Introduction

In this era of technology there are an ever increasing myriad of pharmaceutical options to cure what ails you. As a result, it is becoming increasingly routine to take one or more medications daily. Maintaining this schedule presents limitations for the elderly suffering from memory loss or dementia.

For this reason many elderly rely on caretaker support or institutionalization. In an effort to allow the elderly to live independently longer, some means of maintaining a medication dosing schedule that does not require caretaker support must be developed.

The Pill Keeper is an automated medication management system developed as part of the 2008 RERC-AMI Biomedical Design Competition aimed at improving patient independence, health, and longevity by simplifying the medication dispensing process and maintaining proper medication schedule adherence.

Approximately 20% of persons over 65 in the United States take 5 or more prescription medications¹. Many doctors “[commonly observe] deficits in physical dexterity [and] cognitive skills and memory” among this population, and therefore believe that members of this group are especially likely to fail to adhere to the medication dosing schedules provided by prescribing physicians². Since complications related to patients’ not taking medications as prescribed can require significant, otherwise avoidable healthcare expenditures, there is a genuine value for the patient and for society in ensuring that medications be taken timely and properly². This project was to investigate the feasibility of an electronic in-home device that automatically dispenses medications to a user according to their physicians’ instructions, and document our development of such a device.

In the “User Case Study” section, we evaluate the theoretical utility of an automated medication dispenser in multiple situations in order to define typical characteristics of users in the target market and their expectations of the device’s functionality.

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Target Users

User case studies

To refine the understanding of exactly what our device should accomplish, we present three miniature “case studies,” that illustrate the utility of an automated prescription dispenser. In each case, the user is assumed to be of “substantial” age and have some degree of cognitive disability.

Case 1:User forgets to take, or takes too much of, a medication, and this results in a need for immediate hospitalization or emergency treatment.

This situation is that in which an automated prescription dispenser could most improve the resultant outcome. In an interview study, 11% of patients over 65 admitted to a hospital attributed their admission to failure to adhere to their physician-provided prescription regimen³. Hospitalization and emergency treatment are very expensive, and any condition which requires emergency treatment is likely to be life threatening to the user, and decrease the user’s quality of life through resultant short-term to permanent disability. Although quality of life may appear irrelevant to health care financiers in considering the costs associated with this outcome, it should be noted that a decrease in quality of life can result in increased costs of health maintenance, including increased involvement of medical professionals in the user’s life and increased prescription of palliative medications.

Although by ensuring that a user does not lapse in their adherence to their prescription regimen, an automated prescription dispenser might prevent an emergency healthcare expenditure, we do not expect users facing imminent health deterioration from forgetting one or two doses to form a large part of our market. This is because the more fragile the patient’s health, the less likely physicians and other caretakers will be willing to rely on the patient’s regularly interaction with a computerized device for health maintenance. Nonetheless, patients with an unforeseen, or low, likelihood of acute health deterioration as a result of missing doses may well be saved from hospitalization by an automated prescription dispenser. For these patients serious injury from prescription non-compliance is possible, but the risk of this happening may not be great enough to justify a caretaker administering every single dose in person. On the other hand, the less severe the patient’s condition is, the greater the influence of device cost will be on the physician’s decision to prescribe an automated dispensing device, and the willingness of health care financiers to pay for it. Simpler, cheaper devices for ensuring patients take medication, like watch alarms and pill organizers (boxes with separate chambers associated with each time at which medication must be taken) become more attractive as the perceived risk of adverse health outcomes resulting from regimen noncompliance decreases.

Case 2: User regularly forgets to take a medication, or takes it incorrectly, and as a result the prescribing physician mistakenly determines that the medication is inefficacious or causes an adverse reaction in the patient.

In this situation the negative outcome is less severe than hospitalization, but is sufficient to justify the costs of avoiding it with an automated medication dispenser. From a marketing standpoint, this is a very important situation to consider, primarily because physicians ultimately will have to prescribe the dispenser, and an incorrect assessment of a medication’s effect on a patient can be an inconvenience for the physician. If, as a result of patient noncompliance, a physician mistakenly determines that a medicine does not work on them, the physician will have to deal with extra office visits by the patient for a problem that ideally should already have been resolved. The physician will have to try other medications, which may not work as well, or have more adverse side-effects. In the worst case, the medication mistakenly dismissed as ineffective might have been the only one that is genuinely effective on the patient, and the physician will turn out engaging in a lengthly and fruitless experimentation process with other medications. The outcome is likely similar if a patient reacts adversely to a medication because of taking it incorrectly, and the prescribing doctor does not know the patient did so. More than in the case of a drug seeming to not be effective, physician observation of an adverse reaction to a drug will inhibit them from prescribing the drug to others who might benefit from using it. Naturally, these misevaluations, in requiring greater doctor time, also have the negative impact of increasing costs for health care financiers.

