Improving compliance through dosing aids

Dr Henk-Frans Kwint is A Care Community Pharmacist at Stevenshof Pharmacy affiliated with the SIR Institute for Pharmacy Practice and Policy.dosing aids1

A recent Dutch study on older patients receiving their drugs via a sophisticated dosing aid, called multidose drug dispensing, has shown a higher self-reported medication adherence compared to patients receiving manually-dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving these dosing aids. The research is published in Age and Ageing.

Dosing aids are frequently supplied to older patients who are considered to have problems managing their medication. A variety of  dosing aids are used by older people in European countries. The most common is the dosset  box (divided into days of the week, with several compartments for each day). These are suitable for tablets and capsules only.’. Drugs can also be provided in pre-packed reminder blister or bubble packs which are not reusable.dosing aids3

In the last decade, a new sophisticated dosing aid has been developed and trialed in the Scandinavian countries and The Netherlands, called multidose drug dispensing (MDD). All drugs intended for one dosing moment are gathered in disposable bags and labelled with patient data, drug contents, and the date and time for intake. The number of community-dwelling MDD-users in The Netherlands has increased steadily in recent years reaching 360,000 in 2011

Dr Henk-Frans Kwint of SIR Institute for Pharmacy Practice and Policy and colleagues conducted a study in 215 community-dwelling MDD-users over the age of 65 and using 5 medicines or more (polypharmacy). Patients using MDD were interviewed to assess their medication adherence and knowledge of indication of drugs. For comparison, patients with polypharmacy receiving manually-dispensed drugs were matched on age and gender and underwent the same interview. In both groups, cognitive function was assessed using the  Mini-Mental State Examination (MMSE) for a sub-selection of patients.dosing aids2

Among the MDD-users 81% reported full adherence to all drugs compared to 58% for patients using only manually-dispensed drugs. However, only 40% of MDD-users had adequate knowledge of the indication of their drugs compared to 79% of patients using manually-dispensed drugs. The differences in adherence were independent of knowledge and MMSE-scores. This appears to be the first study of its kind that showed that self-reported medication adherence is higher for older patients using a sophisticated dosing aid like MDD compared to patients using manually-dispensed drugs.  It was furthermore remarkable that most MDD-users seemed not to bother about the indications for their drugs.

The low medication knowledge among MDD-users may have important implications for clinical practice. This low knowledge may raise problems in case of medication changes. Furthermore, the patient’s indifference to  their drugs may lead to insensible use of  analgesics/sedatives or antihistamines that may lead to inadvertent addiction.

Future intervention studies are needed to determine whether dosing aids like MDD can increase adherence for older patients who are non-adherent on manually-dispensed drugs.

Read the full paper on the Age and Ageing website here and an accompanying editorial by Steve Bell et al. here.

1 thought on “Improving compliance through dosing aids

  1. I don’t have access to the articles cited, so I can comment only on the dispensers I’m familiar with.

    My mother used a dosset box for many years, for its convenience – she would load it up herself. But as she has aged, and been diagnosed with dementia, and has had periods of confusion brought on by various infections, she began to need help in maintaining the box content.

    We tried the type of dispenser illustrated in this piece. Some come from the pharmacist as pre-loaded bubble packs, with the required pills in one bubble. They were hopeless.

    What do you do when there is a change in dose? This happens quite often with a patient on several drugs who is balancing a number of conditions. A sudden change in kidney function may require a switch of blood pressure tablet; antibiotics for an infection may screw up the warfarin use and require a temporary dose change. The pre-loaded dispensers don’t come with any indication of which drug is which, so it’s not an easy matter of changing what’s in the pack if you have a week or month supply – as well as not being able to identify tablets it’s such a waste when a whole new set has to be ordered.

    Later she could not reliably use any of this type as it required her to remember to check when to take her meds; and at her most confused she wouldn’t know which day it was, or what time of day it was – she sometimes rang me at midnight, asking why I was not there as promised, at what she thought was noon.

    My daughter spotted the product linked to below. At first I was sceptical about its reliability, but it has been a real help. So much so that I now use two.

    It beeps, flashes and rotates the carousel under a small window, presenting the drugs at the right time. It can be preloaded for 1, 2, 3, 4 times of day.

    The 3 times a day program is inconvenient because there’s an odd number of slots, which rotates to leave an empty slot. And at four times a day you can load it only for 7 days, which is fine if you can reliably meet that schedule, but doesn’t allow for slightly longer periods, such as weekends away or holidays, when I’m not around to manage it. I use two for a 3 times a day schedule. One is loaded morning and evenings for 14 days. The other is loaded for lunch time – and I load it for 14 days, just to keep the two in sync with meds.

    The big benefit is its adaptability.

    Because we get the regular boxed meds from the pharmacy we know which tablets are which – I note the appearance and any markings on the tablet box, if there isn’t a picture already. This is important in case you need to change the dose. Some pharmacies change supplier – atenolol comes as a distinctive orange pill, mostly, but occasionally comes as a small white tablet indistinguishable in most respects from some others. I wish pills were more consistent in appearance and markings.

    Any long or short term change to dose can be dealt with by fishing out unwanted pills and adding any extra as required.

    You can lock the dispenser to prevent easy access – which might be helpful if there are children around. Bear in mind that if it’s going to work as a reminder it needs to be nearby and visible.

    My mother now has district nurses coming to administer insulin injections and to check blood sugar – this device isn’t that smart. Nurses, doctors and other care workers are amazed at how useful this device is, and I’ve been asked by many for the details. I’m actually quite surprised that they are unaware of this type of device, and I wonder how many people are coping with other forms of dispensing that are no longer of any help to us.

    It isn’t perfect. When I open the dispenser to load it I sometimes find a slot has been missed – the pills are still there. Typically this is an evening does – my mother has probably gone to bed in the afternoon for a lie down and has slept right through. But this might be once, maybe twice, in a fortnight. I wonder how many people are missing doses that don’t use this sort of system; I wonder how much worse it could be.

    I have no affiliation with the company or its suppliers, so I’m recommending this only because I’ve found it works for us. I’ve not tried any other electronic dispensers, so there might be better ones out there. I hope it helps others.

    Ivation Automatic Pill Dispenser and Electronic Medication Reminder with Metal Lock and Louder Alarm with Flashing Light. There are clear and opaque topped versions.

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