Greater insights into the role of various biochemicals combined with advances in chemical synthesis and biotechnology are resulting in the development of safer, highly efficacious drugs for the treatment of both rare and prevalent diseases. Surprisingly, the results observed in clinical trials for these novel therapies do not always translate to the marketplace. One of the key reasons is poor patient adherence; drugs cannot be effective if they are not taken properly.
Poor patient adherence takes many forms, including not filling or picking up prescriptions, missing doses or taking them too frequently, and halting treatment too soon. There are also many factors contributing to medication nonadherence: patients’ lack of knowledge; preconceived ideas and beliefs about different types of diseases and medications; expectations for results (i.e., side effects, time to see improvement); mental and psychological state, and cost concerns; treatment timeframes; lack of appropriate education and communication from physicians and pharmacists; and for the elderly in particular, the number of medications and dosing frequency. In 1986, approximately 90% of people receiving Medicare took medications, with half of them taking five or more drugs.1 In addition, different factors may influence adherence for different medications.
In the U.S., over 50% of prescribed medications are taken incorrectly or not at all.2 Of 800 American adults surveyed in 2013, 64% of those who took medications said they didn’t take them as prescribed.3 The consequences of such poor patient adherence are numerous and can be quite severe and costly. In one study, 33%-69% of drug-related adverse events that resulted in hospital admissions were linked to poor medication compliance,2 while other researchers found that up to 40% of nursing home admissions can be attributed to nonadherence.4
Overall, nonadherence results directly in reduced efficacy of the treatment, which leads to more rapid disease progression and an increased need for physician and hospital visits. Overtreatment can also occur if physicians are unaware of lack of adherence and prescribe higher doses to achieve desired results.5,6 In fact, incorrect use of medication has been associated with as many as 125,000 deaths per year in the U.S. alone.2 In addition, the IMS Institute for Healthcare Informatics estimated that at over $200 billion annually, or 8% of the U.S. healthcare expenditures in 2013, the year of the study.7 According to the U.S. Congressional Budget Office, a 1% increase in the number of prescriptions filled by beneficiaries would cause Medicare’s spending on medical services to fall by roughly one-fifth of 1 percent.8
The fact that elderly patients take many different medications for the treatment of multiple diseases, in some cases prescribed by numerous different doctors who may not be communicating well with one another, makes compliance more difficult for this segment of the population. Studies have shown that as the number of prescriptions increases, the likelihood of nonadherence also increases.9 The frequency at which a medication must be taken also influences patient adherence. Studies have shown that, on average, adherence drops significantly when medications must be taken four times per day (80% for one/day to 50% for four/day).10
The ease of use for self-administered drugs is also an important issue. Elderly patients that suffer from arthritis may find it difficult to open certain types of pharmaceutical packaging. Others who suffer from memory and cognitive problems may have difficulty remembering when to take pills, whether or not they have taken them already, or how to measure the correct dose.
Education of patients about their diseases, the action of the medications, the expected response time and the consequences of failing to adhere to prescriptions are crucial for increasing adherence. Physicians must consider their patients carefully and learn how best to communicate with each individual, taking into account his/her risk factors for nonadherence. Similarly, modern technology allows pharmacists to more actively monitor adherence for customers who regularly purchase medications from them.
Simplification of medication regimens and increasing the convenience and access to medications are two key strategies for improving patient adherence. The number of medications can be reduced by using combination therapies and finding alternative drugs that can treat multiple diseases. Switching to extended-release versions of current medications can reduce the frequency at which medications must be taken.
Prescribing the appropriate dosage form in pharmaceutical packaging designed to encourage adherence is important as well. The use of easy-access containers, and particularly single-unit dose formats, can have a significant and positive impact on geriatric patient adherence. Both physicians and pharmacists can help to identify alternative medications and appropriate dosage forms/packaging, as well as lower-cost medications, including generics where appropriate. The pharmaceutical manufacturing industry needs to support these efforts by using advanced manufacturing technology to provide affordable, convenient and easy-to-use drug forms.
Family members can also help ensure effective treatment by actively monitoring the medication adherence of their elderly relatives and intervening with physicians and pharmacists to obtain more appropriate medications.
Unit-dose delivery of medication is widely used in healthcare facilities in the U.S. and Europe to prevent medication errors. Many of the benefits of single-dose packaging can also be realized by elderly patients. Single-dose delivery systems are accurately filled to hold only the quantity of drug intended for a single dose and are meant to be opened only once. Many dosage forms — oral, topical, and injectable – can be packaged as unit doses: blister or pouch packages for oral solid formulations, plastic syringes with rubber tips and squeeze tubes for oral liquid medications, sterile blow-fill-seal forms for ophthalmics and inhalation therapies, pre-filled syringes and cartridges for injectables, and stick-packs for liquids, suspensions, and gels for oral and topical administration.
Single-dose packaging can help elderly patients reduce medication errors. They can be clearly labeled with the product name and also include information on the dosing regimen, such as calendars to indicate when medication should and has been taken. They can also be designed to be easily opened, even by patients with limited dexterity. For active patients that are often away from home, single-dose packaging provides greater convenience because such medications can be easily put in a purse or backpack. There is also reduced concern over contamination when traveling because each dose is surrounded by protective packaging.
The Healthcare Compliance Packaging Council (HCPC), established in 1990 to promote the many benefits of unit-dose packaging, highlights several case studies demonstrating increased patient adherence for various types of medications (e.g., birth control pills, certain antibiotics, hormone replacement therapies, steroids, etc.) through the use of modern packaging solutions, and particularly compliance-prompting packaging that reminds people whether they have taken their medications.11 With the advent of smartphone and networked homes today, the opportunities are even greater.
In all cases, of course, unit-dose packaging for pharmaceuticals must meet regulatory requirements and ensure the stability and efficacy of the medications they enclose. In many cases the use of unit-dose technology allows for the removal of artificial preservatives and longer shelf life. The most effective pharmaceutical packaging designs also serve as deterrents to counterfeiting and incorporate child-resistant features, while still allowing easy access for elderly patients.
Specialists in the development and contract manufacturing of sterile single-dose vials using blow-fill-seal (BFS) technology and liquid stick-packs, Unither Pharmaceuticals is committed to offering innovative and convenient single-unit dosage forms that simplify the lives of patients. Packing of medications via BFS is ideal for elderly patients, because it is possible to create many different shapes and incorporate premolded, presterilized inserts to achieve a variety of delivery methods. Liquid stick-packs offer versatility in terms of volume and barrier properties, and they are compatible with many different processing and filling methods. They are ideal for liquids and suspensions in particular, because no device is required for measurement or delivery. Both technologies allow for preservative-free formulations and provide single-dose packaging that is convenient, portable, and cost effective.
Nonadherence by elderly patients is a significant issue contributing to declining health, greater numbers of hospital admissions, and higher healthcare costs. While there are many factors that contribute to poor geriatric medication adherence, simplification of therapy regimens and easier access to affordable medications have been shown to have a positive influence. Convenient dosing formulations, particularly single-dose options, help reduce dosing errors and can be designed for easy access for patients with limited dexterity and mobility. In addition, blow-fill-seal and stick-pack products can be designed to provide elderly patients with a means for keeping track of when to take and when they have taken their medications. For these reasons, they also offer pharmaceutical companies an opportunity to differentiate their products and better serve their patients.
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