Dose administration aids: Benefits and disadvantages

Not all patients benefit from having medications organised in dosing aids. Detail the potential benefits and limitations for these aids. In what circumstances is a dosing aid disadvantageous (such as disempowering or deskilling otherwise capable patients)? What evidence is available to support their use in patients with dementia or memory related conditions?

What are dose administration aids? 

Dose administration aids are used are used to organise medicines according to the time and date at which they should be taken. They may be filled by patients themselves, or by a third party such as a physician, community pharmacy, carer or relative.   

What are the benefits and disadvantages of their use?

Dosing administrative aids have a number of identified anticipated benefits. These include less missed or incorrectly taken doses, better control of disease(s), closer collaboration between different health professionals in regards to medicines management, reduced stress for both patients and carers, and fewer medicines stored in the home. They are most effective in individuals who are well motivated to take their medicine and, crucially, possess the cognition and physical ability to operate a dosing aid without discomfort. A number of studies highlight that patients often finding dosing administrative aids helpful in regards to simplifying their medicine taking, reducing the associated stress of taking medicines from a number of different packages (1).   

Dosing aids do however have a number of limitations and they are not suitable for all patients. They are occasionally used for patients who would ordinarily have no problems in managing their own medicine from a number of different medicine packs. This may lead to the unnecessary disempowerment and de-skilling of patients who would otherwise by well placed to administer good quality self-care – qualitative studies with patients have also highlighted that some recipients of dosing aids have found them to be symptomatic of a paternalistic health service (2). There is also confusion among health and social care professionals around when they should most appropriately be used – a number of other options such as reminder charts, alarms, and linking medicines to meals could be explored before using dose administrative aids. There is also some criticism around their use in patients who have not been assessed for suitability.  

Is there any evidence to support their use? 

There is a relatively small evidence base for dose administration aids, and only a small number of well designed trials that have investigated the relationship between dosing aids and improved clinical outcomes for patients. A recent systematic review of available studies, undertaken by The Cochrane Collaboration, found that dose administration aids generally increase the percentage of pills taken when compared to individuals who have no dose administration support (3). 

The majority of studies available focus on a single health problem rather than a particular cohort of patients – as a result, there are limitations in regards to generalising the findings of these studies to typical users of dose administrative aids. Typical users are older people with multiple comorbidities, yet there is very little evidence focusing solely on older people and their use of administrative aids as part of their treatment programme. A number of studies were excluded from the Cochrane Review on the basis of being methodologically flawed – many papers demonstrated a high loss to follow up, sample sizes that were too small, and inadequate randomisation processes. 

The Cochrane systematic review also identified a number of studies that focused specifically on patients with diabetes who demonstrated some improvements in blood pressure and HbA1c with the assistance of dose administration.   The UK National Institute for Health and Clinical Excellence (NICE), responsible for developing evidence based clinical guidelines for the British National Health Service, reviewed the use of dosing aids. The review concluded that the evidence of benefit to patients was not substantial enough to recommend their widespread use. As such, the organisation recommended that they should only be used to overcome practical problems with certain patients (4). 

A non-randomised retrospective cohort study conducted in the United States that was investigating the use of a sachet dosing system to save costs found that it did not reduce the cost to the health service in regards to both medicines management and patient care. However, the study revealed that the use of sachet dosing, in conjunction with a telephone follow up from local healthcare professionals, did improve medication adherence in a general population cohort (5). Two additional studies, conducted in the UK, were undertaken to see if dose administration aids improve adherence, but the benefits identified were in such small sample sizes that the findings did not carry enough clinical importance to be considered (6,7). 

There are few trials on dose administration aids that have been conducted in Australia with inconclusive evidence. Despite this, there are still a number of government funded dosing aid programmes and accompanying professional standards to support their widespread use.   

Is there any evidence to support their use in patients with dementia or memory related health conditions? 

The evidence that is available suggests that dose administration aids are not suitable for patients with dementia. A 2015 study, examining the medication of Patients With Dementia (PWD) and dose administration during transitions in care, concluded that general medicines management for PWD was suboptimal but that aids did not improve adherence. Instead, the paper concludes that a number of other strategies such as modified care planning for care transition, improved staff training and the inclusion of pharmacists in multi-agency discussions around discharge / transition planning were more likely to improve adherence (8). A number of other studies have suggested that alternative methods such as the use of automated computer-based reminding aids, online medication monitoring and telemonitoring may be of more benefits for patients with mild dementia (9).   

References

• (1) Larsen AB, Haugbolle LS (2007) The impact of an automated dose-dispensing scheme on user compliance, medication understanding, and medication stockpiles Res Social Adm Pharm 3:265-84
• (2) Nunney J, Raynor DK, Knapp P, Closs SJ (2011) How do the attitudes and beliefs of older people and healthcare professionals impact on the use of multi-compartment compliance aids?: A qualitative study using grounded theory J Drugs Aging 28:403-14 
• (3) Mahtani KR, Heneghan CJ, Glasziou PP, Perera R (2011) Reminder packaging for improving adherence to self-administered long-term medications Cochrane Database Syst Rev CD005025 
• (4) Nunes V, Neilson J, O'Flynn N, Calvert N, Kuntze S, Smithson H, et al (2009) National Collaborating Centre for Primary Care and Royal College of General Practitioners. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. Report No CG76. London: Royal College of General Practitioners. Available online at www.nice.org.uk/nicemedia/pdf/CG76FullGuideline.pdf (last accessed 27th January 2016) 
• (5) Zillich AJ, Jaynes HAW, Snyder ME, Harrison J, Hudmon KS, de Moor C, et al. Evaluation of specialized medication packaging combined with medication therapy management: adherence, outcomes, and costs among Medicaid patients (2012) J Med Care 50:485-93) 
• (6) Winland-Brown JE, Valiante J (2000) Effectiveness of different medication management approaches on elders' medication adherence Outcomes Manag Nurs Pract 4:172-6 
• (7) Buckwalter KC, Wakefield BJ, Hanna B, Lehmann J (2004) New technology for medication adherence: electronically managed medication dispensing system J Gerontol Nurs 30:5-8 
• (8) Deeks LS, Cooper GM, Draper B, Kurrle S, Gibson DM (2015) Dementia, medication and transitions of care J Res Soc Adm Pharm doi: 10.1016/j.sapharm.2015.07.002
•  (9) Arlt S, Lindner S, Rosler A, von Renteln-Kruse W (2008) Adherence to medication in patients with dementia: predictors and strategies for improvement J Drugs Ageing 25(12):1033-47