The Seven Stages of Man: The Role of Developmental Stage on Medication Adherence in Respiratory Diseases
2016; Elsevier BV; Volume: 4; Issue: 5 Linguagem: Inglês
10.1016/j.jaip.2016.04.002
ISSN2213-2201
AutoresRichard W. Costello, Juliet M. Foster, Jonathan Grigg, Michelle N. Eakin, Giorgio Walter Canonica, Fasail Yunus, Dermot Ryan,
Tópico(s)Asthma and respiratory diseases
ResumoThe circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested. The circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested. Information for Category 1 CME CreditCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions.Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI: In Practice Web site: www.jaci-inpractice.org/. The accompanying tests may only be submitted online at www.jaci-inpractice.org/. Fax or other copies will not be accepted.Date of Original Release: September 1, 2016. Credit may be obtained for these courses until August 31, 2017.Copyright Statement: Copyright © 2016-2018. All rights reserved.Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.List of Design Committee Members: Richard W. Costello, MD, Juliet M. Foster, PhD, Jonathan Grigg, MD, Michelle N. Eakin, PhD, Walter Canonica, MD, Fasail Yunus, MD, and Dermot Ryan, MD; on behalf of the Respiratory Effectiveness Group.Learning objectives:1.To understand the different patient-related barriers to medication adherence at each developmental stage.2.To understand the burden and impact of poor adherence for patients with respiratory disease.3.To increase knowledge on the role of research in developing new adherence strategies.Recognition of Commercial Support: The Respiratory Effectiveness Group (REG; www.effectivenessevaluation.org) supported the Expert Adherence Panel Meeting at which many of the concepts presented in this article were first discussed. REG also supported the manuscript submission costs. R.W.C. is supported by the Health Research Board (HRB) Knowledge and Education Dissemination Scheme (2015-1631) and HRB Clinician Scientist Award (611223).Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: The authors declare that they have no relevant conflicts of interest. Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions. Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI: In Practice Web site: www.jaci-inpractice.org/. The accompanying tests may only be submitted online at www.jaci-inpractice.org/. Fax or other copies will not be accepted. Date of Original Release: September 1, 2016. Credit may be obtained for these courses until August 31, 2017. Copyright Statement: Copyright © 2016-2018. All rights reserved. Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease. Target Audience: Physicians and researchers within the field of allergic disease. Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. List of Design Committee Members: Richard W. Costello, MD, Juliet M. Foster, PhD, Jonathan Grigg, MD, Michelle N. Eakin, PhD, Walter Canonica, MD, Fasail Yunus, MD, and Dermot Ryan, MD; on behalf of the Respiratory Effectiveness Group. Learning objectives:1.To understand the different patient-related barriers to medication adherence at each developmental stage.2.To understand the burden and impact of poor adherence for patients with respiratory disease.3.To increase knowledge on the role of research in developing new adherence strategies. Recognition of Commercial Support: The Respiratory Effectiveness Group (REG; www.effectivenessevaluation.org) supported the Expert Adherence Panel Meeting at which many of the concepts presented in this article were first discussed. REG also supported the manuscript submission costs. R.W.C. is supported by the Health Research Board (HRB) Knowledge and Education Dissemination Scheme (2015-1631) and HRB Clinician Scientist Award (611223). Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: The authors declare that they have no relevant conflicts of interest. The European Union–commissioned "Ascertaining Barriers to Compliance" taxonomy for medication adherence outlines 3 key steps in a "temporal sequence" that patients must take to be adherent to their prescribed medication: initiation (picking up and taking a first medication), implementation (using it correctly, as prescribed), and persistence (sustained use).1Vrijens B. De Geest S. Hughes D.A. Przemyslaw K. Demonceau J. Ruppar T. et al.A new taxonomy for describing and defining adherence to medications.Br J Clin Pharmacol. 2012; 73: 691-705Crossref PubMed Scopus (1084) Google Scholar As individuals develop and mature, their social environment, caregiver support, disease characteristics, and cognitive capabilities change dramatically. These factors modify a patient's ability to manage medications and to adequately initiate, implement, and/or persist with the prescribed regimen. In childhood and old age, suboptimal adherence to asthma and/or chronic obstructive pulmonary disease (COPD) treatment has important and serious consequences. Asthma is the most common chronic disease in children and a frequent cause of admission to hospital.2Akinbami L.J. Moorman J.E. Liu X. Asthma prevalence, health care use, and mortality: United States, 2005-2009.Natl Health Stat Rep. 2011; : 1-14PubMed Google Scholar Poor adherence to controller therapy has a significant impact on children's welfare, leading to increased school absence, impaired social development, as well as the clinical adverse effects of increased number of exacerbations.3Arellano F.M. Arana A. Wentworth C.E. Vidaurre C.F. Chipps B.E. Prescription patterns for asthma medications in children and adolescents with health care insurance in the United States.Pediatr Allergy Immunol. 