Based on the value to physicians of knowing whether or not their patients are taking medications as prescribed, it seems clear that the market viability of an automated medication dispenser will benefit from the capability of the device to record and transmit this information to physicians. This feature could give the device an advantage against some simpler and cheaper alternatives, the designs of which are not be amenable to modifications allowing verification of drug consumption. For example, a wristwatch alarm could easily be turned off by the well-meaning user without their taking medications appropriately, either because they do not remember what pills to take, or because they quickly turn off the alarm out of irritation, and forget to procure their medications afterwards.

Case 3: Family members or professional caregivers must visit the user multiple times per day, solely or primarily for the purpose of making sure the user takes medication appropriately.

It is known that "for some elderly individuals, continued independence depends on their ability to take medications as prescribed,” and that nursing home or other full-time care would be significantly more expensive².¹¹. Professional caregivers require payment for their services, and even though no monetary transactions are involved, caregiving by relatives has a real economic cost in terms of lost time and energy that could be used otherwise¹¹. Consequently, keeping senior citizens as independent as possible is not only valuable for them in terms of quality of life, but also economically valuable for society¹¹. An automated medication dispenser could substantially lower the frequency at which caregivers would have to travel to the homes of those for which they care in cases where the caregiver’s primary task is to administer medication. If in the future, as it is feared, higher divorce rates decrease the proportion of children who will voluntarily take care of their elderly parents, the real costs of senior citizen care will become increasingly visible, and technical solutions that can mitigate these costs will become increasingly attractive¹¹.

Case 4: Users with impaired motor functions experience increased difficulty when physically managing medication caps, containers, and small sized medications.

Some patients, varying in age, have difficulty managing containers and extracting small pills with the prevalence of physically debilitating conditions or handicaps. An automated medication dispenser could significantly lower the frequency at which these users need to handle such containers, transforming difficult daily tasks to monthly tasks. The occasionally acquired aid of another person could eliminate such difficulties altogether.

Complete Typical: As is often is the case, our motivations for purchasing goods are based on real world needs that are often a combination of the several of these case studies. Here we present a completely picture of a typical user and illustrated the motivation for her family to purchase a automated medication dispenser.

Etna Mathers. Etna is 74, living in good health independently. She routinely takes blood pressure and cholesterol medication after a heart attack a few years ago. She also takes a multivitamin to provide supplemental nutrients. Insuring that Etna receives her medications on time is of great concern to her children. Over the past few months her mental health has greatly deteriorated. Her children fear she may have Alzheimer’s, and may have been neglecting to take her medication properly.

Her son Alan is very worried that her poor adherence to the medication schedule could allow her heart condition to relapse as another attack or stroke. Her children visit her regularly, at the beginning of the week her medications are be placed into paper cups labeled by the day and time. This helps her remember when it’s time to take her pills, and has worked well to keep Etna on schedule. Alan is also aware of when Etna forgets to take her medications, the paper cups serve as a reminder of missed dosages. While this works well, Alan has considered placing Etna in a retirement home where they are better equipped to deal this type of issue. His mother values her independence, but Alan doesn’t want to spend so much time manually sorting and preparing medication dosages.

An automated medication dispenser would allow Etna to remain independent by providing a consistent method to dispense medications and monitor adherence. Alan would be able to keep a watchful eye on his mother by remotely logging into the device website which maintains a list of times when medications were dispensed. The device provides a convenient, automated method of orchestrating the dispensing process that Alan has previously done by hand. The device would preserve Etna independence and alleviate Alan’s burden of preparing the paper dosage cups. Alan could spend quality time with Etna during his visits rather without being distracted by her medication needs.

¹ Kaufman et. al. “Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States: The Slone Survey. JAMA. Vol. 287. No. 3. p.337-344: 16 January 2002.

² Cramer, Joyce A. “Enhancing Patient Compliance in the Elderly: Role of Packaging Aids and Monitoring”. Drugs & Aging. Vol. 12. No. 1. January 1998.

³ MacLaughlin, Eric J. et. al. “Assessing Medication Adherence in the Elderly: Which Tools to Use in Clinical Practice?”. Drugs Aging. Vol. 22 (3). p, 231-255: 2005.

¹¹ Tennstedt, Sharon. “Family Caregiving in an Aging Society”. Presentation at the U.S. Administration on Aging Symposium Longevity in the New American Century. Baltimore, MD: 29 March 1999.

⁹⁹ Original graphic location: todaysseniorsnetwork.com