Medication is currently perhaps the most important component in the management of both long term conditions and acute illness. Supporting people to manage complex medication regimes is a major objective of many initiatives aimed at avoiding readmission to hospital following an exacerbation or surgery, and especially when they have a cognitive impairment. This article reviews the many technology-based tools that are available to support medication compliance, many of which could be components of a telecare support package. It concludes that these technologies are generally useful but patients may be offered inappropriate telecare services and/or the wrong devices as a result of poor profiling and/or assessment of needs plus a lack of knowledge on the part of equipment prescribers of all the options that are available. Also, it may be apparent that some patients may choose not to take some of their medications some or all of the time through individual choice. Patients need to be offered more information about their medications and need to be assessed more fully and holistically before offering them a support package based on technology. Some ideas on best practice are discussed.
Humans have been treating illness and disease using primitive forms of medicine for at least 15,000 years. Many of the early medicines were based on herbs, berries, or ingredients derived from plants or parts of animals. While many were probably useless, there can be no doubt that some of the compounds being researched by today’s pharmaceutical giants owe their origins to the knowledge of plants passed down through the generations. Medication is today the main weapon used to manage chronic disease and compared with other interventions, such as surgery, is considered to be popular and minimally invasive.
According to the World Health Organisation, the global pharmaceuticals market is worth almost £200 billion a year; the largest drugs companies spend enormous sums promoting and selling new drugs that can be prescribed to cure or help manage illnesses or with symptoms. Ultimately, their success depends on innovation and on their products working better than placebos both in clinical trials and also out in the real world where physicians, patients and their families can confirm their efficacy. This justifies either health services (as in the UK) or individuals (as in private healthcare markets) buying these products. The best outcomes will be achieved only if patients take their medication as prescribed. This means taking the right dose at the right time without fail sometimes for many years. This is known as their adherence, their compliance or their concordance with that prescription. Literally hundreds of studies have concluded that medication performance is well below 100% for all groups and can be as low as 50% for some people with complex needs, especially when their use is measured beyond the initial month of treatment.
It follows that people who need polypharmacy (i.e. many different medications), several times a day to deal with multiple morbidities (i.e. several different conditions), are at risk of failing to follow their prescriptions more often – and perhaps with more severe consequences. Adverse reactions are also a likely consequence of mixing prescribed medications with over the counter drugs, or when prescribing physicians aren’t made aware of existing medications. An ageing population is indeed producing a situation where hundreds of thousands of people will be living with 2 or more long term conditions that are managed by medication. The situation may be worse for people who have recently been discharged from hospital and when they are recovering from a bout of illness as they are likely to be offered additional medication for a short period of time. Therefore, they need support to help them remember when to take their tablets and to avoid taking the wrong ones, or overdosing.
Assistive Technology and Telecare Services can, and should be able to, help – but only if they are selected as a means of managing an individual’s personal risks and lifestyle. This means understanding that individual’s needs and preferences, their support mechanisms, their memory, their lifestyle and their psychological make-up: the reasons for people not taking their medications are complex and variable over time. In some countries, such as Ireland, the cost of medication might also be a factor.
Medication Support Technologies
People have been using reminder watches or clocks for years. Once programmed, they will continue to alert the owner that it’s time to take their medication several times a day until the batteries become flat or the medication regime is changed. They are small enough to be worn, carried in a handbag or in a pocket, and therefore portable and appropriate for anyone with a mobile lifestyle. Provided that there is a family member available to manage any changes in prescription then these low-cost devices are powerful and proven to be effective. Figure 1 shows examples, including devices that speak and which may suit those who have poor hearing or sight.
The telephone can also be used to provide a reminder. Calls can be programmed into some smart telephone devices (usually dispersed alarm units) or they can be generated by a telephone monitoring centre. Usually, the telephone will continue to ring until it is answered or the alarm cancelled. A recorded message can be played to specify the medication that is due. A failure to respond to the call may result in an escalation perhaps involving the notification of a relative.The problem with the use of automated systems is that there is no evidence that they are successful over an extended period of time. There appears to be a real danger that people, and especially those who are socially isolated, may rush to answer the phone but may become disappointed to find that there is no real person there to speak with. This could lead to an early abandonment of the reminder mechanism. Perhaps a more attractive alternative makes use of the Internet and a computer to send the reminder by e-mail (see left of 3 Figure 2) or more directly onto the screen of the TV which can be achieved with a smart TV or through use of a service such as Care Messenger (on right of Figure 2).
