Essenzieller Baustein für eine erfolgreiche und wirkungsvolle Therapie chronisch obstruktiver Lungenerkrankungen ist die korrekte Benutzung des Inhalationssystems. Die fehlerfreie Inhalationstechnik ist aber nur ein, wenn auch wesentlicher Aspekt. Entscheidend bleibt, ob der Patient die vereinbarte Therapieempfehlung im Alltag umsetzt, d.h. wie steht es um die Adhärenz?

Im Alltag verlassen wir uns häufig auf die Intuition, um die Adhärenz des Patienten abzuschätzen. Plaza et al. haben einen praxisrelevanten Fragebogen mit 10 Fragen evaluiert. Das Resultat lässt das Muster der Faktoren erkennen, die zu einer fehlenden Adhärenz führen. In diesem Beitrag haben sich 42% der Teilnehmer bewusst und 26% unbewusst nicht an die Therapievereinbarung gehalten.

Unter anderem wird gefragt, ob der Rückgang der Erkrankungssymptome zu einer Reduktion der Medikation führt oder ob die Sorge bezüglich Nebenwirkungen überwiegt. Im Einzelnen mögen die Fragen trivial sein, dennoch kann der Fragebogen sehr hilfreich sein, um ein strukturiertes Gespräch mit dem Patienten zu führen. Dies gilt insbesondere bei einem unkontrollierten Erkrankungsverlauf.

Dies deutet auf eine weitere interessante Thematik hin. O‘Conor et al. untersuchten den Zusammenhang zwischen Gesundheitskompetenz (health literacy), der kognitiven Funktion und der Adhärenz bei älteren Patienten. Die Gesundheitskompetenz beschreibt die Fähigkeit des Einzelnen, im täglichen Leben gesundheitsrelevante Entscheidungen zu treffen. Dazu müssen Informationen abgerufen, verarbeitet und verstanden werden. Gerade ältere Patienten dürfen bei der Schulung und der Informationsvermittlung nicht überfordert werden. Klare und begrenzte Anweisung sind von Bedeutung.

Nun werden Sie, lieber Leser, anmerken, dass Ihnen diese Sachverhalte völlig klar sind. Warum aber liegt dann die Adhärenz in der Inhalationstherapie näher an 30 als an 50%? Gerade hierzu empfehle ich die Lektüre der beiden folgenden Beiträge.

Plaza V, Fernández-Rodríguez C, Melero C, Cosío BG, Entrenas LM, Pérez de Llano L, Gutiérrez-Pereyra F, Tarragona E, Palomino R, López-Viña A: Validation of the ‘Test of the Adherence to Inhalers' (TAI) for asthma and COPD patients. J Aerosol Med Pulm Drug Deliv DOI:10.1089/jamp.2015.1212.

Background: To validate the ‘Test of Adherence to Inhalers' (TAI), a 12-item questionnaire designed to assess the adherence to inhalers in patients with COPD or asthma.

Methods: A total of 1,009 patients with asthma or COPD participated in a cross-sectional multicenter study. Patients with electronic adherence ≥80% were defined as adherents. Construct validity, internal validity, and criterion validity were evaluated. Self-reported adherence was compared with the Morisky-Green questionnaire.

Results: Factor analysis study demonstrated two factors, factor 1 was coincident with TAI patient domain (items 1 to 10) and factor 2 with TAI health-care professional domain (items 11 and 12). The Cronbach's alpha was 0.860 and the test-retest reliability 0.883. TAI scores correlated with electronic adherence (p = 0.293, p = 0.01). According to the best cut-off for 10 items (score 50, area under the ROC curve 0.7), 569 (62.5%) patients were classified as non-adherents. The non-adherence behavior pattern was: erratic 527 (57.9%), deliberate 375 (41.2%), and unwitting 242 (26.6%) patients. As compared to Morisky-Green test, TAI showed better psychometric properties.

Conclusions: The TAI is a reliable and homogeneous questionnaire to identify easily non-adherence and to classify from a clinical perspective the barriers related to the use of inhalers in asthma and COPD.

O'Conor R, Wolf MS, Smith SG, Martynenko M, Vicencio DP, Sano M, Wisnivesky JP, Federman AD: Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. Chest 2015;47:1307-1315.

Background: We sought to investigate the degree to which cognitive skills explain associations between health literacy and asthma-related medication use among older adults with asthma.

Methods: Patients aged ≥ 60 years receiving care at eight outpatient clinics (primary care, geriatrics, pulmonology, allergy, and immunology) in New York, New York, and Chicago, Illinois, were recruited to participate in structured, in-person interviews as part of the Asthma Beliefs and Literacy in the Elderly (ABLE) study (n = 425). Behaviors related to medication use were investigated, including adherence to prescribed regimens, metered-dose inhaler (MDI) technique, and dry powder inhaler (DPI) technique. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of fluid (working memory, processing speed, executive function) and crystallized (verbal) ability.

Results: The mean age of participants was 68 years; 40% were Hispanic and 30% non-Hispanic black. More than one-third (38%) were adherent to their controller medication, 53% demonstrated proper DPI technique, and 38% demonstrated correct MDI technique. In multivariable analyses, limited literacy was associated with poorer adherence to controller medication (OR, 2.3; 95% CI, 1.29-4.08) and incorrect DPI (OR, 3.51; 95% CI, 1.81-6.83) and MDI (OR, 1.64; 95% CI, 1.01-2.65) techniques. Fluid and crystallized abilities were independently associated with medication behaviors. However, when fluid abilities were added to the model, literacy associations were reduced.

Conclusions: Among older patients with asthma, interventions to promote proper medication use should simplify tasks and patient roles to overcome cognitive load and suboptimal performance in self-care.

2016
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