a lot we can do to redirect our non-compliant glaucoma patients to success.
BY SIMON SHAAW
of the most difficult things that we often face in practice is the non-compliant
patient. This is particularly true when we deal with patients who have glaucoma.
Due to its lack of symptoms until late in the disease process, it's often difficult
to convince patients of the importance of using their medications as prescribed.
This, combined with glaucoma's chronic nature, provides the perfect framework for
It's a situation that can prove disastrous, so it's imperative that we doctors find
ways to prevent it.
There's always an excuse
There are many reasons patients give
for non-compliance, including forgetfulness, lack of understanding, lack of support
(either social or financial) and pre-conceived medical beliefs. Further, when dealing
with medications, other factors may arise, such as side effects, costs and complexity
of the treatment regimen.
Lastly, difficulties in the patient-provider relationship and poor communication
can derail compliance.
'em off at the pass
Here are some things to consider
when trying to keep glaucoma patients compliant with their therapy.
the patient at each visit if they are having problems or concerns with their medications.
Start with open-ended questions, such as "Are you having any problems or concerns
with your current eye medications?"
It may help the patient to open up with
you. It also may take a few visits until the patient gets sufficiently comfortable
with the provider to discuss some of his concerns, so it's important to ask at each
encounter you have with the patient. For instance, a patient suffering from decreased
libido from a beta-blocker may be hesitant to admit this to the doctor until he's
established a greater level of trust and rapport. Also be sure to ask about specific
side effects that are common with a particular medication, such as eyelash growth
or iris color change with prostaglandins.
the patient to repeat his treatment regimen. It is important to ask patients which
drops they are using and how often. They may not know the exact name of the drop,
but should be familiar with the bottle size or color. This way you can clarify and
remedy any misunderstandings about dosage. Also, periodically ask patients to demonstrate
how they instill their drops. Offer techniques that may help if they are doing so
written instructions on proper drop administration with the patient's specific drug
regimen. This serves as a handy reference for the patient after they leave your
office and may prevent them from calling back because
they forgot which drop to use when and how often. Further, because written instructions
may contain your practice information, they can also be a valuable tool to help
grow your practice through referrals and word-of-mouth.
patient education, preferably in writing. It's important to educate the patient
on the reasons for treatment despite an absence of obvious symptoms, such as pain
or decreased vision. Further, general information concerning glaucoma, again in
writing, in the form of brochures or pamphlets, is also valuable. Several software
programs are available that can provide quality patient education in terms the patient
can understand, and can also be customized with his individual medications, dosages,
and your practice information.
positive feedback if IOP is within target. We all like a pat on the back from time
to time as acknowledgment for doing a good job. Your patients are no exception.
Therefore, make it a point to tell your patient if you are pleased with his current
IOP control, and if they appear to be remembering to use their medications as prescribed.
Not only will this help build rapport, it will also strengthen their desire to continue
with the treatment as they can begin to see that it is making
your patient to acknowledge missed doses. This is especially important if you are
considering adding another medication or changing therapy. Acknowledge to the patient
that you understand it may be difficult to recall their medications all the time,
but that it's very important for them to confide in you if they are using them,
so that you don't recommend a change unnecessarily. This is especially important
in your older patients, who may have memory or cognitive impairments, and may also
be on multiple medications, not just for their glaucoma but for systemic reasons
in mind that compliance may increase just prior to an exam. Just like you probably
floss your teeth before a dentist appointment, compliance may increase right before
an exam. This may be done in an attempt to make the doctor happy, or simply because
they remembered to start using the drops due to their appointment reminder. Whatever
the reasoning, you may get a good IOP reading that leads to a sense of false security.
Again, it's important to encourage the patient to be honest regarding administration
of his drops, especially if you're considering altering the treatment.
Use the least number of medications to achieve your
desired response. Studies show that patients who take only one eye drop per day
report approximately 49% compliance with their medications compared with 39% compliance
for twice daily dosing. And, more than one medication further decreases compliance
to about 32%. Therefore, it is important to use the least number of medications,
with the easiest dosing regimen possible, to achieve the desired response. A decreased
number of medications also means decreased cost for the patient, as well as decreased
potential side effects and drug interactions.
medications first, add additional medications second. If a patient demonstrates
a poor IOP response to a specific mediation, resist the temptation to automatically
add medications. For example, if a patient does not achieve the desired IOP reduction,
such as the 25% or so we come to expect with a prostaglandin, try a different class
of medication or another prostaglandin before simply adding a second medication.
As stated above, additional medication will only hinder compliance. There is plenty
of literature that suggests some patients may respond better to one prostaglan-din
than another. Further, not all patients will respond equally to all classes of
combinations in patients who need more than one medication. In a patient who requires
a greater reduction in IOP than can be achieved with a single medication, consider
using a combination, such as Cosopt (dorzolamide hydrochloride 2% plus timolol maleate
0.5%, Merck). Again, a smaller number of drops per day will help to increase compliance. In fact,
one study revealed that almost half the patients surveyed stated they would be willing
to pay more for an eye drop that included two medicines in a single bottle. While
this is the only combination currently commercially available, several companies
are working on plans to develop combination beta-blockers and prostaglandins.
the treatment regimen to fit the patient's lifestyle. For example, we know that
prostaglandins tend to get the best IOP response if taken in the evening. However,
if you have an elderly patient who falls asleep watching television every night
before administering his medication, it's perfectly legal to recommend taking the
drop in the morning. Studies have demonstrated that the IOP response with morning
administration of prostaglandins is still very good. Simply explain to the patient
that while the evening administration has been shown to be more effective, you would
prefer the patient to remember using the drop consistently, regardless of the time,
rather than not at all.
patients to become active in their treatment plans. Just as it is important to let
the patient know when you are pleased with the IOP control, it is equally important
to let them know when you are not pleased, and when you feel that it's necessary
to make a change in their treatment regimen. If possible, let the patient feel
that they are part of the decision-making process by allowing them to have input
into the different strategies you are considering. This will go a long way in establishing
patient-provider rapport and increasing compliance.
Demonstrate field loss on a visual field. Showing the
patient with field loss the gray scale on the visual field printout can often be
a powerful patient education tool. This is especially true if you can demonstrate
some worsening over time attributable to non-compliance. The "black spots," showing
areas that the patient is unable to see is powerful, especially since most patients
do not notice this field loss until late in the disease process. Conversely, showing
fundus photos of the optic nerve head is of little value, as the patient generally
cannot appreciate or understand the difference between healthy and unhealthy appearing
alternative treatments with the patient. When you can't obtain appropriate control
of IOP with topical medications alone, consider other treatment modalities, such
as argon laser trabeculoplasty, selective laser trabeculoplasty and
Don't look at these as punishment for non-compliance, but rather as alternatives.
Discuss all therapies with patients, including your recommendations.
It's worth the effort
Convincing glaucoma patients, especially
those with no noticeable field loss or other symptoms, of the importance of proper
compliance is a true challenge. Some of these strategies may help decrease
non-compliance and lead to better treatment outcomes. Moreover, connecting
with these patients on a personal level to help them avoid complications from
their glaucoma can be very rewarding.
available on request.
is Chief of Optometry at the Sepulveda
Veterans' Affairs Ambulatory Care Center and Nursing Home, and an Assistant Professor
at the Southern California College of Optometry. He has also published several
articles in optometric journals.