Taking Charge Of The Non-Adherent Patient With Diabetes

Thomas Belken, DPM, and Neal Mozen, DPM, FACFAS, CWS

   Understanding the dynamic of the patient’s household may also shed light on the non-adherence. Is the patient the caregiver for others? Does the patient have to do all of the grocery shopping and errands him- or herself? We instruct patients to limit their activities but if they have no one else to rely on, what can they do? Not everyone has the luxury of having family that is in close proximity or is willing to help. Fortunately, there are programs that can help patients with day-to-day chores and activities.

   Have patients bring in some pictures of their house and neighborhood. This will not only let the physician evaluate the living conditions and the physical demands on the patient (number of steps, hills, sidewalk conditions, etc.), but it also helps further the relationship with the patient. Ask questions since many people like to talk about themselves.

How A Rehabilitation Center Can Facilitate Non-Weightbearing

In regard to applying these principles, we encountered a patient in his late 50s with diabetes, who had sustained a calcaneal fracture. The fracture occurred a couple of years prior to the patient presenting to our practice. It appeared to be a Rowe type II fracture. A previous doctor fixated the fracture without incident. The patient is on dialysis and has peripheral neuropathy.

   By the time we met the patient, he was essentially walking on his talus with his calcaneus displaced laterally. After discussing expectations, treament options and possible complications, we determined a plan for the surgery but this was only a portion of the overall picture. Lengthy discussions ensued with the patient about his living situation, medical needs and the absolute necessity to remain non-weightbearing.

   Armed with as much information as we could gather, we decided to have the patient go to a rehabilitation facility for the month or so of the postoperative peroid. This may not have been exactly what the patient wanted but we were able to explain the importance of remaining non-weightbearing, maintaining proper nutritonal status, smoking cessation, glycemic control and monitoring of his mental health. All of these were things that the facility offered.

   We performed a talo-tibial-calcaneal arthrodesis with an intramedullary rod and external fixator. The postoperative course continued as planned without incident.

   Despite your best efforts, wounds dehisce and ulcers get infected. When the dust settles, you end up just being fortunate that the patient was able to keep the leg.

When The Patient Wants A Quick Fix

Another patient that comes to mind is the exact opposite of the previous patient example. A patient with a venous stasis ulcer, she always wanted a quick fix to the problem whether it was skin grafts, hyperbaric oxygen and superficial venous ablation. However, the patient would constantly miss appointments, remove her dressings and place whatever she felt like on the ulcer.

   We were frustrated. The patient only seemed to come in when it was time for pain medication or she needed a form filled out for disability. We pondered whether she really wanted to get better. Eventually, the patient received a second opinion and we were relieved to be rid of this incredibly non-adherent patient.

   Reflecting on it now, we knew things about the patient but did not really get to know her. We never met her family nor did we really know all of the stresses in her life. Maybe if we had gone the extra mile and developed a more significant relationship with the patient, she would have had a different outcome.

Helping Patients Focus On The Big Picture

A final example involves a patient we just recently met and whom we are currently deciding how best to manage. The patient is a non-adherent patient with diabetes who is in the early stage of a midfoot Charcot. Even in her own admission, she has noticed changes in the way her foot looked between our first and second visits. Despite what her own eyes have observed, she was more concerned with going in the pool over the Fourth of July weekend than the long-term consequences of her actions.

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