Medication adherence may also involve working memory

Adherence is defined as taking a prescribed medication at the appropriate time in the correct amount and manner (e.g., with food). Adhering to medicines requires the recruitment of executive function, because taking medicines consistently involves developing and implementing a plan to adhere; remembering to adhere, which may require time-based (e.g., at 2:00 p.m.) or event-based prospective remembering (e.g., with meals); and remembering whether the medicine was taken as desired (source monitoring). The ability to monitor source, that is to determine if the medication was taken as intended, is likely to become more difficult when the action is repetitive (Einstein, McDaniel, Smith, & Shaw, 1998). Taking medicines for chronic conditions is often repetitive because the same medicine is taken in the same way day after day.

Medication adherence may also involve working memory. For example, a person must keep the intention to take medicines active in working memory while doing other things, such as checking the time, pouring a glass of water, and getting the medicines. The investigators created conditions in which younger and older adults retrieved intentions but then had to briefly delay (5–30 s) performing the action. They found dramatic memory losses in older adults in as little as 5 s and proposed that maintaining the intention over brief delays is particularly difficult for older adults. This converges with a variety of theoretical views about the proposed function of working memory to keep representations active in the face of distraction and to maintain an integrated representation of the task context .These results also are consistent with age-associated deficits in inhibitory ability (presumed to be an executive function), which would make older adults highly susceptible to both internal and external distraction over delays If medication adherence involves executive processes and working memory, then adherence should be associated with measures of these processes.

In addition to executive processes and working memory, medication adherence may depend on the encoding and storage of information about the medicine (why is the medicine important, why does the person need to take it) and instructions concerning when and how (e.g., with food) the medicine is to be taken. If this is the case, then the performance on cued recall and recognition tasks should also predict adherence.

Although there is no clear-cut evidence, the literature suggests that adherence is predicted by measures of cognition, especially executive function and working memory For example, cognitive impairment has been associated with twice the risk of non-adherence in a population-based investigation on antihypertensive drug use in the elderly population (The Rotterdam Study; see Salas et al., 2001). Cognitive processes have been associated with medication adherence among individuals who are HIV positive. In this study, an interaction was found between executive function and regimen complexity on medication adherence, suggesting that as regimen complexity increases, compromised executive function leads to increasing difficulty in adhering to medication. In contrast, Morrell and his colleagues found that neither a measure of working memory nor a vocabulary test was significantly associated with adherence to antihypertensive medication, but the investigators cited some methodological concerns related to these findings. In summary, there is some evidence associating cognition and adherence, particularly with measures that assess executive function.

Taking your medicine as prescribed or medication adherence is important for controlling chronic conditions, treating temporary conditions, and overall long-term health and well-being.

According to the WHO, improving adherence to medical therapy for conditions of hypertension, hyperlipidemia, and diabetes would yield very substantial health and economic benefits. To improve medication adherence.

Adherence = Compliance (medication consumption as instructed, % pills taken) +Persistence (duration of time during which medication is consumed, 1-discontinuation).

=The amount of time someone is taking medications as instructed.

Adherence/Compliance • Typical non-adherence to medications is 50% – 24-90% in mental health

• Adherence influenced by – Extent, duration, and severity of disease Complexity of treatment regimen

Cost of medications – Education, social support

Medication adherence is best when

• the diagnosis is short term/self-limiting
• The symptoms are predictable & improve with the medication
• The medication is taken for a short period of time
• The medication is taken once a day
• The medication does not have side effects
• The medication is inexpensive

What can providers do to improve adherence:

• Simplify regimen
• Discuss reminder system
• Involve family/significant others
• Stress the importance of honesty
• Facilitate shared decision-making & mutual goal setting

IBD is a lifelong chronic disease " Decreased risk of disease progression " Decreased risk of flare ups

Increased chance of disease regression " Possible decreased risk of colon cancer

Time-saving Adherence Methods for Patients

• Smart phone alarms/ reminders
• Combining medications together in one place −Pill box
• Put medications with another routine activity (i.e. Toothbrush)
• Chart medications and symptoms

Why do patients do not take their meds?

Cost:Some patients simply cannot afford the cost. The doctor may send the prescription thinking it is the best medication for the patient but then the patients shows up at the pharmacy and learns the price is out of their budget. Many times it is because the medication is not n their insurance companies’ formulates, so they are forced to foot the entire cost themselves. Sometimes the patient is too embarrassed to call their doctor back and admit this, so they go without. But, many alternatives are available in this case. An equivalent medication of the same class may be available that is on the formulator, or maybe a generic of another class may get the job done. The doctors’ office can do a prior-authorization and try to get coverage for the non-formulator medication, although this does not always work. But, no patients should go without needed medication. With the costs of pharmaceuticals these days, these drugs have become cost-prohibitive for most people without any coverage.

Misunderstanding:The patient does not understand why they should be taking a medication and no one wants to take something they don’t need. I often see patients come who don’t know why they are taking certain medications. It is the job of the doctor to ensure the patient understands why a specific treatment is being recommended. If a patient leaves the exam room without knowing this, the doctor has failed in the treatment of that patient.

Myths: We have all seen those lawyer ads on TV that tell people to call them if they took a certain medication. The truth is that all medications have side effects. These side effects need to be balanced with the benefits the medication may offer the patient. And this discussion should happen between the patient and the doctor and a decision made with the knowledge of the risks. Often, a patient will experience a side effect or hear about one and just stop the medication, and the doctor will not know about it until weeks later. It is best to contact the doctor as soon as you decide to stop a medication. There may be other options available. If the medications were so dangerous as the lawyer ads suggest, they would be pulled from the market and no doctor would want to prescribe it.

Time: It seems a simple thing just to swallow a pill. However, many people are so busy that they simply forget. Many medications need to be taken with food or on an empty stomach. Some patients are on multiple medications that cannot be taken at the same time as others. It can result in a very careful scheduling balancing act every day. We need to simply this, such as prescribing once daily medication versus multiple doses when possible. There are many reasons patients don’t follow our advice and take their medications. As health care providers, we do a great disservice to our patients when we fail to give them the proper educations to why they should be taking a certain medication or what to expect in terms of side effects. We can be prescribing the best therapies in the world for our patients.

The treatment of chronic illnesses commonly includes the long-term use of pharmacotherapy. Although these medications are effective in combating disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Factors contributing to poor medication adherence are myriad and include those that are related to patients (eg, sub-optimal health literacy and lack of involvement in the treatment decision–making process), those that are related to physicians (eg, prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and those that are related to health care systems (eg, office visit time limitations, limited access to care, and lack of health information technology). Because barriers to medication adherence are complex and varied, solutions to improve adherence must be multi-factorial.