Mobile phones have become ubiquitous, and are already owned today by groups of all ages, including people aged over 75; they can be used to provide reminder messages as either automated calls or through basic SMS which has proved extremely useful for health promotion in India and in Africa. Of course, ownership isn’t sufficient to ensure satisfactory reminding: the individual must carry the phone on them, leave it switched on, and read and respond to their messages frequently. Assessors don’t always consider such things when profiling the individual.
In the future, increasing percentages of mobile phones will be smart, ensuring that they can be programmed to meet both the needs and the deficits of their users. This will allow the use of genuine mCare apps to support multiple medication regimes. Some screen-shot examples of low cost apps (such as MedsLog, Medsy and Dosecast) for the most popular operating systems are shown in Figure 3. These are customisable and can issue reminders when more supplies are needed for example.
More advanced services based on mobile phones, tablets and similar digital media include MediSafe Project; they can be customised to deal with issues at an individual level. Some systems in the USA offer incentives for the patient if they comply with their medication regime. This approach may be controversial in the UK in the context of people having a disease due to an unhealthy lifestyle and then being rewarded with free medication and other benefits if they take their pills as directed. However, the NHS could also benefit and such innovative approaches may become standard when personal health budgets are employed more systematically.
In the USA, reminders have often been attached to the caps of pill bottles. Count-down timers are sold in pharmacies for less than $5 while more sophisticated versions, such as Glow Caps, can work alongside other reminder media such as lights. Ultimately, the clarity of instructions on the label can be an important factor in determining the level of adherence.
There was a time when technologists believed that they could solve the problems of medication management by simply designing a better and more intelligent bathroom cabinet, in which they assumed that everyone kept their medication, high up on the wall and away from the threat of being raided by young children. But some vulnerable people are unable to leave their homes due to mobility problem and must rely on others to deliver their medication; this can also prevent them from storing their medications in an appropriate place. They might therefore keep their tablets close by them at all times, often in the pharmacy bags in which they arrived. This can cause major problems in finding and taking medications when they are needed, especially when instructions for use aren’t clear.
When it became apparent that a “medicine cabinet” approach was not practical, designers introduced containers with multiple compartments into which medication could be inserted after being sorted. This is effectively a form of secondary dispensing which can introduce mistakes. Nevertheless, many people are happy to have family and friends manage these boxes for them. Figure 4 shows a range of devices including round and oblong designs; some offer separate compartments for each day (for a week or a month), while others allow 4 different medication windows per day. These devices are available from pharmacies or through many retail outlets and catalogue suppliers. This ensures plenty of choice both in size and appearance to meet the medication needs of the vast majority of patients.
The simplicity of medication boxes has inspired many manufacturers of drugs to supply them in blister-packs rather than in the bottles which were associated with medication for a century or more (and which remain the norm in the USA). Blisterpacks works well for young women who take oral contraceptives once a day, and for otherwise healthy people who might need a single course of antibiotics. But this approach may be more difficult for people who need to take some medications several times a day but others less frequently. Many pharmacists now make up their own blister packs for individual patients using special foils and sealing equipment, producing disposable arrangements that replicate medication boxes but with the advantage that the contents have been prepared by a pharmacy thus avoiding the need for secondary dispensing. Pharmacists are also ideally qualified to identify drugs that aren’t suitable for presenting in this way. Figure 5 shows a variety of blister packs in common use. They all provide a rapid visual indication of compliance and should also greatly reduce the possibility of overdosing. The BioDose arrangement also allows oral medicines to be sealed into such units.
3. Combining Reminders, Organisation and Medication Management
The success of low-cost organisational technologies such as dosette boxes and blister packs is limited only by practical issues such as the size and number of compartments, and the need to sometimes include liquid or other oral medicines and eye-drops. There are solutions in each case but none of these simple approaches can necessarily help if the user simply forgets the time and their medication needs. It follows that Assistive Technologies that combine the reminder function with the organisation and delivery of the appropriate tablets at the right time should overcome many of the problems that can lead to poor medication management.
It is not surprising that the devices designed to combine these functions were effectively electro-mechanical versions of the medication boxes shown in Figure 4. The CompuMed device (left in Figure 6) replicated the 2 dimensional matrix approach of oblong dosette boxes using a moving belt arrangement to deliver medication at the appropriate time. However, the device is necessarily heavy (and is electro-mechanical in operation) and cannot therefore be considered to be portable. The jon device from MedMinder (on the right of Figure 6) doesn’t require moving parts allowing access to the right compartment at the right time. It is linked through a mobile network enabling remote monitoring of the device, but isn’t currently available in the UK. The Pivotell device (centre of Figure 6) has been available in various forms for a number of years. The original version, which has no connectivity, has proved successful in a number of trials across the UK.
