We mandate anyone who wants to drive a car to first pass a driving test. Should we have a similar competency test before we allow someone to take his or her medications independently?
Provided the individual gets to receive some education about the medication, we often trust the individual will be able to take the medication properly, especially when there is ongoing follow up and monitoring. The exception to this rule is when there is a health decline cognitively, mentally or physically.
A self medication assessment may be warranted when the individual’s ability to take medication safely is called into question. Below are some key domains I focus on in a self medication assessment:
Cognitive impairment – When an individual has dementia or early stages of cognitive impairment, it may affect the ability to remember if medications have been taken or not- so there is a risk of overdose or lack of treatment. Available scores from cognitive assessment such as MMSE or MoCA may help to understand the extent of the impairment. However when there is lack of information available, some short questions of recall or simply asking the individual to identify familiar faces may be sufficient to detect any major or minor impairment.
Physical Impairment – Individuals with Parkinson’s disease, stroke or other movement disorders may have difficulty with fine motor skills. They may not be able to hold onto the tablet or to swallow the tablet whole. So it is important to appreciate if there are alternative dosage forms (e.g. fast dissolving tablet, liquid, topical patch) that may be easier for the individual. Sometimes frailty may be another factor; an individual may be so weak that simply keeping up with a complex medication regimen may be impractical or impossible.
Sensory impairment – Often we neglect to assess for the individual’s sensory impairment. The individual may be colour blind, in which case he or she may not be able to identify a coloured tablet correctly. If there is difficulty with hearing, then it may be challenging to receive verbal directions accurately related to the medication.
Mental Stability – If the individual has recently had an acute illness in which his or her mental health may be unstable (e.g., bipolar affective disorder, or major depressive disorder), it is important to determine if there is any safety risk or whether the individual is capable of taking the medication as prescribed.
Knowledge Acquisition – While it is important to understand why an individual is taking a medication, I find that this domain needs to take the perspective of the different age groups. For the elderly population when a paternalistic relationship with their physicians has been the acceptable norm for a long time, they trust their physicians without questioning much, including the need to understand what and why they need to take different medications. Hence, the lack of knowledge of their medications does not necessarily mean they are not competent to self medicate. However, I would expect an individual from the millennial generation to know a lot more about their medications from their innate internet research skills.
Health Literacy – We sometimes take for granted that the usual language used in health care may be foreign to individuals without any healthcare background. Something as simple as taking one tablet twice daily may be misinterpreted as taking two tablets simultaneously. Or to take a medication on an empty stomach may be misinterpreted not to have a meal for an extended period of time after taking the medication. It is important to verify understanding by asking the individual to describe how he or she takes the medications in any given day.
For more detailed resources on self medication assessment tool, I find the following webpage quite helpful. This webpage presents training modules and the latest version of the Self-Medication Assessment Tool (SMAT) developed by Dr. Janice Irvine-Meek (Horizon Health Network) and Dr. Odette Gould (Mount Allison University) in New Brunswick, Canada