50% in patients with chrnic illnesses Frustratin factr Delays the reslutin f a prblem Cmplicatins require mre aggressive and cstly treatments Burden n ur ver-burdened health care resurces Yung Minrity Illiterate Indigent Scial/family relatinships Scial supprt Experiences with health care system Patient s perceptins abut illness and medicatins Is There a Prblem with Adherence and DFUs? Purpse T evaluate the activity f patients with diabetic ft ulceratins and their adherence t pressure fflading devices 20 patients with UT 1A ulceratins All were prescribed a RCW Activity steps per day waist RCW cncealed munted device Mean 1,219 steps per day 874 steps RCW ff 345 steps RCW n Patients wre the RCW 28% f their ttal activity per day Is There a Prblem with Adherence and DFUs? Purpse Assess the assciatin between fflading adherence and healing after 6 weeks f treatment. Additinally, assess ptential physical and psychlgical determinants f fflading adherence 79 patients prspective, multicenter, randmized trial Standard DFU management All were prescribed a RCW Activity steps per day waist RCW cncealed munted device Hspital Anxiety and Depressin Scale (HADS) Neurpathy and Ft Ulcer Quality f Life (NeurQL) Revised Illness Perceptin Questinnaire(IPQ-R) Better fflading adherence predicted a greater amunt f DFU healing at 6 weeks On average, devices were used 59% f the subjects activity Increased adherence Larger baseline wunds Mre severe baseline wunds Mre severe neurpathy Greater NeurQL ft pain Decreased adherence Pstural instability Armstrng, DG et al, Activity Patterns f Patients with Diabetic Ft Ulceratin. Diabetes Care 26:2003, Crews, RT, et al. Rle and Determinants f Adherence t Offlading in Diabetic Ft Ulcer Healing: A Prspective Investigatin. Diabetes Care 2016; 39:

3 Depressin and Diabetes Depressin and DFUs Neither the mechanism fr the c-ccurrence f diabetes and depressin nr the directinal pattern f causality is knwn, yet the relatinship and its implicatins are clear. Meta-analyses have shwn that the prevalence f depressin in peple with diabetes is 2-3x mre cmmn than in the general ppulatin Negative impact n quality f life, functinal decline and additinal burden fr family and caregivers Bilgic relatinship studies allude t linking depressin and diabetes via an inflammatry respnse at the cellular level increasing activatin f the hypthalamicpituitary-adrenal axis When higher levels f depressin are present, there is decreased ability t cmply with treatment directins, instructins, medical adherence t diet, and apprpriate preventative care including physical activity Screening fr depressin and incrpratin f mental healthcare prviders as members f the multidisciplinary team remains lw Bilgic Risk Factrs Duratin f diabetes Persistent hyperglycemia Peripheral neurpathy Defrmity Peripheral Arterial Disease Culd psychlgical factrs such as depressive disrders help t explain the high rates f mrbidity and mrtality? Primary Hypthesis In peple with diabetes, depressin is assciated with increased risk f mrtality fllwing the nset f their first ft ulcer cmpared t thse that were nt depressed Secndary Hypthesis Depressin was prspectively assciated with wrsening glycemic cntrl Steel, A, et al. Understanding the Relatinship Between Depressin and Diabetic Ft Ulcers. J Sc Health and Diabetes 2016; 4:17-24 Khalida I, et al. A Chrt Study f Peple With Diabetes and Their First Ft Ulcer: The Rle f Depressin and Mrtality. Diabetes Care 30: , June 2007 Depressin and DFUs Depressin and DFUs Prspective study f a chrt ppulatin with diabetes and first ft ulcer Fllwed 18 mnths Date and cause f death First amputatin, recurrence and healing status SCAN 2.1 (Schedules fr Clinical Assessment in Neurpsychiatry) HbA1C measures baseline, 12 mnths and 18 mnths 253 subjects 171 n depressin (68%) 21 minr depressin (8%) 61 majr depressin (24%) 40 Deaths (15.8%) 36 Amputatins (15.5%) 99 Recurrent Ulcers (43.2%) 1/3 diabetic peple with their first ulcer have clinically significant depressin Depressin carried a threefld increase risk f mrtality N assciatin with depressin at baseline and glycemic cntrl 18 mnths later Hemglbin A1C (%) Cnclusin: Evidence is emerging that depressin increases mrbidity and mrtality in peple with diabetes but the mediating factrs are unclear. Khalida I, et al. A Chrt Study f Peple With Diabetes and Their First Ft Ulcer: The Rle f Depressin and Mrtality. Diabetes Care 30: , June 2007 Khalida I, et al. A Chrt Study f Peple With Diabetes and Their First Ft Ulcer: The Rle f Depressin and Mrtality. Diabetes Care 30: , June

