Patient behavior and the drivers of vertigo treatment adherence

Treatment adherence offers a significant opportunity for improved outcomes

Characterizing the nature of vertigo treatment non-adherence is challenging given the number of underlying conditions and treatments associated with vertigo. In the narrowest sense, vertigo is caused by peripheral or central vestibular disorders, and common examples of these include benign paroxysmal positional vertigo (BPPV) and Meniere’s disease.1 Treatment of these diseases often requires complex approaches that incorporate medical treatment, specific physical exercises, and psychological help. If the underlying diseases are diagnosed and treated correctly, vertigo is often reduced, and the patients may recover their usual way of life. Without proper treatment, the patient’s lifestyle may be significantly altered: Patients are left afraid of going out, performing normal daily tasks, and with other concerns that have a significant negative impact on their quality of life. 

The drivers of non-adherence are complex 

Non-adherence is a complex issue, making it difficult for health care providers to know when and how to intervene. The World Health Organization has five classifications for non-adherence:socioeconomic, health care team and system-related, disease-related, therapy-related, and patient-related factors.2 Recent interventions using a variety of approaches to address have demonstrated efficacy. These approaches include providing information (individual or group education), behavioral aids (calendar reminders, pill boxes, coaching, etc.), and strategies for improving social support (e.g. family involvement).12 Despite extensive research by behavioral and clinical scientists to organize patient-related non-adherence, there is still no comprehensive and widely accepted model. As a result, effective, standardized, and reliable patient-focused interventions remain a significant area of opportunity to improve outcomes,4 and there are useful tools and approaches based on the known drivers of patient behavior that can use to improve adherence. 

Intentional non-adherence is typically more common than unintentional non-adherence (e. g. forgetfulness).  Intentional non-adherence is based on a cost-benefit analysis, and it involves the weighing of perceived risks against perceived benefits of treatment.

Patient non-adherence may be intentional or unintentional

Recent studies have sought to characterize the types of non-adherence behavior its causes. In general, two major types of non-adherence have been identified: 

  • Intentional non-adherence is deliberate and largely associated with patient motivation.4 The patient’s decision not to take medication as prescribed may the result ofa cost-benefit analysis, involving comparison between the perceived effort (cost) required for adherence versus benefits of the treatment. This thought process may be influenced by the patient’s beliefs about medication, the patient’s self-efficacy and the patient’s knowledge of the disease.3 In reality, there are many more subtle psychological factors at play, but the patient almost inevitably expresses the decision as a rational one (whether or not it actually is), and physicians can interact with patients at this level.
  • Unintentional non-adherence is driven by a lack of capacity or resources to take medications.4 It includes forgetfulness, regimen complexity, financial difficulties, or physical limitations.

Non-adherence drivers for vertigo therapies may be both intentional and unintentional

This classification provides a useful starting point for communication about patient adherence. In general, medication non-adherence for chronic conditions is largely intentional, involving deliberate decisions to take medication differently than prescribed.5 While adherence information for vertigo is limited, using the analogy of adherence for pain medications, adherence levels are surprisingly low, and similar behavior can reasonably be expected for vertigo.7 

Because an episode of vertigo has significant differences from an episode of pain, parallel with pain treatment is not perfect, but further insight can be gained by examining reports from doctors and patients. Commonly reported problems linked to vertigo include psychological issues, such as anxiety and depression, with particularly poor prognoses for patients experiencing recurring symptoms; this is likely linked to fear of sudden-onset vertigo episodes.8  Experiences with other ailments indicate that patients subject to moods disorders can be expected to have lower adherence rates, particularly with respect to physical activity.9  

The following quotes from physicians are typical: “They (patients with vertigo) can’t drive, they can’t take walks, and for people who are by themselves, if they fall, they don’t have people who can come and get them”; other doctors go as far as saying: “Truth is, when you have vertigo, life stops.”10Typically, prescribed therapy includes regular exercise, such as walking, but that sort of activity can be daunting when fear of falling is overwhelming.11 Therefore, in order to address non-adherence to treatment, physicians need to reassure patients, provide motivation to follow treatment recommendations, and be sensitive to the patient’s perceived cost-benefit perceptions. All this is easier with an understanding of the patient’s decision-making process.

