Page 917 - Cardiac Nursing

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C HAPTER 4 0 / Adherence to Cardiovascular Treatment Regimens 893
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errors in recall or reporting; for example, underreporting food Several devices measure exercise adherence. The Polar moni-
consumption 76,77 and overreporting energy expenditure 75,78 are tor can be worn during ambulatory exercises (walking, bicycling).
common phenomenon among obese subjects. Moreover, there are It includes a microprocessor that measures and sequentially stores
concerns specific to self-report of eating and exercise behaviors. It average heart rate values, which provide data on adherence to the
is difficult for individuals to accurately estimate the portion size exercise prescription (Polar Electro, Inc., Lake Success, NY). 89,90
and components of mixed foods. Because there are so many di- Pedometers are used to measure steps and miles during ambula-
mensions of exercise, it is a challenge for individuals to accurately tory activity and are the most inexpensive objective monitoring
characterize the type of exercise, its frequency, duration, and in- device for physical activity. However, pedometer accuracy is influ-
tensity. 78 Staff need to be trained on how to teach participants to enced by walking speed; there was significant improvement in pe-
record the information, and potential problems with memory and dometer accuracy in fast pace walking, compared to that in slow
social desirability need to be reduced. For example, recording the pace walking. 91–93 Electronic accelerometers are motion sensors
behavior immediately reduces forgetting and conveying an expec- that register body accelerations and decelerations, and thus pro-
tation of a full range of behaviors may help reduce less than truth- vide a direct and objective measure of movement intensity and
ful reports. Despite their limitations, self-report measures are frequency during physical activity. The Actigraph accelerometer
common, easy to use, inexpensive, and provide information on (Manufacturing Technologies Inc., Fort Walton Beach, FL) and
the circumstances surrounding the good or poor adherence. the Caltrac accelerometer (Muscle Dynamics Corp., Torrance,
CA) were used to assess physical activity levels among adults with
Biologic Measures congenital heart disease, 94 and among individuals of all ages from
the 2003 to 2004 National Health and Nutritional Examination
95
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Adherence is often reported in terms of biologic end points, such Survey. The SenseWear Armband (BodyMedia, Inc., Pittsburgh,
as serum cholesterol or glycosylated hemoglobin level. Other bio- PA) is a relatively new product that monitors physical activity and
logic assays frequently used include serum, urine, or saliva level of energy expenditure. It is worn on the upper right arm. It includes a
a drug or its metabolites. Examples include antihypertensive med- two-axis accelerometer, heat flux sensor, galvanic skin response sen-
79
ication adherence measured by serum bromide level, dietary ad- sor, skin temperature sensor, and a near-body ambient temperature
80
herence measured by urine sodium, smoking cessation by serum sensor, which enables it to measure heat produced by the body as a
or saliva thiocyanate or cotinine, 81 and exercise by direct or indi- result of basic metabolism and from all forms of physical activity.
rect calorimetry and maximal oxygen uptake. 82 Doubly labeled Data are stored up to 12 days and can be uploaded to a personal
18
2
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water ( H 2 O), a procedure that requires the subject to ingest computer for analysis using the SenseWear Software. This device
2
water enriched with 18 O and H isotopes, is the most accurate has been shown to reliably determine energy expenditure in both
measurement of total energy expenditure available, 83 but is too the active and resting state, and thus measures activity adherence in
costly to be used on a widespread basis. 84 A limitation of biologic an unsupervised setting. 96–99
assays is that daily variability in compliance cannot be detected. Electronic hand-held diaries are available to answer a set of pro-
Instead, they indicate if the person has been adherent close to the grammed questions, report symptoms or cravings, when prompted
time of assessment and may serve as a validation of the behavior. by a sound, 100 or to record eating and physical activity behav-
Moreover, biological measures are not available for many drugs iors. 65,70,77,101,102 Because recalling events or symptoms is plagued
and dietary factors; moreover, biologic assays may be influenced by biases and inaccuracies, the electronic diaries attempt to avoid
by many other factors such as ethnic differences in urinary sodium this barrier by having individuals record experiences close to the
excretion. 85 time of their occurrence. 103 Moreover, these monitoringdevices
permit objective measurement of adherence to a recording schedule
Electronic Monitoring under naturalistic conditions. An added benefit is that the data are
directly entered by the person and later uploaded to a computer for
Technology has provided tools for ongoing and detailed assess- analysis. Acceptability of the hand-held computers has been re-
86
ment of adherence behavior. Electronic methods include unob- ported as excellent. 65,104,105 Stone et al. compared the use of a pa-
trusive electronic medication monitors, heart rate monitors, per diary equipped with a light sensor to record the day and time of
electronic motion detectors for exercise (pedometers, accelerom- diary openings with an electronic diary (similar to a personal digi-
eters, SenseWear Armband), and electronic diaries for self-report tal assistant). They found that 95% of participants using the per-
data. 86 The Medication Event Monitor System (MEMS; sonal digital assistant (PDA) recorded in the diary while 90% using
APREX, a division of AARDEX Ltd., Union City, CA), consists the sensor embedded paper diary reported that they recorded in the
of an electronic chip housed inside the medication bottle cap, diary but in reality, only 11% recorded. 86 Burke et al. 106 used the
provides date and time data on medication bottle openings and same sensor embedded diaries as the ones used by Stone and Shiff-
closures. This assessment is based on the assumption that bottle man and found that study participants often falsified the date and
opening leads to pill removal and ingestion. 87,88 An additional times of their recordings so that it appeared that they were record-
applications of an electronic monitor for medication use in- ing on a daily basis when in reality they were recording several days
cludes the IDAS II (Intelligent Drug Administration System, of behavior at one time. 69,106 Other innovative approaches to self-
Bang and Olufsen Medicom, Denmark) that accommodates monitoring include the use of web sites for patients to log onto and
blister pill packs. 88 This new device uses visual and audible re- record behaviors. 107,108 In addition, programs are available on the
minders to the patients to enhance adherence. Similar to the Internet that provide the structure for self-monitoring, for example,
MEMS, the IDAS II has been demonstrated to be acceptable to www.FitDay.com, www.sparkpeople.com, and www.caloriecount.
people with hypertension. 88 Santschi et al. 88 reported that there com. In summary, electronic monitors provide a detailed picture of
was a tendency for patients using the IDAS II to take their drug the temporal pattern of adherence, from medication taking to
more regularly. self-reporting symptoms or eating or physical activity behaviors.