Effects Of Cognitive Impairment And Low Health Literacy On Medication Adherence Essays

Effects Of Cognitive Impairment And Low Health Literacy On Medication Adherence Essays Effects Of Cognitive Impairment And Low Health Literacy On Medication Adherence Paper Effects Of Cognitive Impairment And Low Health Literacy On Medication Adherence Paper Scientific and social changes of the 21st century have brought a radical change in the Health care delivery system. Medical intervention is an important component of the health care delivery system and the role of a health care professional in patient welfare has no boundaries for praise. The health care profession has evolved through time to establish a firm role in the medical domain based on strong ethical, moral and professional principles. The medical professionals are ‘accountable’ today. The civil war (1860-65) enhanced the growth of health care in United States and the two World Wars saw the ‘nobility’ of the medical practice. The changing role of these professionals as significant members of the health care team has brought about radical change in Health Care delivery system. Practice methods like â€Å"The collaborative model† shows a radical shift from the past. â€Å"Evidence based Practice† is another model in practice today. In such a scenario, clinical care of cognitively impaired is a complex practice and involves the key concepts of knowing the patient and reflective thinking. BACKGROUND Communication is the pulse of medical practice with the elements of intimacy and reflective practice. Communication barriers of the mentally and cognitively impaired patients seem to erode the quality of medical care due to assumptions and attitudes. Lack of communication due to cognitive impairment and lack of health literacy clearly affects the medication adherence of the older patients, especially ethnic minority in origin. More than sixty percent of the minority population does not comply with the prescribed drug regimen in the USA. Non-verbal communication seems to be effective in such settings. Effects of cognitive impairment on the reliability of geriatric assessments has been studied recently (Phillips et. al, 1993) to explore the relationship between cognitive status and reliability of multidimensional assessment data. The studies have proved that the reliability of the patients communication and sensory ability are affected by cognitive status. Hence caution should be exercised in treating cognitively impaired patients. The cognitive impairment that contributes to unreliable assessment of patients includes those related to communicating, vision and hearing. Communication problems of hearing impaired patients have been studied as well (Hines, 2000). The studies have proved that such patients are seriously disadvantaged by the disability. The major factor contributing to the disadvantage has been the inadequacy in training of both health care professionals in deaf awareness and associated communication skills. Other factors include the patient’s concealing their disability, work pressure and poor communication of the staff. Monolingual and Bilingual communication between patients with dementia and their care givers have been studied and have shown that the relationship between a demented terminally ill patient and the care giver is an important factor which forms the foundation of the interaction between them. This communications is complex with different aspects of perception and practice (Sirkka, 1996). Non-speaking patients are the worst affected and it is important to improve their communication to allow them receive care and comfort. The ethnic old patients in Canada have been shown to have remained an isolated group as aliens in their own land. This ethnic population has been shown to be unable to communicate with their care givers (Saldovt, al 1994). Problems developed in such patients without interpreter services have been termed serious. Thus, the problems encountered in communication between health care professionals and patients can be based on cultural needs and cognitive status; Cognitively impaired or comatose are often neglected. Studies on demented terminally ill patients to evaluate the time care givers provide for direct patient care have showed that more time is being spent with non demented than with the demented. The patients were shown to react in five categories of communication types during interactions The patients enjoyed contact, Patient avoided contact, The patient was aggressive, Showed only slight reaction and Does not react. Studies pertaining to specific verbal communication interactions in such elderly patients have been carried out (Jones et. al 1986). The studies were carried out under the categories ‘words spoken’, ‘commands given’, ‘statements made’, ‘Questions asked and answered’ with there ethnic groups namely immigrant, Canadian born and Anglo-born. The studies highlighted the need for health care professionals be aware of the implications of differences with there groups. Another studies on communication with severely demented patients by the health care professionals have shown that care of such patients need clear communication during care procedures. Thus, use of non-verbal communication skills (NVC) to improve care, especially with people who have learning disability has been assessed in a study (Chambers, 2003). The study outlines a health care professionals’ diagnosis of altered non-verbal communication and a new wellness diagnoses for enhanced non-verbal communication with detailed discussion on use of NVC with people with comprehension difficulties. The study stresses on the fact that health care professionals can be important in enhancing the non-verbal skills of the patient to help them communicate. Adding support to the view, the importance of improving communication by touch has been documented (Vortherms, 1991). The article views touch as an integral aspect of care, with the language of touch including tactile symbols of duration, location, action, intensity, frequency and sensation. The article classifies touch as affectional, functional and protective. The article stress that age is not a category to decide upon touch in terms of reduced needs of touch. An examination of touch between health care professionals’ and elderly patients (McCann et. al, 1993) has shown that most touch interactions in a care of the elderly are instrumental in nature and expressive touches are usually given to body extremities like the forehead, arms and the legs. Caring mentally ill patients undergoing therapy with antipsychotic drugs like clozapine and benzodiazepines involves careful monitoring of the patient’s physiological condition as well. Such drugs have marked side effects like sedation, hyper salivation, increase in transaminases, EEG changes, cardiovascular respiratory dysregulation, overweight, mild Parkinsonism, akathisia, tardive dysakinesia, increase of liver enzymes, hypotension, fever, ECG alterations, tachycardia, and delirious states. These drugs also pose the risk of seizures. With medical litigations on the rise, the interventions should be based on the competence of the patient. However in psychiatric cases there seems to be a group of individuals who are marginally competent. This group seems to lie in-between the two extremes of competence and incompetence and competence in this case thus appears to be a matter of degree. Mentally retarded persons who have some understanding of the reality and are able