Non-adherence to treatment Clinical Coaching Brief Advice Behaviour Change Councelling Motivational Interviewing.
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Non-adherence to treatment
Clinical CoachingBrief Advice
Behaviour Change CouncellingMotivational Interviewing
Topics
• Non-adherence to treatment• Motivation• Clinical Coaching• Brief Advice • Behaviour Change Councelling• Motivational Interviewing
Adherence to treatment
Adherence vs. compliance to treatment
• Adherence: active involvement of the patient in treatment processes
• Compliance: patients simply follow doctor´s orders
• Better adherence = better clinical outcomes
Non-adherence to treatment
• Taking too little (drug or excercise too little, etc..)• Taking too much• Not taking at the prescribed intervals (or excercising too or
less frequently as required)• Taking other medication without the knowledge of the
prescribing medical professional • Not taking the treatment for the prescribed duration
30% of patients
Examples?
Clinical example: Course of psychotic disorders and the prescribed duration of the treatment
Early warning
signs
Early warning
signs
1st. attack
1st. relapse
Remission
CC
Antipsychotics (neuroleptic medication) for psychotic disorders: Recommendation for the relapse prevention
• After 1-st episode: 1-2 years• After 2nd episode: 5 years• Three and more episodes: life-long treatment
Reality?
10 days 6 months 12 months 24 months
25%
33%
40%
76%
69%
discharge
nonadherence(%)
Perkins, 2002; Kamali et al., 2006, Lam et al, 2002; Weiden et al., 1997
Psychotic disorders:Treatment nonadherence
Disease factors:No or few or mild symptoms
Fluctuating courseLack or no insight
Healthcare factors:Poor availability,
Long waiting time
Psychosocial factors:poor support
Psychological factors:Depression;
Attitude, beliefs, perceived benefits
Treatment factors:Complex regimen
Side effects
MD´s factorsAbility to communicate and provide information
Why?
Case: Jirka
Promoting adherence• Discuss the patient´s beliefs, concerns, and intentions relating to
treatment• Where possible customize the regimen in accordance with the patient´s
wishes• Simplify the regimen• Provide simple, clear instructions for taking medication• Elicit the patient´s feelings about his ability to follow the regimen and
discuss stratgegies for enhancing adherence• Consider the use of medication-taking systems including electronic
reminders• Emphasize the value of prescribed regimen and the importance of
adherence for producing the best treatment outcomes• Obtain any necessary help from family members, friends, etc.
Promoting adherence
• Monitor adherence. Watch for the mardkers of nonadherence such as missed appointments, missed refills, and a lack of response to medication
• Express approval of adherence and encourage continued adherence.
• Ask the patient about nonadherence and barriers to adherence in an understanding, non confrontational way
• If adherence appears unlikely, prescribe medication with lon half-lives, depot (extended release) or transdermal medication
How to do it???
Adherence and non-adherence:
Patient´s attitude not symptom!
How to influence patient´s attitude?
What do they have
in common ?
Clinical Coaching
Education
Motivational Interviewing
Barrier-free Access
doctoras sparingpartner, shares knowledge,communicates comprehensibly, respects patient´s opinion, negotiates procedure,offers choice
doctorsearches for inner motives for change,addresses ambivalencerespects wishes,solves problems together
Doctor educates to the patient´s needs
Intervention Brief Advice (BA) Behaviour Change Councelling (BCC)
Motivational Interviewing (MI)
Time 5-15 minutes 5-30 minutes 30-60 minutesSetting Mostly opportunistic Opportunistic or help-
seekingMostly help-seeking
Goals Demonstrate respect, communicate risk, provide information, initiate thinking about change in problem behaviour (Ask, Assess, Advise, Assist, Arrange)
BA + Establish rapport, identify client goals, exchange information, choose strategies based on client readiness, build motivation for change
BA + BCC+ develop relationship,resolve ambivalence, develop discrepancy, elicit commitment to change
Practitioner-recipient
Active expert – Passive recipient
Councelor-active participant
Leading partner - partner
Motivational Interview
How to influence the clients´s attitude and promote behavioural
change
Motivational Interviewing• Diet and physical activity change• Smoking cessation• Behavioural and drug addiction councelling• Medication adherence• HIV prevention• Chronic illnesses: diabetes and cardiovascular diseases• Public health problems: preventing infection (ebola!!)
Motivation
• Motivation is a drive to act• Motives: • Biological (to eat, to reproduce): to ensure
homeostasis of an organism• Psychological and social (to achieve particular
status, need to influence or control others; to make impression on others..)
What is your motivation to
study medicine?
Theory of motivation: Incentive theories
• External factors trigger and regulate motivation
• Expectations and values• Knowing more about motives means we can
address the situation more constructively
Theoriy of motivation: Drive theory
• Drive theories: behaviour to ensure the stability in bodily functions that is necessary to survive.
• A lack of equilibrium between our current state and our needs creates a tension which we are motivated to reduce
Give an example of abnormal extremes of
biological drives.
Give an example of a disorders with strong
motivational component
Motivation to drink alcohol
????
Craving
• Strong motivational effect
• Worsening of cognitive functions
• Physiological symptoms: increase of heart rate and increase of skin conductance
• The same as stress
Reward System Basic neurobiological system for survival and reproduction.A collection of brain structures to regulate and control behavior by inducing pleasurable effects. When activated, reinforces behaviors.
Primary evolutionarynatural incentives:air, water food, Sexual partnerSafetydopamine
Nonnatural incentives:Drugs:Activate the systém more than natural podněty and Change the activity of the reward systém
Reward System: Abused by drugs!
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