MEDICAL SOCIOLOGY LECTURES (PART B)
by Dr PHUA Kai Lit
School of Medicine and Health Sciences
Monash University Sunway Campus
Bandar Sunway, Malaysia
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NONADHERENCE: This simply means failure to follow medical instructions and advice e.g. don't take medicine at all, improper dosages are taken, the medicine is taken along with unprescribed drugs (including traditional medicine). This can lead to adverse drug interactions. Nonadherence includes failure to follow advice on nutrition e.g. during pregnancy and lactation.
EXTENT OF NONADHERENCE: Nonadherence is common and widespread - as high as 50%. As many as 1/3 of patients don't take their medicine at all!
CONSEQUENCES: These can be severe in patients with insulin-dependent diabetes mellitus or in patients with hypertension.
FACTORS AFFECTING ADHERENCE: These include the personality of the patient, the quality of doctor-patient interaction, cognitive factors (forgetting, unclear instructions, too complex medications, carelessness e.g. forgetting to pack medication when going on trips overseas). Other factors include uncomfortable side-effects, drugs are too expensive, patient frustration with being dependent on medicine for his or her well-being, "testing" by the patient. Food taboos and beliefs may affect adherence to nutrition advice during sickness, pregnancy, lactation and menstruation.
STEPS TO IMPROVE ADHERENCE
Here are some steps:
Give simple and clear instructions
Better doctor-patient communication
Ensure that the patient really understands what you are trying to convey i.e. you need to stress important points, repeat if necessary, give specific advice
Simplify the regimen
Prescribe cheaper generic drugs in place of expensive, branded drugs
Inform patient about the side-effects to be expected
Change the medication if the side-effects are too severe
Make sure the patient takes the entire course of antibiotics
Get family members to monitor adherence
Deal with food taboos and beliefs i.e. ignore those which are harmless, encourage those which are beneficial and discourage those which lead to nutritional deficiency during sickness, pregnancy, lactation or menstruation.
* REMEMBER: Partial adherence is better than total nonadherence!
* CARE in prescribing to children, the elderly and the immunocompromised.
* The doctor SHOULD look out for uncomfortable side effects, adverse reactions (e.g. Reye's syndrome whereby there is severe allergic reaction to aspirin use - including liver failure) and adverse interactions (between two drugs - including between a prescribed drug and a traditional drug. Or between a drug and alcohol).
Myths about the Elderly (see graphic below!)
INDIVIDUAL VERSUS POPULATION AGEING: Population ageing is when the % of elderly in a population increases from 3% to about 25%. Due mainly to low birth rates.
CHANGING DEFINITIONS OF THE ELDERLY: In some societies, a person in his or her 40s would be considered "elderly". In Malaysia, the retirement age is 55 while in America, it is 65.
WHO ARE THE ELDERLY?: The "young-old" versus the "old-old" ( > 80 years old). There are more elderly women than elderly men (especially in the oldest age groups). This is because women tend to live longer than men on the average.
INDIVIDUAL AGEING
Physical/biological ageing:
Different people may undergo some of these at different rates (depending on how they take care of themselves)
Vision
Hearing
Skin
Blood pressure (systolic blood pressure)
Kidneys (fall in ability to excrete toxic wastes)
Lungs (loss of elastic recoil)
Menopause in women
"HEALTHY AGEING": Most of the elderly are relatively healthy. People can take action so that they can stay healthy as long as possible. "Healthy ageing" through a healthy lifestyle and prevention of disease. Our jobs can affect our rate of ageing. "A common belief is ... that much of the disease and loss of function which accompanies ageing is inevitable and due to the "ageing process" .. We now know that these conditions (such as osteoporosis) can be prevented or even improved" (Quote from Dr Philip Poi, Universiti Malaya)
SOCIAL CHANGES
Family e.g. kids grow up and leave home, people become grandparents
Work and retirement e.g. drop in income and status after retirement, dependence on grown children for support
Bereavement e.g. death of spouse
Coping strategies e.g. deal with social isolation because of retirement, physical disability, death of spouse or friends
PSYCHOLOGICAL CHANGES
Personality - little change
Caution e.g. less risk-taking behaviour
SOCIETY AND AGEING
Respect versus ageism
"Ageism" = prejudice and discrimination against people on the basis of their age
* New roles need to be created for the elderly in urban, industrial society
SPECIAL HEALTH PROBLEMS OF THE ELDERLY
Falls
Urinary Incontinence
Adverse drug reactions and interactions e.g. because of "polypharmacy" (taking many kinds of drugs because the person suffers from more than one disease)
Abuse of the elderly
Higher risk of suicide
Multiple health problems are common, e.g., an elderly person may suffer from hypertension, diabetes and arthritis at the same time
* Who will provide care for the elderly?
The Government, the community, commercial companies, family members, self-help groups.
REFERENCES
Wallace, R.B. ed. 1998 "Maxcy-Rosenau-Last Public Health and Preventive Medicine" 14th ed. Stamford, Connecticut: Prentice-Hall International Inc.
Cassens, B.J. 1992 "Preventive Medicine and Public Health" 2nd. ed. Philadelphia: Harwal Publishing
Lucas, A.O. and H.M. Gilles 1990 "A New Short Textbook of Preventive Medicine for the Tropics" 3rd. ed. Sevenoaks, Kent: ELBS with Edward Arnold
McWhinney, I.R. 1997 "A Textbook of Family Medicine" 2nd. ed. New York: Oxford University Press
Patrick, D.L. and G. Scrambler 1982 "Sociology as Applied to Medicine" London: Bailliere Tindall
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