More sophisticated versions of the Pivotell have been introduced which overcome some of the issues found when dealing with people who have sensory or dexterity problems. They can also be linked directly into telecare systems enabling them to utilise 24 hour monitoring centres for reporting non-compliance. The latest version has mobile connectivity enabling web-based monitoring and programming. The Pivotell range of devices has become the Gold Standard for medication dispensing in the UK and, provided that there are appropriate arrangements for loading and exchanging medication carousels, they can be very successful in managing both reminder and organisational problems.
4. Avoiding Secondary Dispensing
If individual medications are loaded into separate boxes from which they are sorted by the individual or by a machine, then the problem of secondary dispensing is overcome, as is the need to find an appropriately qualified person to fill dose boxes. The Med Signals approach (see left hand of Figure 7) relies on the individual being told from which box they should take a pill by the machine. The device is also web-enabled but can accommodate only 4 different types of tablet. The Dispense-a-Pill device (right of Figure 7) is much bigger than the MedSignals unit, enabling it to contain both more types of pill and a greater quantity of each medication – up to a month’s supply. However, the great innovation of the Dispense-a-Pill is that it picks the pills and dispenses them in a box that the patient removes. This allows a simple filling process that doesn’t involve an unqualified person dispensing individual doses. Unfortunately, the device is bulky and is therefore for home use only.
The above devices keep each medication separate, but are not suitable for medication where exposure to the air can cause degradation. Both these devices connect to the Internet enabling prescriptions to be changed – but only with respect to the number of pills and the times when they should be taken. Other methods of reminding and dispensing which overcome the problem of exposing medication involve the use of blister packs. Bespoke packaging arrangements with electrical contacts are being developed but may not be necessary for the vast majority of users; this would add an overhead to the cost of supplying all medication. The Medido system (left of Figure 8) and the Pico unit from Vitaphone use centrally packaged pouches which contain all medications for each medication window. The pouches are produced on a roll by robot systems in a clean room facility and are delivered at appropriate times in an internet-linked arrangement. Unfortunately, the whole batch of pouches has to be discarded if there is a change in the medication requirement.
The Electronic Medication Management Assistant (EMMA) shown in Figure 8 (right) punches pills from relevant blister packs according to the programmed prescription. This is being redeveloped for European markets but works only with those medications that are available in a standard blister pack arrangement.
5. Confirming Compliance
Many of the devices described above provide useful feedback on how well medication is being managed. This ranges from data recorded on a web-based system that shows how quickly, and how often, the patient responds to a reminder through to the monitoring of how many pills remain uncollected and unused in pill boxes where access was possible only at the appropriate time. None of these arrangements are capable of confirming that the medication has actually been taken rather than being thrown away. It remains the case that some people might choose not to take medication for fear of overdosing when they can’t remember whether they have already taken a dose. In addition, there will be people who deliberately choose not to take their medication for some reason after accepting the reminding and after taking the pills from the pack or dispenser. This latter case is perhaps the most difficult to detect and also offers physicians a particular challenge in managing illness because they wont know that the medication is not being taken.
There may be opportunities to embed miniature “tags” within pills which can then be detected either as they are swallowed or when they enter the stomach, or when they pass through the body. The Magnetrace system shown on the right of Figure 9 is perhaps an extreme example of such technology with sensors being provided either on the chest or on a necklace. More realistic are special pills (see left of Figure 9) which have embedded sensors – these are being trialled by Lloyds pharmacies where the pills can contain sensors that can monitor physiological parameters. Similar technology (EQ02 LifeMonitor capsule) was used recently to monitor the temperatures to which firefighters in Australia were exposed during the recent hot spell there. However, the cost of ingestible sensors on each pill would be excessive and perhaps only justified for research purposes and for monitoring patients with severe diseases, such as schizophrenia where care in the community can be maintained only if medication is taken as directed.
People with intellectual disabilities are often challenged by long term conditions such as epilepsy; they may need a cocktail of medications to keep them well, and it is essential that they take their tablets correctly and on time. Support staff are often employed to supervise the taking of these medications, a role that is sacrificed when sleep-in staff are removed in order to increase the independence of the service users.
Fortunately, many of these people have learnt to use technology to great effect. In particular, they are skilled in using digital photography and computers. This enables them to communicate regularly with family, friends and remote support staff using Skype, for example.
As more people use tablet computers in the home (e.g. Kindle Fire HD and Nexus devices which run the powerful Android operating system and cost under €200), it opens up a more personal world of communication and the ability to use the built-in camera to verify to a remote support worker (or family members) that medication is being taken appropriately. Figure 10 shows a family member viewing a relative taking a pill while connected through their tablet device using Google Talk. Similar opportunities are available using the more expensive Apple devices through Face Time. Although these apps encourage communication, they might overwhelm a support worker if several people wanted to show themselves taking their pills at the same time. They might then be encouraged to simply record their medication event using an app such as Bambuser to allow subsequent viewing by appropriate friends. A combined reminder and communication app might be ideal for some people.