2011; 22: 469-476Crossref PubMed Scopus (27) Google Scholar, 4Civelek E. Sekerel B.E. 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In this review, we discuss the determinants of medication adherence that are of particular consequence to children, adolescents, and the elderly, focusing specifically on patients with asthma and COPD. Suboptimal adherence to asthma medications has been reported at each step of the adherence pathway. Studies have recorded noninitiation to inhaled therapy in 14% to 20% of children15Wu A.C. Butler M.G. Li L. Fung V. Kharbanda E.O. Larkin E.K. et al.Primary adherence to controller medications for asthma is poor.Ann Am Thorac Soc. 2015; 12: 161-166Crossref PubMed Scopus (93) Google Scholar and even higher rates (50%) of noninitiation for those discharged from hospital after an exacerbation.11Kenyon C.C. Rubin D.M. Zorc J.J. Mohamad Z. Faerber J.A. Feudtner C. Childhood asthma hospital discharge medication fills and risk of subsequent readmission.J Pediatr. 2015; 166: 1121-1127Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Studies using electronic monitoring devices to quantify therapy implementation in pediatric patients with asthma have also reported rates of less than 50%.16Klok T. Kaptein A.A. Duiverman E.J. Brand P.L. It's the adherence, stupid (that determines asthma control in preschool children)!.Eur Respir J. 2014; 43: 783-791Crossref PubMed Scopus (71) Google Scholar In the case of asthma—primarily managed by inhaled therapy—observational studies have repeatedly reported poor inhaler technique in children and poor proficiency of inhaler administration by caregivers12Bourdin A. Halimi L. Vachier I. Paganin F. Lamouroux A. Gouitaa M. et al.Adherence in severe asthma.Clin Exp Allergy. 2012; 42: 1566-1574Crossref PubMed Scopus (46) Google Scholar, 17Capanoglu M. Dibek Misirlioglu E. Toyran M. Civelek E. 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E Fouda A. Steroid phobia among parents of asthmatic children: myths and truth.Iran J Allergy Asthma Immunol. 2010; 9: 163-168PubMed Google Scholar, 33Rydstrom I. Hartman J. Segesten K. Not letting the disease get the upper hand over life: strategies of teens with asthma.Scand J Caring Sci. 2005; 19: 388-395Crossref PubMed Scopus (21) Google Scholar Beliefs about the efficacy of the medication or a misunderstanding about how the medications work may impact both the initiation and persistence phases of adherence. A caregiver may administer medication for the minimal time believed necessary during an exacerbation, but not persist as prescribed thereafter. In addition, depression among caregivers has been shown to have a negative effect on medication adherence among the children they care for and on their overall levels of asthma control.34Otsuki M. Eakin M.N. Arceneaux L.L. Rand C.S. Butz A.M. Riekert K.A. Prospective relationship between maternal depressive symptoms and asthma morbidity among inner-city African American children.J Pediatr Psychol. 2010; 35: 758-767Crossref PubMed Scopus (32) Google Scholar With respect to peer networks and school environments, children report concerns of stigmatization of their asthma when they use an inhaler in public. Missing school activities and inability to partake in sports can negatively affect children's emotional state and medication adherence, in particular their adherence to ICS controller therapy.35Schneider J. Wedgewood N. Llewellyn G. McConnell D. Families challenged by and accommodating to the adolescent years.J Intellect Disabil Res. 2006; 50: 926-936Crossref PubMed Scopus (39) Google Scholar School policies or lack of care coordination can result in children having limited access to asthma medications during school hours.36Keeton V. Soleimanpour S. Brindis C.D. School-based health centers in an era of health care reform: building on history.Curr Probl Pediatr Adolesc Health Care. 2012; 42 (discussion 157–158): 132-156Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Increased monitoring and direct observation of medication use by school nurses has been shown to facilitate improved medication implementation.37Snow R.E. Larkin M. Kimball S. Iheagwara K. Ozuah P.O. Evaluation of asthma management policies in New York City public schools.J Asthma. 2005; 42: 51-53Crossref PubMed Scopus (25) Google Scholar Young children are known to have greater difficulty using inhaler devices correctly than do other older children. Spacers are recommended to improve drug delivery and reduce common inhaler technique errors in younger patients, but they are seldom used in practice.38Castro-Rodriguez J.A. Escribano Montaner A. Garde Garde J. Morell Bernabe J.J. Pellegrini Belinchon J. Garcia-Marcos L. Spanish Pediatric Asthma Study Group. 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Reasons behind non-adherence of healthcare practitioners to pediatric asthma guidelines in an emergency department in Saudi Arabia.BMC Health Serv Res. 2012; 12: 226Crossref PubMed Scopus (28) Google Scholar Furthermore, spacer use, as well as inhalers, can add to the stigma around asthma treatment in older children and further reduce their motivation to implement and persist with prescribed therapy.37Snow R.E. Larkin M. Kimball S. Iheagwara K. Ozuah P.O. Evaluation of asthma management policies in New York City public schools.J Asthma. 