4 Cgnitive Impairment with DFUs ADA and IWGDF published a glbal cnsensus, evidence based guidelines n management and preventin f diabetic ft cmplicatins. The dcuments emphasize Patient educatin Self-care practices Cnsistent appintments Fllw recmmendatins fr changes in medicatins Healthy lifestyle habits Increase in self-care burden als represents and increase in the cgnitive demands needed fr ptimal adherence t medical recmmendatins. Learn, understand and remember new infrmatin Plan and initiate self-care behavirs Adpt changes that invlve psychmtr abilities Maintain behavirs while cntrlling and repressing impulses Cgnitive Impairment with DFUs Purpse: T examine whether the cgnitive prfile f patients with DF differs frm that f peple with diabetes withut the DF cmplicatin Individual cgnitive assessment perfrmed by a neurpsychlgist 99 patients with DF 95 patients with n DFU 1.5 hur extensive cgnitive evaluatin Cmpared t thse patients with DM but withut DFUs, patients with DFUs: REMEMBER LESS HAVE DECREASED ABILITY TO CONCENTRATE MORE DIFFICULTY WITH LEARNING LESS INHIBITION SLOWER COGNITIVE AND PSYCHOMOTOR RESPONSES LESS VERBAL FLUENCY The DF Persn s Paradx mre challenges with fewer cgnitive resurces Natvich, R et al. Cgnitive Dysfunctin: Part and Parcel f the Diabetic Ft Diabetes Care, published nline 5/13/16 Natvich, R et al. Cgnitive Dysfunctin : Part and Parcel f the Diabetic Ft Diabetes Care, published nline 5/13/16 Multifaceted Adherence Strategies Wund Care Cgnitive Interventins educatin Instructins n plan f care Why a particular plan is chsen Patient s rle in executing the plan Reprting prblems prcuring supplies Behaviral Interventins alter r eliminate behavirs that wrk against the desired utcme Methds f elevatin / fflading Safe and prper ambulatin Nutritinal supprt Affective Interventins help patients alter r accept feelings related t having a wund Feeling scared, guilty, verwhelmed, helpless, hpeless Neutralize these feelings and fcus n the gal f healing Hw D Yu Treat Nn-Cmpliant Establish patient-fcused care Health care delivery fcusing mre directly n the diverse needs f each patient Increases the patient s willingness t share ideas with the prvider Opens pprtunities t cllect imprtant patientspecific infrmatin Multi-directinal Rter, DL, et al. Effectiveness f Interventins t Imprve Patient Cmpliance: A Meta-analysis, Med Care 1998;36(8):

5 Summary Advice Patient Nn-adherence Patient Factrs Prvider Factrs System Factrs Nt all nn-adherence is spiteful. Try t understand the barriers t adherence. Explain the lgic behind therapeutic advice tell them WHY Understand patient s perceptins abut the efficacy f treatment Include family and ther significant peple in educatin Simplify cmplex wund care r drug regimens What treatments interfere with lifestyle Prvide pre-printed handuts with instructins Screen fr depressin and make referrals Help facilitate patients t find their wn slutins Luga, A et al, Adherence and Healthcare Csts. Risk Manag Healthc Plicy 2014; 7: Thank yu! 5

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