If poor medication compliance was only the result of poor memory (or easy distraction) then the problem would have been solved many years ago using a range of different reminder techniques. There are at least two other factors to consider:
(a) Compliance deteriorates over time for most people; and
(b) Changes in the overall prescription cause confusion.
The former suggests that medication routines break down after a few weeks, while the latter suggests variations from the routine can also cause problems. Different people might therefore, be susceptible to different failure mechanisms as far as medication is concerned, indicating a need to understand rather more about the individual before attempting to support them in managing their medication intake and avoiding missed or too many doses. Researchers have found that people often choose not to take their medication (rather than forget) and for a variety of reasons including:
- A perceived failure of the treatment to produce a positive response
- Denial that they have a condition for which a medication is required
- A cognitive impairment which prevents them from managing their medications
- Believing that they are cured and no longer in need of the medication
- Feeling well enough to be able to skip some medication
- An inability to deal with side-effects such as nausea, loss of appetite, weight gain or change in libido
There is clearly a need for more education of patients so that they understand the role of each pill, and the likely consequences of poor adherence. In Wales, community pharmacists are involved in an initiative to help explain medication to patients; hopefully, this will reduce the incidence of deliberate rejection of some expensive medications. However, there is also a need to determine whether a patient is capable of overcoming some of the challenges that medication produces, so that they can be supported effectively before their compliance declines. This means regular reviews, especially if there is data on compliance available through an on-line approach.
Perhaps the most extreme form of medication is chemotherapy which is administered to help in the treatment of certain cancers. The drugs employed are highly toxic and can cause the hair to fall out and other serious side-effects. Patients must typically endure 5 or more cycles of the treatment. Most who fail to comply with the therapy pay with their lives, but those who are mentally tough have the resilience to see the treatment through. Fortunately, there are standardised measures of mental toughness, such as the MTQ48, which can identify people who have poor mental resilience and, more importantly, indicate the support needed to become stronger. While some may need incentives, others need coaching using some of the principles of cognitive behavioural therapy.
At a practical level, there is a fundamental need to identify the support that people need to improve their medication compliance. This means an assessment of their cognitive and functional abilities, their level of family support, their lifestyle choices, the number and type of medications (and the frequency for them to be taken), their understanding of the significance of their medications, their ability to accept and use connected assistive technologies, the quality of their senses, and the level of external support that they need to overcome their challenges. Some will need no assistive devices but most will require at least a reminder device or service, some of which might only be suitable if they have broadband and a computer, or if they watch TV all day. New telecare services from the USA may package these elements into a form that delivers an assisted living experience, including medication support, through a tablet computing device. It remains to be seen if this can provide an individualised service at a competitive price.
A questionnaire may be used to collect most of the information required for assessment during the profiling process, but there is no certainty that the answers provided by the patient will be correct. It might therefore be useful to employ a medication dispensing device that is linked to the internet as an assessment tool as this will allow the performance to be monitored in a direct manner. If this is provided using a mobile connection for only a week, it should help determine the type and level of medication support that will be needed in the longer term. In addition, when there is a need for a temporary new medication to deal with an infection or a bout of illness, it may be appropriate to introduce a second medication management device which is only used for a short period of time. Pharmacists are ideally placed to provide such devices as they will know the patient and will be able to load the medication for them. It may be apparent that the assessor must have available a (large) toolbox of medication support devices and systems and these must be deployed selectively after determining the individual needs of the patient. The idea that “one size fits all” is no longer appropriate as telecare services mature.
There are already a large number of different technologies available for supporting medication management. These range from simple, low cost devices and systems based on basic telephony through to more sophisticated technologies that effectively dispense the required medication doses to the patient at the right time provided that they respond to a prompt. There is a danger that people who need very little support are offered sophisticated devices that are expensive and which then threaten their independence by making them unnecessarily dependent on the technology. This could be due to poor assessment of capability and need, an attempt to “overprescribe” technology for commercial reasons, or simply a lack of understanding of why an individual’s compliance is poor.
A medication support assessment tool should be constructed which explores both the individual’s needs and available resources (including informal carers, internet access, use of mobile phone) and their willingness to follow a prescription without compromise and irrespective of the consequences. This approach will be explored in a future article and will involve using technology as an assessment tool in the same way as activity monitoring systems such as Just Checking, iCare, SensorMind and ADLife are currently used to determine an individual’s movements and actions as a function of time.