Medication adherence: HYS Circle discussion July 2014

At the July 9 AIP meet-up, an ad-hoc group of people spent approximately 30 minutes discussing the topic of medication adherence.  The fundamental problem is that there are a very great number of products already on the market to address the problem of keeping elderly people complaint with their medications.  Nevertheless, medication adherence remains a problem for many.  The fundamental question posed was why this is the case?  Specifically, is the problem (a) that nobody has come up with the right product, or (b) that the problem is so complex and diverse that it needs a large and growing number of solutions.

Diverse medication adherence use cases and issues

The group approached this question by recounting specific problems and issues that we are aware of, either first hand as caregivers or anecdotally.  What we found is that there appear to be many different issues, perhaps as many issues as there are people who have medication compliance problems!.  A summary of the issues that we developed is as follows:

1. Memory.  Elderly people often have memory issues.  These issues range from simple forgetfulness to short term memory loss associated with dementia to full blown Alzheimer’s disease. People with simple forgetfulness may need a simple “alarm” reminder, whereas people with Alzheimer’s probably need to be hand given their medications, as their memory loss is so severe as to become cognition problems.
2. Cognition.  Some elderly people have diseases, such as Alzheimer’s, that renders them unable to put sufficient thoughts together to understand even simple instructions.  Reminders and other memory aids are insufficient for medication adherence with these people because they are unable to connect instruction and action, even when they are sufficiently reminded of the instructions.
3. Physical Limitations.  Some elderly people fall out of medication compliance because they are unable to physically comply, even when they remember to take the medications and understand the need to do so.  One example of this is Parkinson’s disease.  Parkinson’s can render people unable to open bottles or dispensers and/or unable to control the muscle action needed to get the medications into their mouth.
4. Vision Impairment.  Elderly people may suffer from vision impairment such as Macular Degeneration.  These impairments may prevent them from being able to see all of their medications and thus they are unable to know if they have taken all of them.
5. Compliance Anxiety.  Another anecdote was presented about an elderly person taking their medications too early and too close to previous doses because they were overly concerned about forgetting to take the medications at the proper time.
6. Spectrum.  “Medications are not just pills” was one remark that we all took to heart.  Many solutions assume that medications are just pills and cannot deal with liquids, injections, etc.  Even among the pills, the size, shape, and color of pills is wide ranging and thus difficult to automate.
7. Change.  Change is confusing to everyone and medications are sometimes changed over the long run but are also sometimes changed over a short period of time.  One example:  a person with an infection might be given a 2 week course of antibiotics and must stop some other, regular, medication during this short time period owing to drug interactions.  Such short term changes to long term patterns can be confusing to anyone, the elderly in particular.

Costs and caregivers matter too of course

Additional aspects of the problem that we discussed were:

1. Cost.  Many devices on the market are expensive and some require monthly monitoring fees.  Medicare and private insurance does not usually cover these costs and they can be prohibitive.
2. Caregiver.  The caregiver has to monitor compliance and maintain whatever device(s) are used by the patient.  Many solutions seem to address patient needs but are difficult or confusing for the caregiver.  If the caregiver rejects the solution, it is not available to the patient.

Our conclusion from this brief brainstorming session was that the problem posed to us was definitely “(b)”: that the problem is so complex and diverse that it needs a large and growing number of solutions.  We did not have time to delve into any specific solutions, nor did we have time to analyze the current product offerings against the issue list, above, to identify gaps.  This might be a suitable topic for a future meet-up “unconference” session.