to express their wishes and desires can also be considered marginally competent. Mentally ill individuals whose illness has not completely impaired their understanding and capacity to express their wishes and desires are also considered marginally competent. These individuals are not incompetent though they suffer from specific deficits due to destroyed faculties. These marginally competent individuals make a significant group and recognizing the existence of such group of marginally competent individuals will help define competence better towards the documentation of informed consent and advance directives during interventions. A Psychological well being was shown to be enhanced by the humanistic personal interaction with the health care professionals and the professional interaction was shown to enhance physical well being. The patient’s feelings of well being always depended on the psychological well being according to the study. (Jane, 2002). Another studies on communication with severely demented patients by the health care professionals have shown that care of such patients need clear communication during care procedure and the health care professionals were vogue in their verbal communication and some patients were verbally active after the health care professionals leaving the bed side. A small scale pilot study has explored the educational base and needs of qualified care givers with reference to terminally ill patients with learning disability. The study has shown the lack of knowledge and skills in health care professionals to deal with the LD patients. The study has also recommended the introduction of communication and interpersonal skills in the care and Management of terminally ill patients with LD in the curriculum. The role of communication in care for elderly as documented by a literature review (Varhellan et, al. 1997) indicate a lack of observational instruments to effectively evaluate the interactive nature of patients communication especially with reference to reliability and validity. LIMITATIONS AND RECOMMENDATIONS The negative influence of elderly patients mental impairment on patient interaction has been documented in a study using the Clifton Assessment Procedure (Armstrong et, al 1986). 23 students were assessed under three categories of lucid, slightly confused and demented. Data on interactions with nursing staff were gained by direct observation. Studies concluded that health care professionals interact less with confused category them lucid category. Most of the health care professionals were more directed in the physical care of the patients them the psychological interaction or restorative activity. The patient’s inability to provide an accurate history of his problem and to participate in self-care blocks the usual process of care, often resulting in medical uncertainty inadequacy and frustration for the physician (Wendy L. , et. al, 2005). This shifts the goal from cure to care and shifting the goal of care from curing the patients illness to caring for the patients quality of life is problematic. The doctor–patient relationship changes dramatically often with ethical dilemmas related to patient autonomy and decision-making. Communication problems seem to erode health care professional’s commitment to care (Ekman et. al, 1991). Continuity of care seems to be a significant factor in psychiatric care as documented by research studies (Backrush, 1981). Continuity of caregivers where a single, continuous treatment team is responsible for patients in both inpatient and outpatient settings (Fuller Torrey 1986) seem also to complement continuity of care with improved cognitive function self-care skills. Cognitive impairments and low health literacy pose a serious barrier on the reliability of patient assessments. Hence, there is a need for training the health care professionals on communication skills with reference to cognitive impairments and designing awareness programs for such patients towards better health care. GOALS AND OBJECTIVES The main Objective of the study is to evaluate self-reported medication compliance in patients 50+ years of age and to compare physician assessments of patient’s adherence to a prescribed drug regimen provided on the â€Å"Predictive Score Sheet† to data obtained in telephone survey. The main goal of the study is to administer Medication Adherence Telephone Survey to all patients that completed the initial RAND SF-36 Survey, to complete double entry of data using SPSS software, to design and implement a statistical analysis plan to address the stated research question and to understand the effects of self-reported data on the validity of a research study MATERIALS AND METHOD In such a context, a demographic survey and two health assessments were administered to a convenient sample for a consecutive two week period utilizing CLOX, an executive clock drawing test to screen for cognitive impairment and the Rapid Estimate of Adult Literacy in Medicine (REALM) test to measure health literacy. A stimulated patient chart reviews and a telephone survey to record medication adherence behavior was conducted. One hundred cognitively impaired patients with treatment-resistant schizophrenia referred for Clozapine therapy were studied over the period of two weeks of treatment. Clozapine is a tricyclic dibenzodiazepine derivative 8-chloro-11- (4-methyl-1-piperazinyl)-5H-dibenzo [b, e] [1,4] diazepine. It is available as 25mg and 100 mg tablets for oral administration. Clozapine is widely used in refractory Schizophrenia. There seems to be a cultural and geographical variations in dose response relationship and tolerability to the drug making the dose response unpredictable. The effective and tolerable range is between 100 mg to 900 mg, which makes it difficult to make a predictive, significant and valid correlation. There has been no positive correlation with serum level too. Adherence to medication is important in clozapine therapy for results. The study was open level, naturalistic, and prospective, involving all patients, consecutive one hundred, referred for Clozapine during the year 2006. Data was obtained from patients and key relatives after informed consent. After therapy began, patients received a follow-up evaluation on day 4, 8 and again on the last day of treatment. The patients included 62 men and 38 women of low to middle socio-economical class, ranging in age from 52 to 56 years, averaging 54 years of age. 38% were married, 43% were single, and 19% were separated. The duration of illness prior to the study ranged from 5 to 21 years, averaging 7 years. Patients’ duration of illness before first psychiatric contact ranged between 5 months and 46 months, averaging 20 months. Prior to the study, 55% of the patients had a history of hospitalization, averaging 2 prior hospitalizations and the mean duration of hospitalization was 2 months. A history of violence was recorded in 46% of patients and 72% had a history of behavioral disruption. 28% of the patients had attempted suicide. Some were unable to function in society- 66% were socially disabled and 74% had little or no occupational functionality. One fourth of the patients had a positive family history of some psychological disorder. Schizophrenia was diagnosed in 16% of those relatives: 5% in siblings, 8% in parents, and 3% among offspring. Other psychological disorders, including alcoholism, depression, and suicide attempts were confirmed in first-degree relatives among 9% of the patients.