Influencing the patient cost-benefit analysis may improve non-adherence

Given the prevalence of non-adherence among patients with vertigo, medication decision making processes and cost-benefit analyses merit further investigation.In patients with depression and vertigo, the perceived benefits may be close to zero, so there may be no motivation to adhere. Effective, personalized solutions for improving non-adherence incorporating a behavioral science-based understanding of how people incorporate risk assessment into their decision-making process may yield the best results. Nudge techniques  easily employed by physicians can have a considerable impact on how patients rate the costs and benefits of taking their medication as prescribed.  This and other techniques will be examined in future articles. 

References

  1. Eva Kovacs et al. (2019). “Economic burden of vertigo: A systematic review,” Health Economics Review, (9):1 p. 37. https://doi:10.1186/s13561-019-0258-2
  2. Marie T. Brown & Jennifer K. Bussell (2011). “Medication adherence: WHO cares?” Mayo Clinic Proceedings, (86):4, pp. 304–14. https://doi:10.4065/mcp.2010.0575 
  3. Bart J.F. van den Bemt, Hanneke E. Zwikker, & Cornelia H.M. van den Ende (2012). “Medication adherence in patients with rheumatoid arthritis: A critical appraisal of the existing literature,” Expert Review of Clinical Immunology, (8):4, pp. 337–351. https://doi: 10.1586/eci.12.23 
  4. Gerard Molloy et al. (2014). “Intentional and unintentional non-adherence to medications following an acute coronary syndrome: A longitudinal study,” Journal of Psychosomatic Research, (75):5, pp. 430–432. https://doi:10.1016/j.jpsychores.2014.02.007 
  5. Rebecca Meraz (2020). “Medication nonadherence or self-care? Understanding the medication decision-making process and experiences of older adults with heart failure,” Journal of Cardiovascular Nursing, (35):1, pp. 26–34. https://doi:10.1097/JCN.0000000000000616. 
  6. Michael Weiser et al. (1998). “Homeopathic vs conventional treatment of vertigo,” JAMA Archives of Otolaryngology–Head & Neck Surgery, (124):8, p. 879. doi:10.1001/archotol.124.8.879.
  7. L. Timmerman et al. (2016). “Prevalence and determinants of medication non‐adherence in chronic pain patients: A systematic review,” ACTA Anesthesiologica Scandanvica, (60):4, pp. 416–431. https://doi.10.1111/aas.12697
  8. Claas Lahmann et al. (2015). “Psychiatric comorbidity and psychosocial impairment among patients with vertigo and dizziness,” Journal of Neurology, Neurosurgery, & Psychiatry, (86):3, pp. 302–308. https://doi:10.1136/jnnp-2014-307601
  9. AMA (2015). “8 Reasons patients don’t take their medications,” American Medical Association, 16 October, 2015. https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications.
  10. Alli Maloney (2017). “Getting diagnosed with a chronic disease with no treatment or cure is like entering a Kafka novel,” Quartz, 20 February, 2017. https://qz.com/909898/getting-diagnosed-with-a-chronic-disease-with-no-treatment-or-cure-is-like-entering-a-kafka-novel/
  11. Ekaterina Pichugina (2018). “Dizziness: What is behind one of the main ailments of the elderly,” MKRU, 12 March, 2018. https://www.mk.ru/social/health/2018/03/12/ golovokruzhenie-chto-stoit-za-odnim-iz-glavnykh-nedugov-pozhilykh.html.
  12. Sunil Kripalani, Xiaomei Yao, & R. Brian Haynes (2007). “Interventions to enhance medication adherence in chronic medical conditions: A systematic review,” JAMA Internal Medicine, (167):6, pp. 540-50. https://doi:10.1001/archinte.167.6.540