Maybe There is a Reason to Patient Noncompliance!

We all struggle with and are frustrated by the problem of patient compliance with our treatment plans and other instructions. After all, we only have their best interests in mind; so, why are they not doing what we asked? You may (or may not!) remember my editorial from April 2007¹ addressing our frustration of trying to help our patients. Even now, I continue to wonder why patients who have diabetes mellitus and a foot ulcer cannot understand that a blood sugar > 500 mg/dL and a HbA_1c of 12% are not good. Still, after a patient has lost a toe, part of a foot, or even part of the leg to diabetic foot complications, they do not seem to change; they do not seem to understand that these are not going to help them and will, most likely, result in continued problems. You know the patients about whom I am talking. It is almost like they just do not get it. I have pondered this question the past several years and tried to arrive at a reasonable answer so that maybe we could help these people.

The only reasonable explanation I could come up with might be that it is related to some underlying condition. Of course, the most frequent underlying condition that our patients have is diabetes mellitus. Diabetes is now the most prevalent noncommunicable disease worldwide.² Associated with diabetes mellitus is the potential development of numerous complications including peripheral and autonomic neuropathy. Almost 60% to 70% of people with diabetes will develop symptoms of neuropathy during the course of their disease.³ Since neuropathy can affect the nerves in the extremities and organs of the body, I wondered if there might be some neurological effect that might cause patients not to understand the seriousness of their disease. Much to my surprise, there is literature addressing the changes to the brain caused by diabetes, including its effect on a patient’s cognitive abilities. Could this possibly be the problem?

Apparently, the effect of diabetes mellitus on the brain has been studied for some time, with the term diabetic encephalopathy being used to describe the problem.⁴ Evidence has shown that diabetes mellitus can result in cognitive decline resembling dementia. According to neuropsychologists, cognition involves intelligence, learning and memory, speed of information processing, executive function, academic achievement, and visual motor integration.⁵ Executive function (ie, ability to plan, pay attention, and suppress inappropriate behaviors) seems the most applicable cognition type to our situation, which could explain a patient’s inability to choose to be compliant with prescribed treatments — sound familiar to you?

Studies^6,7 have shown this cognitive change can occur in patients with type 1 or type 2 diabetes. It is found in children with type 1 diabetes; an early manifestation of the disease results in more prevalent and severe cognitive problems.⁶ Adults with type 2 diabetes can be a challenging problem when their cognitive problems become apparent.

You might think this explanation only gives patients with diabetic foot ulcers a possible answer for their noncompliance with treatments and instructions; however, remember that about 30% to 40% of all patients we see with wounds have diabetes mellitus. They may not have diabetic foot ulcers but are being treated for venous ulcers, arterial ulcers, or even traumatic wounds. If this cognition problem is affecting them, this may explain their behavior as well. If this proves to be true, it may help us be a bit more tolerant of their unhealthy choices, because, at this time, there is no treatment for this cognitive problem once it develops.

As research seeks to find a treatment or prevention for this problem in the patient with diabetes, we may need to apologize to some of our patients for the thoughts we have had about them in the past.