Confronting the Challenges

It can be challenging to identify instances of non-adherence. Direct observation or electronic monitoring are considered to be very effective. However, it may not be realistic or possible to take these measures. Laboratory tests, such as measuring drug concentrations in the blood, are also a useful objective measure, but can be expensive and are not always reliable, particularly if someone is taking multiple medications.

Refill records could help indicate adherence, but this doesn’t show whether and how people are taking their medications after they fill the prescriptions. More promising are newer innovations such as wearable devices and smart pills that can help monitor when someone takes their medications. There also are devices such as necklaces that detect swallowing and smart watches that track pill-taking behaviors. Medication reminders can be useful if non-adherence is due to the person having memory or other cognitive issues that cause them to forget their medications.

Having patients self-report their medication adherence via efforts such as questionnaires, medication diaries, and follow-up phone calls or interviews also help identify non-compliance issues. Of course, those close to the person, such as a family member or caregiver, can help identify red flags, such as worsening conditions, pill boxes not being filled, or full pill bottles that go unopened. It is important to engage caregivers and family members as adherence partners, particularly if the person has dementia or other cognitive deficit.

Nazir stressed the importance of conversations with residents and caregivers. Otherwise, he suggested, they may dismiss the issue and convince themselves that they don’t really need the medication or don’t have to take it every day. He said, “I always have a conversation when I start someone on a new medication.” Specifically, he will talk to the residents about the medication, why they need it, and why it’s important to take it as directed. Giving the individual an opportunity to express any concerns or ask any questions should be part of this discussion, he noted.

This also is a good time to discuss any potential challenges, such as lack of transportation or financial resources, that may keep them from getting their prescriptions filled. When appropriate, Nazir also may talk with the resident’s family to assess any issues that may affect compliance. He said, “I’ll ask about their loved one’s attitude about or approaches to medications. For instance, how have they responded when their physician has prescribed a new medication in the past? Have they ever had problems with any medications they’ve taken?” Sometimes, he said, he will relate that he takes medications; this helps them see that the physician understands how they feel.