Pill reminders: Adressing non-adherence owing to forgetfulness

• Medication adherence is an important factor that determines the treatment efficacy for any disease
• Forgetfulness is the most commonly reported unintentional cause of non-adherence
• Reminder systems are effective in counteracting forgetfulness; however, it is more efficient for patients who remain motivated to take their treatment
• Combining reminders with other adherence modifying strategies has the potential to cater to intentional causes which are often hidden behind the forgetfulness^1-3

“You can look for external sources of motivation and that can catalyze a change, but it won’t sustain one. It has to be from internal desire.”
– Jillian Michaels

Medication adherence is defined by the World Health Organization as “the degree to which the person’s behavior corresponds with the agreed recommendations from a health care provider”². World Health Organization (WHO) suggests that patients are considered adherent if they take 80% of their prescribed medicines⁴. There are different stages of treatment where non-adherence can occur. Firstly, during treatment initiation, where patients may decide not to start their treatment at all. This is followed by the treatment implementation stage, where patients may use prescribed treatment suboptimally or not follow the medication schedule. Lastly, patients may stop treatment prematurely, leading to premature treatment discontinuation⁵.

Impact of medication non-adherence:

Medication non-adherence is not just consequential for patients and their families, but also has wider implications for the healthcare system. Studies suggest that adherence to therapies averages 50-70% in high-income countries, while, it ranges from 30-50% in low-income countries⁶. Low adherence rates worsen health conditions increasing the need for prolonged care, and can even result in death². It also leads to waste of medication as well as increased use of medical resources such as nursing homes, hospital visits, and admissions². Therefore it is a significant economic burden on healthcare systems. As per reports the morbidity and mortality associated with sub-optimal medication usage costs around $100 to $290 billion in the US, €1.25 billion in Europe, and approximately $A7 billion in Australia⁷.

Forgetfulness: Most common cause of medication non-adherence

Patients often report forgetfulness as the cause of non-adherence. As per one report forgetfulness was the reason for non-adherence in 22-73% of patients¹. It is major reason for non-intentional non-adherence, a passive behavior that stems from difficulty in following complex regimens, poor memory, or poor recall of prescription instructions⁴. Intentional non-adherence is a process in which the patient actively decides not to use treatment or follow treatment recommendations. It is a rational decision-making process based on patients beliefs and level of cognition aided by skepticism about medication usage, side effects, long-term efficacy, and fear of drug dependency⁴.

Non-adherence with elderly people is often caused by forgetfulness and is believed to be mostly unintentional. Younger adults can also forget their medication unintentionally owing to their busy lifestyles¹. Notably, adherence rates are generally lower among patients with chronic conditions implying a direct correlation between forgetfulness behavior and the duration of therapy².

Reminder systems for improving medication adherence

Various forms of reminders are available to patients to tackle forgetfulness. These reminders are primarily based on the principles of behavioral learning theory. The theory of behavioral learning proposes that behavior can be modified after sufficient repetition of external stimulants such as reminders¹.

Reminders can be broadly classified into passive and active reminders. Passive reminders such as reminder packaging or pill boxes have reported modest improvements in adherence to chronic disease medications. On the contrary, active reminder systems such as electronic reminders are gaining traction and have shown positive effects on adherence rates¹. Some commonly used reminder systems are listed below (Table 1):

1. Reminder audio/video phone calls: These are the direct reminders given by healthcare professionals to the patients over audio or video communication. Research shows that they are effective in the short term and could be combined with alternative strategies for optimal result³.
2. Short Message Service (SMS): Given high mobile device penetration, SMS reminder is being increasingly implemented for improving medication adherence. A study reports a 90% decrease in the rate of missed doses with the help of SMS reminders⁸.
3. Reminder packaging: Special drug packaging, such as weekly boxes or single-dose blisters with an indication of day and time can also help in improving adherence by facilitating the organization and intake of medicines⁹.
4. Electronic medicine box: Electronic medicine box keeps a detailed record of drug intake by registering the date and time the box was opened. It also offers the opportunity to send an SMS if the patient does not open the box within a certain time frame. Research shows improvement in adherence with real-time monitoring combined with SMS reminders⁴.
5. Automatic pill dispensers: These are computer-based systems that can enhance adherence by performing various functions, such as alarms, sorting medications into compartments, and dispensing the correct dosage⁸.
6. Digital pill: This novel drug-device technology uses “smart” pills with an embedded sensor that helps in tracking the drug status in real-time using a simple mobile application. These devices are currently undergoing further review relating to ethical and safety concerns¹¹.
7. Health Apps: There is an abundance of health apps available to patients which aims at improving medication adherence through audio/video alarms and notifications. Research shows improvement in medication adherence in patients using medication reminder apps¹². For more information on mobile apps for medication adherence, see our article – Mobile apps to improve adherence to chronic diseases.

Table 1: Advantages and disadvantages of commonly used reminder systems

Do reminders work- a glass half full or half empty?

Clinical research suggests a positive correlation between reminders and the rate of medication adherence³. However, there is a dearth of quantitative measurement data in this regard owing to differences in measurement methods. For instance, some researchers use electronic tracking devices to monitor medication use, while others rely upon self-reporting and dose count, which are likely to overestimate adherence data³. Therefore adherence reported from such studies cannot be compared with each other to assess the superiority of the respective interventions. This is a major impediment in assessing the usefulness of reminder tools.

The success of reminders is also dependent on other complex determinants of medication usage, such as medication type, patient population, or disease process. Reportedly, reminders are more effective in patients displaying highly motivated medication-taking behavior³. Therefore, incorporating behavioral counseling to enhance patients’ motivation along with reminder interventions is proposed to work better in lowering non-adherence.

Conclusion

Forgetfulness is one of the key barriers to medication non-adherence. This behavioral folly could be potentially remedied using various reminder systems. Reminder technology has evolved from passive methods to electronic and automated systems¹. Numerous studies have found these reminder systems to have a positive correlation with the improved adherence rate. However, in the longer term, adherence may not improve if these systems do not address the underlying reasons behind low adherence³. Overtime, patients also lose interest in reminders, especially if there is a lack of motivation or in the case of intentional non-adherence. Thus, further research is needed to understand what types of reminders are effective for different patients and disease types and how much improvement in adherence is sustainable over time. Moreover, there has been plenty of ongoing research on other types of adherence-modifying strategies, as well as combination strategies, personalized approaches, and cost-effectiveness for widespread implementation.