Dosing Instructions Confuse Older Patients on Multiple Drugs — Would Standardized Names for Periods of the Day Help?

© 2011 Peter Free

 

04 March 2011

 

 

Due to non-standardized dosing instructions, many patients do not realize they can take some medications at the same time

 

Misunderstanding leads patients to complicate dosing regimens.  Doses can be missed or multiplied.

 

Researchers wondered whether dividing the day into four periods for purposes of creating standardized dosing instructions (for physicians and pharmacists to use) might reduce patients’ confusion:

 

Many older patients, who take an average of seven medicines a day, are so confused by the vague instructions on prescription bottles that they don’t realize they can combine their medications to take them more efficiently. A new Northwestern Medicine study shows patients thought they had to take seven medicines at least seven and up to 14 separate times a day.

 

Wolf and colleagues have proposed a universal medication schedule that standardizes medicine prescriptions into doses at four clearly identified periods of day – morning, noon, evening and bedtime (instead of twice daily or every eight hours.)

 

© 2011 Marla Paul, Confusion About Multiple Drug Dosing, Northwestern University News Center (28 February 2011)

 

 

The research team found evidence that a problem does exist

 

Dr. Wolf’s group showed that today’s non-standardized dosing instructions confused a significant proportion of a 464-person sample of 55 to 74-year old patients.

 

From the paper’s abstract:

 

Participants were given a hypothetical, 7-drug medication regimen and asked to demonstrate how and when they would take all of the medications in a 24-hour period. The regimen could be consolidated into 4 dosing episodes per day.

 

Participants on average identified 6 times . . . in 24 hours to take the 7 drugs.

 

One-third of the participants (29.3%) dosed their medications 7 or more times per day, while only 14.9% organized the regimen into 4 or fewer times a day.

 

Instructions for 2 of the drugs were identical, yet 31.0% of the participants did not take these medications at the same time.

 

Another set of drugs had similar instructions, with the primary exception of 1 drug having the added instruction to take "with food and water." Half of the participants (49.5%) took these medications at different times.

 

When the medications had variable expressions of the same dose frequency (eg, "every 12 hours" vs "twice daily"), 79.0% of the participants did not consolidate the medications.

 

© 2011 Michael S. Wolf et al., Helping Patients Simplify and Safely Use Complex Prescription Regimens, Archives of Internal Medicine 17(4): 300-305 (28 February 2011) (paragraphs split)

 

 

I’m not sure that the Wolf team’s four-block day standardization will help

 

The fundamental problem is that patients do not recognize that medications can be taken together.  If so, standardizing on four extended time periods — morning, noon, evening, and bedtime — is not going to help.

 

Morning and evening are long periods, so one runs into the same semantically ambiguous problem that one does with “twice per day” dosing.

 

And unless patients recognize that “noon” is a time, they will likely turn that into an extended period (mid-day), as well.

 

Only “bedtime” has the kind of semantic specificity that the researchers apparently hope for.  And even there, patients who do not recognize that medications can be combined will try to scatter dosing during the lead-up to bedtime.

 

 

 

An improved solution would add a pharmacist/physician-dependent step to the four-block day proposal — personalized, written specificity

 

There is no reason that pharmacists could not use the Wolf group’s “morning, noon, evening, and bedtime” blocks to organize older patients’ medication lists into written dosing instructions.

 

Older patients often use the same pharmacy for their prescriptions.  Pharmacists are significantly better trained than physicians are to spot risks for drug interactions.  They also already generate detailed instructions to go with the medications they dispense.

 

There is also no reason that these individualized patient dosing lists could not be software-generated.

 

Some physicians might resist pharmacists’ increased involvement as interfering with doctors’ top-dog rank in the medical-delivery system.  My opposing view is that the pharmacy profession’s skill and knowledge has been historically under-utilized in exactly the area where it is trained to shine.  It’s time for our society to even the playing field a bit.

 

 

 

Even more ideally, primary care physicians would generate multi-medication dosing instructions in written form

 

It would not be unreasonable — in a world arguably more professionally and electronically integrated than ours — to ask primary care physicians, or their nurses, to personalize written patient dosing instructions for the whole medication list, whenever a new drug is added or an old one refilled.

 

Nor would it unreasonable to require that specialists report newly prescribed medications back to the referring primary care physician.  In a digitally-integrated medical world, this would be a snap.

 

The reality, however, is that this kind of professional integration is not likely to happen in the foreseeable future.