Managing Disruptive Patients _ ________________________________________________________________
of written materials that reflect a fourth or fifth grade reading level is appropriate so that the patient’s level of health literacy is not overestimated. Patients with cognitive deficits may not be able to learn. Patients must have an adequate attention span to be capable of concentrating and learning new behaviors. If the patient has little focus or scope of attention, the healthcare profes- sional should attempt to consult with a family member or other support person and determine who should receive healthcare information because the patient is not capable of understanding it. Similarly, patients with changes in mental status may be unable to integrate new learning material effectively. Their judgment may be significantly impaired. A thorough mental status examination is needed if there is any indication that a patient’s mental status is compromised. Some patients may be in denial, a defense mechanism used to guard against uncomfortable feelings. They may be too frightened by their illness to be able to accept it. This can cause them to feel their treatment recommendations are unneces- sary. They need time to adjust and an opportunity to discuss these difficult feelings. Denial is a normal part of grieving and sometimes occurs in people when they find out they have a terminal illness. Illness and hospitalization involve losses for people regardless of the prognosis, and denial may be part of any patient’s presentation. Sometimes giving patients time to adjust to their new status is sufficient and they will be ready to accept and, ideally, adhere to their new treatment needs. Anxiety reduces the ability to process information or to make decisions. An anxious patient might exhibit several differ- ent emotions and behaviors, including anger, complaining, demanding, withdrawing, or even crying. When a patient’s anxiety is reduced, it will help the patient in adhering to the treatment regimen. Many patients are fearful of the unknown. Education often allays these fears. Dependence on medications and illegal substances affects adherence because these drugs may be the priority in the individual’s life. If the treatment regimen interferes in any way with the behaviors surrounding the need to maintain the drug to avoid withdrawal, the patient will not be adherent until the substance use disorder is treated. The classic example of this is the patient with an alcohol use disorder who has cirrhosis. The recommended treatment is abstinence from alcohol, but few patients who misuse alcohol can accomplish this without professional intervention. A person who suffers from a depressive disorder will not take in information or make decisions as well as one who is not depressed. Individuals who are depressed are more likely than others to be nonadherent to treatment plans. They com- monly have low self-esteem and feelings of hopelessness that can interfere with their ability to follow a regimen to better their health. To a large degree, they lack the energy to com-
ply. Although depression is the most common mental health problem in the United States and one of the easiest to treat, it is the least treated; thus, patients who are depressed are often overlooked. Patients with depression often have other physi- cal inflammatory illnesses such as heart disease, diabetes, or chronic obstructive pulmonary disease. Finally, patients enter the healthcare system with ideas and beliefs that affect the course of their current hospitalization. Previous experiences that were negative can affect a patient’s expectations. If a patient enters the system expecting the worst, chances are good that healthcare recommendations will not be viewed in a positive light. Healthcare professionals can influence these patients to take a more positive outlook by building trust and meeting their expectations as much as possible. When healthcare professionals cannot meet these expectations, it can be helpful for them to explain why. AGE The estimated rate of nonadherence for older adult patients is 50%. They are more at risk for nonadherence than other adult patients. Because of their unique needs, older adult patients present a challenge in adherence. Their hearing, vision, and cognitive functioning are likely to be impaired in some way. These impairments, as well as years of ingrained habits, make changes in behavior more difficult. Most patients 60 years of age or older require vision correction of some sort. These impairments make self-administration of medications particularly difficult. Almost one third of all people aged 65 to 79 years have significant hearing impairment. In older adult patients, recall is best when material is given verbally. Information must be delivered slowly and audibly. Reinforcing verbal instruction with written materials is essen- tial and teach-back will assess understanding. Print materials with large-type fonts and pictures are most effective. Depression is common in older adult patients. It often goes undetected and untreated. Depression lessens the ability of older adult patients to adapt to changes in lifestyle. Seemingly simple tasks such as picking up a pill become difficult. Plans for self-management must take this loss of dexterity into account. Older adults often find that their social support systems are shrinking. Friends and relatives may be ill, dying, or making changes in living arrangements. This resulting isolation can affect adherence. The number of medications prescribed for older adult patients can be a problem. At least one-fourth of older adult patients recently discharged from hospitals have six or more prescrip- tions that require self-administration. Medication costs must be considered, as well as the ability to obtain the medications if transportation and mobility are issues (Stewart, 2023). It is easy to see why the nonadherence rates for older adult patients are high. This population is also less likely to be asser- tive about their needs with healthcare providers. Older adult patients constitute a major part of general care patients today.
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