‘Remembering to remember your medicines’

Stan Dobrzanski

Recently Retired Assistant Director of Pharmacy Bradford Teaching Hospitals Foundation Trust

(Who has never completed a 5 day course of antibiotics in his life)

With help from Bev Carradice and Usha Kaushal-Bolland

‘Did you forget to take your tablets?’

It is difficult to remember to take medicines Medication adherence is not 100 % even in patients groups where you might think that it might be. Transplants fail where patient forget immunosuppressants. Adherence falls off with time. Following coronary stenting by 6 months only 42% of patients were taking clopidogrel Failure to remember to take the dose may be a factor

Does a patient take their warfarin?

Did you remember to take your warfarin? The question posed in all anticoagulant Clinics?

Patients probably do remember if the INR is always in range

Therefore monitoring warfarin adherence provides a useful means of identifying those patients who are particularly good at remembering to take their medicines What is it these patient do to help themselves to remember?

We asked patients – how do you do it?

Here are the answers that patients themselves developed

The study Patients with an in range INR at the last 3 clinic visits were asked during their warfarin clinic visits if they would be prepared improve the care of clinic patients with poor INR control by sharing any routines that they used that helped them to remember to take warfarin. They were also asked if anybody had given them any advice about how best to remember to take medication

The results

We asked 60 of the ‘best’ patients whose INR was always in range:

31 female 29 male (8 South Asian patients) Average age 62 years Age range 16 to 88 years

Patients who bought Trays 15 Patients (25% of study group) These patients used trays (that they had bought in a ‘Pound Shop’) and filled themselves. A tray reminded them if they had taken a dose.

Took warfarin when doing something else 13 patients linked warfarin with a routine activity and this included: • Taking warfarin with the evening meal • When watching TV (the Chase or Pointless or Paul O’Grady who takes warfarin and says ‘6 pm - its time to take your warfarin, viewers’) • When coming home from work or from the gym

• When brushing your teeth

• When charging the mobile phone

• When taking other medicines at the same time

Relied on a relative 13 patients and this included: • The relative administered the warfarin (from a tray that they had filled) • The family filled the tray and phoned their relatives each evening to take their medicines • Great grandmother – relied on her great-grandaughter (Age 7) ! to phone her at 6 pm each evening with (‘Have you taken your warfarin nan?’) • Wife, husband or daughter (Age 13) prompted patients

• Husband took his drugs at 6 pm and this reminded wife (‘It’s the only thing we do together after 30 years of marriage’)

Put the warfarin where it would be noticed 11 patients and this included • Placing warfarin in the cutlery drawer on top of the teaspoons and taking it with the first cup of tea of the day

• Warfarin was also kept next to the Cornflakes or the Kettle

• Keeping the warfarin in the knickers drawer and taking it when getting dressed (not for men!)

• Placing the warfarin cartons in brightly coloured dishes kept in the kitchen

• Placing tablets on the bedroom window ledge – morning tablets on opening the curtains – night-time tablets when closing the curtains

• Keeping tablets by the bed with a jug of water and beaker and taking the warfarin either when waking or when going to sleep

What medicines do women keep with their knickers? A poorly researched area and possible project How do they remember to take the Pill?

Where do patients keep their medicines?

The population in this study were elderly and medicines were not locked away – and seeing the medicines reminded patients to take Them. However, what should we advise about where to keep medicines if there is a 2 year old charging around the house? Locking medicines away removes the visual reminder to take them What should we advise if medicines are kept out of sight? Some patients have a dedicated alarm clock. Maybe younger patients would adopt technological aids more enthusiastically? This study involved mostly older patients.

How useful are mobile phone reminders? • How good are telephone ‘Apps’ such as Meds on Time My INR+ Care4 Today ? Another project ?

Other ways of remembering

5 patients Kept a written record of what had been taken – either in the Yellow Book or on a calendar sheet

ONLY 5 out of 60 patient simply remembered !! Included a military man with a belief in self-discipline ‘if you are given orders you follow them’

Comments

This study shows that it is difficult to remember to take warfarin – even for the ‘best’ patients –

only 5 of the 60 patients simply remembered !! Not one of the patients had been given these ideas by a pharmacist apart from taking tablets in the morning. Pharmacists simply browbeating patients not to forget. They knew no other way! Except - some advised that it is not the end of the world if you take warfarin with all your other tablets in ‘one go’ in the morning.

Remembering to remember

There are Prospective and Retrospective memories

Retrospective – remembering that UK voted for Brexit Prospective – forgetting something in the future such as posting a letter

With warfarin – taking the tablets each evening means that you have to recall to carry out a specific task at a particular time in the future

The strategies adopted by the patients in the study appeared to directed at ‘spontaneous retrieval’ of a prospective memory

You can have ‘vigilant’ prospective memory where you tell yourself over and over again that you have to take warfarin at 6 pm – but spontaneous retrieval is easier

And this is what the patients were doing when putting tablets in cutlery trays or on window ledges.

Patients were planning not to forget (Pharmacists not involved) Patients who relied on family members

Planning not to forget a task – two people less likely to forget than just one person Patients who bought trays or recorded taking doses

It seemed that these were highly motivated (vigilant?) people who were anxious to comply with whatever had been prescribed for them and ‘planned’ not to forget doses.

Mobile phone reminders

Setting an event based cue for memory retrieval Taking warfarin when doing something else

Setting an event based cue – linking the task to an established habit Placing the warfarin where it will be noticed

Maximising the chances of seeing a cue.

Blaming the patient?

Rather than blaming individuals for inadvertent lapses in prospective memory, should pharmacists be doing more to support patient in remembering? Can pharmacists advise on:

• Use of external memory aids such as the alerting calendar on cell phones • Counselling about avoiding multitasking when one of your tasks is critical • Carrying out crucial tasks immediately instead of putting them off until later • Creating reminder cues that stand out in a difficult-to-miss sites • Linking the target task to a habit that you have already established

But do this in a safe way: Keep out of the reach of children

How to engage with patients?

Should we terrify patients with the consequences of non-adherence or is there some better way or engaging with the patient and acquiring their support? Should we offer more technical solutions to non-adherence? Have we ignored behavioural modification as a way forward?

What do we teach our pharmacy students about these approaches? What do pharmacists in general know about this subject?

Homework Fill a bottle with 14 Tic Tacs Take one each evening for 14 days Reflect on what you did not to forget – is it an easy homework? What solutions would you develop? Idea borrowed from: Efthymia (Effi) Mantzourani – Lecturer at Cardiff School of Pharmacy Who are going to use the material in this lecture in their pharmacy student teaching

Magic wand

Transport all the patients from the Bradford warfarin clinic here to listen to your ideas. I think they would be fascinated to learn from you At present patients are having to find solutions all by themselves And bring all the pharmacists here too!

How much of what I have said stands up to critical

scrutiny – or is it just psychobable?

Do you think that what I have said is more suitable for a Cosmopolitan article rather that a august Pharmacy

conference?

Actually published in: Dobrzanski S, Carradice B and Kaushal Bolland U Prospective memory and remembering to remember to take warfarin Int.J.Pharm Pract. 2016, 24: Suppl 3, pp. 108-109