Medication adherence refers to the extent to which a person’s medication-taking behavior corresponds with recommendations from a healthcare provider. The world Health Organization reports that adherence to medications averages 50% among patients with chronic diseases, although it can vary substantially by patient population, age and location.
As expected, nonadherence to medications leads to significant detrimental clinical outcomes. Hospitalizations and death. Medication nonadherence can arise from taking more or less of medication, dosing at the wrong times, discontinuing prematurely or not filling a prescription. It can be an intentional decision or passive unintentional process.
Intentional nonadherence arises when a patient actively decides to not adhere to medication regimen. Commonly cited reasons include adverse effects, lack of expected benefit or stigma, unresolved concerns about diagnosis, lack of symptoms or the time it takes to observe or experience an effect from medication.
Unintentional nonadherence results from factors such as forgetfulness. Elderly patients are particularly vulnerable to unintentional nonadherence resulting from physical and/or cognitive limitations in their capacity to manage medications, as well as polypharmacy and complex medication regimens.
Given the impact of nonadherence on hospitalization, morality and healthcare costs, extensive interest lies in developing technological solutions to address unintentional nonadherence, especially in older adults. Smart electronic medication reminders and AI monitoring using mobile devices serves as a convenient economic solution to improve drug nonadherence in older patients.
Pharmacists are in enviable position of being able to identify patients who may be non-adherent to medications, guide the choice and use of appropriate adherence technology, guide the choice and use of appropriate adherence technology, and provide real-time monitoring of adherence. Once unintentional nonadherence has been detected in an older adult, pharmacist can be an excellent resource for patients and their care-giver.
Determine the cause of the unintentional nonadherence
In older adults, unintentional nonadherence can arise from physical and/or cognitive limitation, as well as, polypharmacy and medication regimen complexity. Several tools are available to help clinicians examine an older adult’s ability to manage medications. Identifying the challenges an older adult is facing with medication management-whether related to vision, hearing, dexterity or grip strength, forgetfulness, cognitive impairment, polypharmacy or complex medication regimens-is important in deciding which electronic medication adherence product will be most appropriate. For example if a patient does not have the strength or dexterity to open a medication vial or puncture a blister cavity, an automated dispensing device may be an appropriate solution but if patient forgets an electronic reminder or Mobile app would be your choice.
Examine the features of electronic medication adherence aids to determine product appropriateness, based on patient’s specific medication management limitation.
Electronic adherence aids vary in packaging design; number of compartments, units or pockets to hold medications; number and type of alarms or patient reminders (e.g., beeps, flashing lights, vibration); and portability. Some products restrict the dispensation of medications to specific time periods, or provide a locking capability with a lock and key or passcode. New products with blue-tooth connectivity allow real-time monitoring of dispensing activity, provide summary reports, AI analysis, and have the ability to program real-time reminder or pop-up notifications on cellular phones through the use of cellphone application. Using AI in PK+ app generates alarm notification to care-giver or clinician. A patient’s specific limitation in medication management ability, as well as their individual preferences, will help determine whether a product will be used successfully or not. You must examine which features are necessary to improve medication-taking capacity, before recommending a product.
Establish that the patient is able to set up, fill and use the electronic medication adherence device at home.
Many electronic medication adherence products have complex instructions and require many steps to set-up the device for home use. In a study we conducted (unpublished), older adults could not complete the set-up of many of the devices without assistance. Setting up a device requires self-scheduling and self-dispensing of medications into specific compartments and/or pockets. This, in turn, requires an accurate understanding of the medication dosing regimen. If errors arise in self-scheduling or medication dispensing from prescription vials, the adherence product may not solve current concerns about nonadherence and may produce unintended consequences in medication taking, including the potential for harm. For example, older adults may fill the compartments inappropriately, set the alarms inaccurately, or may inadvertently lock the device if they forget the passcode, limiting the dispensation of the medications. Instructions for appropriate use are provided with many of these products and are also available online. It may be necessary to review the instructions with the older adult and or a caregiver. Some products provide helplines for assistance with appropriate setup. Many “smart” medication adherence products offer training at home to ensure appropriate setup and use. Some require dispensation of specific packaging of medications by community pharmacies, with some requiring multi-dose packages while others are able to use blister packaging.
Determine if a caregiver needs to monitor adherence in real-time—if so, a “smart” electronic medication adherence device may be needed.
In some cases, where a caregiver has taken on the responsibility of monitoring medication intake and adherence (e.g., for an older adult who requires assistance with medication management), the caregiver may request a “smart” electronic medication adherence product that allows for real-time monitoring for medication dispensing. Many (if not all) of these “smart” products provide connectivity, text message reminders and an interactive platform for communication between patients, caregivers and/or clinicians. AI (artificial Intelligence) helps in analyzing mishaps early and proper notification
Determine if the older adult can afford their electronic medication adherence product, and/or the subscription fee for smart device use.
The cost of these products varies from tens to hundreds of dollars. Some that provide connectivity also require a monthly subscription fee, which can add up to hundreds of dollars annually. As the cost for these products is not reimbursed or covered by many insurance providers, including provincial insurers, you must establish whether the older adult is able to afford to use these products.
With the increasing number and availability of electronic medication adherence products, pharmacists are in an ideal position to help older adults navigate this exploding field. These five tips can be used in the decision-making process when matching product to an older adult patient’s needs.
Curtsey of : Tejal Patel (firstname.lastname@example.org) is an assistant clinical professor at the University of Waterloo School of Pharmacy and at the Department of Family Medicine, Michael G. DeGroote School of Medicine, McMaster University. She is also a practising clinical pharmacist with the Memory Clinic at the Centre for Family Medicine Family Health Team in Kitchener, ON.
1. Sabate E. World Health Organization report: adherence to long-term therapies – evidence for action. World Health Organization; Switzerland: 2003.
2. Hugtenburg JG, Timmers L, Elders PJM, et al. Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions. Patient Prefer Adherence 2013;7:675-82.
3. Granger BB, Bosworth H. Medication adherence: emerging use of technology. Curr Opin Cardiol 2011;26:279-87.
4. Thomson SC, Walker AT. Use of modern technology an aid to medication adherence: an overview. Patient Intelligence 2011;3:49-55.
5. Yap AF, Thirumoorthy T, Kwan YH. Medication adherence in the elderly. J Clin Gerontol Geriatr 2016;7:64-7.
6. Elliott RA, Goeman D, Beanland C, et al. Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review. Curr Clin Pharmacol 2015;10:213-21.
7. Farooqi M, Carter C, Patel T. Electronic medication adherence technologies: classification to guide use in older adults. Can Pharm J 2017;150:S26.
8. Elliott RA, Marriott JL. Standardised assessment of patients’ capacity to manage medications: a systematic review of published instruments. BMC Geriatr 2009;9:1-9.
9. Advinha AM, Lopes MJ, de Oliveira-Martins S. Assessment of the elderly’s functional ability to manage their medication: a systematic literature review. Int J Clin Pharm 2017;39:1-15.