Section
Description
Page Number
1
Rationale of Crisis
1.1 Greater medical non-adherence among elderly with no caregivers
1.2 Importance of medical adherence and impact of medical non-adherence
Pg 2 – 3
2
Analysis of Crisis (reasons)
2.1 Non-medical adherence in elderly
2.1.1 Effects of cognitive decline and role of polypharmacy
2.1.2 Problems that may arise during taking of medicine
Pg 4 – 7
3
Current measure
3.1 Evaluative criteria for measure needed
3.2 Current measure: Pillbox
3.2.1 Process of sorting medicine into pillbox by elderly
3.3 Evaluation of current measure
3.4 Rationale for new measure
Pg 8 – 10
4
Case study
4.1 What led to the crisis that United States Postal Service (USPS) faced from 1960 to 1963
4.2 Why the ZIP code system was not a long term solution to the crisis
4.3 Similarity between medical non-adherence in the elderly and increase in deficit in mail industry
4.4 Differences between medical non-adherence in the elderly and increase in deficit in mail industry
4.5 Solution adopted to tackle the problem
4.6 What was learnt from the measure and modifications to the differences
Pg 11 – 18
5
Idea Generation
5.1 Idea: How does it work?
5.2 How the idea reduces the medication non-adherence rate in the elderly
5.3 Limitations of idea
Pg 19 – 24
6
References
Pg 25 – 27
Section 1.1 Greater medication non-adherence among elderly with no caregivers
[1]According to the Aging Clinical and Experimental Research, not receiving help from caregivers increases medication non-adherence among the elderly. Caregivers reduce the impacts of cognitive decline on the elderly by reminding them to follow their medical regimen, hence reducing the impact of medication non-adherence. As such, it can be inferred that elderly without caregivers are more medically non-adherent than those with caregivers.
Our project aims to benefit the elderly without caregivers by enabling them to have a more effective medication process.
Section 1.2 Importance of medication adherence and impact of medication non-adherence
Type of Drugs for common chronic diseases that the elderly suffer from
Medication Prescription
Effects of not following prescription
Anticoagulant for diseases such as atrial fibrillation
Timing
Dosage
Delaying or taking 2 tablets at once may cause increased risk of bleeding
[2]Taken twice daily;12 hours gap required.
If dosage is missed, can be retaken up to 6 hours prior to next dose
Only one tablet should be taken at once
Pyridostigmine
[2]Twice daily
Must not skip prescribed dosage
Increase the risk of symptoms such as muscle weakness
Figure 1: Importance of medication adherence and adverse effects of not doing so
As shown in figure 1, it is clear that not adhering to their prescription will not only reduce their recovery rate but also cause detrimental effects. As a result, it can be concluded that medical adherence is imperative and thus is crucial to improving adherence among struggling elderly.
Section 2.1.1 Cognitive decline and polypharmacy decreases medical adherence in elderly
Polypharmacy and decline in cognitive ability of the elderly were identified as the main causes for non-medical adherence in the elderly.
In general, amount of medication consumed increases with age due to the natural increase in the number of diseases.
The use of multiple medications, known as polypharmacy, generally refers to the consumption of five or more prescribed drugs per day.
The increase in the number of medicine adds to the strenuous nature of sorting medicine appropriately according to the prescription. This process is more difficult for the elderly due to greater cognitive decline than other age groups.
Cognitive decline is the reduced ability in processing information. Processing ability is defined by how much the brain can remember, and connect different pieces of information more efficiently and effectively.
Processing ability is needed to remember the time intervals at which each specific type of medicine should be taken at. As shown in figure 2, an elderly suffering from polypharmacy will have to remember the different time intervals for each of the 5 kinds of medication.
Figure 2: Different medications and timings to be eaten at
Section 2.1.2 Problems that may arise in the process of taking medication
Figure 3: Medication schedule in 24 hours (with reference to medications from fig. 2)
Figure 4: Mandatory prescription stickers on medications by hospitals or clinics
Elderly will have to consolidate the different medications to be taken in 24 hours like in figure 3. However, as they are incapable of connecting different pieces of information efficiently and effectively due to cognitive decline, the elderly are unable to categorise the different medications with similar time intervals together.
Elderly are unable to remember which medicine to take at a specific timing. This is because the medications consumed by the elderly may be taken at different time intervals, as shown in figure 2, on top of cognitive decline.
