Transitions of Care: Assessing Patient Cognition and Medication Management Skills

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.

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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. The pharmacist observed that 11/15 doses were correct and used this method to educate the patient in an effort to achieve pillbox-loading accuracy.

The patient’s cognitive/pillbox skill scores created a conundrum with regard to predicting his success in managing his medications due to mixed performance on assessment score results: MMSE passed, 86%; pillbox comprehension passed, 90%; loading assessment failed, 75%; and Mini-Cog failed, 0% (Figures 1 and 2). He failed the Clock Drawing Test (CDT)—the first portion of the Mini-Cog screen—due to numeral placement outside of the circle drawn for the clock face, per the 2-point clock scoring system.7 Potential for medication mismanagement—specifically new medications—and adherence to regimen was predictably poor for Mr. S. His daughter was apprised of his need for medication assistance.

Outcome of Case 1
Despite the results from the screenings suggesting that the patient had demonstrated significant short-term memory deficit, Mr. S was discharged to live alone in the community. His family was reticent to have him reside in their home due to a history of relational conflicts. His daughter was attentive to his needs and vigilant in observing his medication adherence via pillbox checks several times a week.

Two weeks after discharge, Mr. S’s daughter expressed concern regarding her father’s nonadherence to his regimen and reported that he would dump out his pills and tell the doctor he was taking them. Two of his medications were levothyroxine and donepezil. Adherence to these medications may have slowed the rapid decline in memory that occurred over the following months. Mr. S forgot how to use his microwave oven or turn on the shower. In an effort to bathe, he threw a bucket of water over himself as a quick bath prior to his primary care appointments.

The patient had a history of paranoid behavior, which increased, and he accused anyone who tried to help him of stealing from him. Mr. S was taken to a mental lock-down facility for safety precautions, where he resided for two years. He refused to eat or drink very much because he was convinced that the food and water were poisoned. Finally, according to his daughter, with the support of an excellent caseworker, he was discharged to a hospice facility. His daughter reported, “They cleaned him up, shaved him, massaged him after a whirlpool session, and he was given whatever he wanted to eat. He died peacefully in the middle of his first night there.”

Case 2
Dr. H, a 64-year-old white male with a PhD in engineering, was post-CVA and had contractures with chronic pain. He smoked three packs of cigarettes per day and had bipolar disorder with a history of attempted suicide by cocaine overdose. Along with taking numerous medications, Dr. H was morphine-dependent due to long-term pain management. Despite these impairments, Dr. H had been living independently for the past ten years. Dr. H self-referred to the VA Extended Care Unit for rehabilitation and gait training for contractures secondary to his stroke.

Dr. H was highly frustrated over his physical limitations and his struggle to maintain independence. He refused assistance from the staff, began to miss his physical therapy appointments, and had several falls on the unit. Psychotropic medication doses were increased to ameliorate his increasingly contentious mood that made care difficult for the staff. Further worsening his limitations was an incident in which he crashed his electric wheelchair and injured his leg, necessitating higher doses of pain medications. The combination of psychotropic and pain medications resulted in oversedation, which caused Dr. H to demand discharge from the unit. The staff refused due to danger to self, and he threatened to leave the facility against medical advice.

Dr. H’s MMSE score was 30/30, but the provider had documented, per professional judgment, that the patient had cognitive impairment and referred him for further assessment. The impasse over the appropriate discharge setting and the patient’s need for assistance with medication was resolved when Dr. H’s son agreed to observe his father’s cognitive and pillbox organizational skills conducted by the pharmacist. While taking the Mini-Cog screen, Dr. H attempted to look at his wristwatch for cues during his CDT (Figure 3, top). His clock was incorrect, and he missed one word in the TIR, thus failing the Mini-Cog with a score of 2/5. His Medication Transfer Screen (MTS) score was also 2/5 (Figure 3, bottom; see Figure 4 for MTS form). The cognitive and pillbox skills scores together formed a failing Medi-Cog test (a combination of the Mini-Cog and the MTS, described below). He scored 4/10 (Figure 3; scoring system, Figure 5).

Outcome of Case 2
Dr. H was discharged home from the Extended Care Unit. Through a pillbox set up by his son and a caregiver to aid with bathing and verify his adherence to regimen, Dr. H was able to live in his mobile home for two years before being admitted to an assisted living facility. His success in extending his time in the community was largely related to his tenacious will to be independent and his adequate adherence to his prescription medication regimen. His greatest adherence challenge arose when his caregiver stole his morphine. It was difficult to replace both the home healthcare support and the morphine. During this time he suffered intensely from inadequate pain management.
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Discussion

Successful patient navigation between care settings requires the avoidance of a plethora of pitfalls through excellent communication and adept coordination within the healthcare team, as well as a good measure of intervention by patient advocates. Ideally, the patient and his/her wishes are at the center of decisions made. Many patients with cognitive deficits, however, would fail independent living sooner if it were not for the attentiveness of family members and/or caregivers. Triaging whether medication education should be focused on the patient, the caregiver, or both is essential. Screening for the ability to decipher prescriptions and accuracy in organizing a pillbox, as well as providing medication education, should occur at each level where responsibility for medication management falls. Often, caregivers are not screened for their skills in pillbox organization—and they should be.