2005; 42: 51-53Crossref PubMed Scopus (25) Google Scholar Ineffective inhaler use has important clinical consequences because it can negatively affect both the implementation and persistence phases of adherence (through perceived lack of treatment benefit by the child and/or the caregiver) and lead to suboptimal treatment outcomes and possible unnecessary escalation of therapy (eg, referral to severe asthma services, or increased medication dose) by the clinician. "Full of strange oaths, and bearded like the pard,Jealous in honour, sudden, and quick in quarrel,Seeking the bubble reputation"28Shakespeare W. As You Like It. Act 2, Scene 7. New Ed edition. London, UK. Penguin Classics 2005.Google Scholar Adolescence is a developmental period that is marked by increased interpersonal conflict as individuals seek to separate from their parents and become more independent. It is not surprising, therefore, that medication adherence is a particular casualty during this stage of personal development as adolescents seek to take on more responsibility for their medications without parental monitoring and support. Research has demonstrated, across chronic illness groups, that medication adherence and clinic attendance decline significantly during adolescence.42McQuaid E.L. Kopel S.J. Klein R.B. Fritz G.K. Medication adherence in pediatric asthma: reasoning, responsibility, and behavior.J Pediatr Psychol. 2003; 28: 323-333Crossref PubMed Scopus (322) Google Scholar There is a known paradox during adolescence with regard to medication adherence. During this time, the patients' knowledge and understanding about their disease and related medications improves, while their adherence to medication declines. One explanation is that adolescence is characterized by changes in reasoning and hypothetical thinking, which, in turn, can affect how information on medications and illness is received (and needs to be communicated) to help optimize adherence to therapy.43Mosnaim G. Li H. Martin M. Richardson D. Belice P.J. Avery E. et al.The impact of peer support and mp3 messaging on adherence to inhaled corticosteroids in minority adolescents with asthma: a randomized, controlled trial.J Allergy Clin Immunol Pract. 2013; 1: 485-493Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Unless the adolescent has been engaged and involved in the decision to use a medication, and his or her concerns have been addressed, initiation, implementation, and persistence will be at risk. As adolescents begin to take on more responsibility for their medications, and as they establish autonomy and independence from their parents, they may become less motivated to take medications or may be more likely to forget them than when supervised by a caregiver. As parents begin to withdraw their support and supervision, persistence may fall.42McQuaid E.L. Kopel S.J. Klein R.B. Fritz G.K. Medication adherence in pediatric asthma: reasoning, responsibility, and behavior.J Pediatr Psychol. 2003; 28: 323-333Crossref PubMed Scopus (322) Google Scholar Frequently, this change in responsibility occurs without direct communication between adolescents and parents, which can lead to misassumptions about who is responsible, increased parent/child conflict, and subsequent lower adherence. In adolescence, other psychosocial influences, such as psychological distress, depression, family conflict, and substance abuse, correlate with poor adherence to medications.44Jaser S.S. Psychological problems in adolescents with diabetes.Adolesc Med State Art Rev. 2010; 21 (x-xi): 138-151PubMed Google Scholar The organization of the health care system can influence medication adherence in school-aged children with asthma, with one obvious facilitator being good access to health care coverage. In the United States, for example, children have access to health insurance through Medicaid or state programs, which provide their medications free of charge, or for a nominal fee. Coverage also extends to preventive health care administered through a primary care physician. These features of childhood insurance plans permit continuity of care and offer an opportunity to optimize adherence to therapy in children. For these services to be most effective, it is important that providers use established asthma care guidelines, which recommend the use of objective asthma control questionnaires and ongoing inhaler instruction to improve adherence (all steps) and overall asthma control.45Okelo S.O. Eakin M.N. Riekert K.A. Teodoro A.P. Bilderback A.L. Thompson D.A. et al.Validation of parental reports of asthma trajectory, burden, and risk by using the pediatric asthma control and communication instrument.J Allergy Clin Immunol Pract. 2014; 2: 186-192Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Adolescents represent a potentially rich resource for adherence research—their engagement in participatory research can help identify and inform developmentally relevant interventions.46Goh Y.Y. Bogart L.M. Sipple-Asher B.K. Uyeda K. Hawes-Dawson J. Olarita-Dhungana J. et al.Using community-based participatory research to identify potential interventions to overcome barriers to adolescents' healthy eating and physical activity.J Behav Med. 2009; 32: 491-502Crossref PubMed Scopus (95) Google Scholar The increasing technological sophistication of young adults, often exceeding that of clinicians and clinical investigators, suggests that technology-based solutions could offer a promising opportunity for targeting adherence interventions. Substantive improvements in important asthma outcomes in children, such as increased school attendance, were reported in association with the introduction of electronic reminders to prompt preventer therapy use.47Chan A.H. Stewart A.W. Harrison J. Camargo Jr., C.A. Black P.N. Mitchell E.A. The effect of an electronic monitoring device with audiovisual
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