Annals of Long Term Care

Introduction
Risk is inherent in the journey as a patient navigates through a healthcare crisis, and for successful transition to the community from a facility, it is imperative to ensure that an individual can self-manage medications safely. Patient cognition and medication management skills are often inadequately assessed. Routine protocols for brief cognitive evaluation and pillbox skills screening prior to discharge provide the opportunity to identify patients at risk for self-harm due to medication mismanagement. Timely interventions to educate the patient or caregiver regarding the use of a pillbox, or other adherence tools, would facilitate safer transition between levels of care.

Historically, the Mini-Mental State Examination (MMSE) has been the gold standard quantifier for cognitive assessment incorporated into medication management assessments. In recent years, medication adherence tools have proliferated; however, to date, few exist that serve well for routine use in the clinical setting.¹

This article describes two cases in which pharmacists developed and implemented brief cognitive screens and pillbox organization assessment tools. After medication management education, patients were discharged from a facility to the community setting. Successful strategies to implement the knowledge acquired from cognitive and pillbox skills screening presented an additional challenge, as highlighted in the following two cases.

Case 1
Mr. S, an 81-year-old male Asian veteran, post-cerebrovascular accident (CVA) with posttraumatic stress disorder, learned that his home had been sold and that he was to be moved across the country to live in an apartment near his daughter. In preparing for discharge from the Veterans Affairs rehabilitation unit, Mr. S insisted on self-managing his medications. He was wary of Western medicine and preferred herbal preparations because they were “safer.” Regimen adherence concerns were addressed with education regarding his prescribed medications. Screening for cognition and pillbox management skills ensued to honor the patient’s desire for independent medication management. Mr. S had some prior experience in loading a pillbox and indicated that he would like to use one upon discharge. His ability to read prescription bottles reflected a high education level. Verbal fluency and expressive articulation also suggested adequate cognition for managing a pillbox.

Mr. S’s cognition was assessed with the MMSE and Mini-Cog exam, and scores were as follows: MMSE 26/30, Mini-Cog 0/5 (Figure 1). Three Item Recall (TIR) scores were 0/3 on four attempts—as a part of two MMSE and two Mini-Cog screenings—which confirmed short-term memory deficit.^2-8 Pillbox comprehension scores (Figure 2) provided an objective measure of his ability to: (1) read prescription labels, which he was able to perform perfectly (9/9); (2) state the purpose of each medication (9/9); (3) decipher the prescription instructions correctly (9/9); and (4) identify each medication by sight (7/9). Of note, Mr. S had only two new medications during his hospital stay, and these were the medications that he failed to identify after standard patient medication education in preparation for discharge. The inability to retain new information reinforced concern regarding independent medication management. He was asked to fill the pillbox using a medication calendar as a guide. The calendar was integral to the Veterans Affairs’s regular discharge protocol. Reconciliation, the comparison between the medication calendar and the accuracy score quantifying how he loaded his medications, was 75%. As a self-check for accuracy, the patient was asked to count the pills in the Saturday compartments using the medication calendar as a guide.