In the first case presented, the knowledge gained from Mr. S’s screening suggests that the Mini-Cog was more valuable in predicting the success of pillbox organization than the MMSE. Mr. S’s short-term memory deficit should have driven a case for transfer to assisted living or long-term are rather than discharge to the community setting. The pillbox-loading task required an arduous hour to conduct and spawned the idea for the MTS (Figure 4), a paper-and-pencil task designed to evaluate both literacy and the ability to sequence and locate pills in a pillbox. The MTS screen requires less than five minutes for most individuals to perform.

In the second case, Dr. H demanded autonomy in managing his medications, but in viewing the results of his own cognitive/pillbox skills screening, he acquiesced to receiving his son’s assistance. The son’s commitment was secured when he saw the results of his father’s Medi-Cog assessment, and realized that his father needed his pillbox organized in order to live independently. The present author contends that research is warranted to ascertain which patient-specific and /or treatment-specific variables foster a high correlation between Mini-Cog screening and MTS pillbox competency testing with medication organizational skills and adherence.

Descriptions and Applications of the Cognitive Screening Tools

The Mini-Cog is a rapid screening tool developed to identify clinically significant cognitive impairment. It is sensitive in identifying early stages of cognitive decline. A combination screen of the CDT and TIR, it provides a measure of both long-term and short-term memory. The Mini-Cog is used widely in clinical practice, and the methods of administration, scoring, and application have been documented.^2-8 It is a brief screen, and results must be confirmed by other cognitive tests to determine a definitive diagnosis for cognitive decline.

The MMSE is a standardized screen for dementia and is used widely in clinical practice. In recent years, other screens have demonstrated greater sensitivity to identifying early cognitive changes. The MMSE, however, has been relied upon for purposes outside its original scope, and new tests are now entering clinical practice that serve as more sensitive and specific instruments for measuring various aspects of cognitive function.

The pillbox-loading evaluation presented in this article was a prototype of a published version of the Pillbox Assessment.² Typically, a “pill count” refers to a retrospective review to determine how many pills remain untaken after a patient uses a pillbox for a week. In Mr. S’s evaluation, the pill count was used prospectively to evaluate pillbox-loading accuracy.

As mentioned above, the MTS was designed to serve as a brief literacy/pillbox skills screen to quantify a patient’s ability to read instructions on a pill vial, decipher the instructions, and translate them into loading tablets into a pillbox (Figure 4). The MTS was developed as a paper-and-pencil screen to avoid the time-consuming process of having a patient load his/her medications. The top half of the sheet is empty for the patient to perform the Mini-Cog CDT. The MTS is pre-printed on the bottom half of the page. There are four prescriptions to be deciphered,with instructions for the patient to make marks in a grid representing a pillbox. Each mark represents a tablet. The fifth item is a counting task. Each item is scored 1 point to quantify performance. The average patient is able to perform the MTS in less than five minutes.

In summary, the Medi-Cog is a combination screen of the Mini-Cog and MTS (Figure 3; scoring system, Figure 5). The seven-minute Medi-Cog provides a literacy/pillbox skills score in addition to Mini-Cog screening. Correlation between the Medi-Cog score and a patient’s accuracy in filling his/her own medications in a pillbox was 0.72 (P < 0.001); r2 = 0.53 (P < 0.001).² Further studies are underway to measure the accuracy of the Medi-Cog screen in predicting a patient’s pillbox organization in correlation with health outcomes.

Acknowledgments

This work was supported with resources and the use of facilities of the Department of Veterans Affairs. The author would like to thank Soo Borson, MD, UW, creator of the Mini-Cog; Sandra Jue, PharmD, Clinical Professor of Pharmacy Practice, Idaho State University; and Stanley Hall, APRN-C, FNP, MSN, Veterans Affairs of Boise, ID, for their support throughout the development of the MTS and Medi-Cog. In addition, the author expresses gratitude to Forrest Smith, PhD, for mentorship and editing assistance in manuscript preparation, and for the thoughtful contributions of Catherine Willmore, PhD, RPh, and Jeanie Smith, PharmD, faculty of Harding University College of Pharmacy.

The author reports no relevant financial relationships.

Dr. Anderson is an Assistant Professor of Pharmacy Practice, Harding University College of Pharmacy, Searcy, AR.

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