Elderly are unable to remember whether he has already consumed the required dosage of a specific medication or not. This requires the elderly to count and note down the number of pills in the packet after the previous consumption. Currently, not many of them are doing so.
[3]A 1994 study of adults and seniors found more self-administration medication errors with 9 vs. 12 or 14 point font and Courier vs. Helvetica fonts. This shows that in order to ensure medical adherence in the elderly, a minimum of 12 point font is needed. However, as indicated in figure 4, both fonts on the packaging are below 12 point font.
Elderly with poor eyesight will have a hard time reading these small words, and hence read the instructions wrongly. For example, elderly might read the number 3 as 5 and take 5 times a day instead of 3.
Only English instructions are given, resulting in a language barrier. [4]According to the Organisation for Economic Co-operation and Development (OECD), it can be inferred that most elderly in Singapore are English illiterate, with older adults, particularly 55-65 year olds, attaining some of the lowest scores in literacy among all participating countries. Hence, elderly will not understand the instructions and interpret them wrongly is no one translates for them.
The problems mentioned above decreases medical adherence in elderly.
Section 3.1 Evaluative Criteria for measure needed
To tackle the problem of medical non-adherence among the elderly, measures should follow specific criterion to effectively reduce or eliminate medical non-adherence.
Such criterion includes:
Measures should ease the involvement of having to use one’s cognitive ability by helping them to classify the medications according to:
Name of the medicine
The timing to be consumed at
Measure should help tackle their memory decline by reminding them to eat their medicine
Sustainable design with low maintenance so that the elderly would no need to worry about the working status of the measure
Section 3.2 Current measure: Pillbox
One of the measure available now is the usage of a pillbox.
[5]Figure 5: Image of current measure and its functions
Section 3.2.1 Process of sorting medicine into pillbox by elderly
Steps taken by elderly
Problems that may arise in the process of sorting
Implications
Read the prescription label
As explained in section 2.1.2, point 4, the issue of a small font is still present when the elderly are sorting out their medication into their pillbox.
As explained in section 2.1.2, point 5, the issue of language barrier is still present when the elderly are sorting out their medication into their pillbox.
Appropriately plan out the timings at which they are supposed to consume every one of their medicines at
╳
╳
Plan the quantity of medicine they are supposed to take at the specific times
╳
╳
Put them in the pillbox accordingly
Only 3 sub-compartments in a day in the pillbox. The compartments not enough as some medicine needs to be taken every 4 hours.
At least 4 compartments will be needed in 24 hours. Using this pillbox, time critical medicine will not be taken on time, leading to dire consequences on the elderly’s health.
* ╳ represents no significant problems / implications
Section 3.3 Evaluation of current measure
Pros of current measure:
With low maintenance required and straightforward usage of the pillbox, the elderly will be more receptive towards using the product. In addition, in-built alarm that reminds user to take medication at the allocated timings (morning, noon, and night) helps tackle the issue of poor memory commonly experienced by elderly. The elderly can also check if they have yet to consume the required dosage needed for that day by checking if that particular section of the pillbox is filled.
Cons of current measure:
As explained in Sections 3.2.1 and 3.2.2, the issue of small fonts on packaging and language barrier still remain. In addition, there is an insufficient number of sub-compartments on the pillbox. However, this device only helps the elderly during the consumption process by reminding the elderly when to consume medication. The device does not help the elderly with the process of sorting the medication according to timing and quantity.
Section 3.4 Rationale for new measure
In section 1.1, we have shown that there is greater medical non-adherence among elderly with no caregivers. As the pillbox is only effective for those who receive external assistance, this poses as a challenge for the elderly with no caregivers to find a solution to becoming more medical adherent. Hence, a new measure is needed to cater to not only those who receive external help, but more importantly, for those who do not.
Case Study
Section 4.1: What led to the crisis that United States Postal Service (USPS) faced from 1960 to 1963
Figure 6 : Increase in pieces of mail handled by USPS from 1965 to 1990
The development of computers brought about centralization of accounts and sent a growing mass of bills and payments, bank deposits and receipts, and credit card transactions through mail at that time. This resulted in a drastic increase in the volume of mails that USPS had to handle as shown in Figure 6 above. This dramatic increase caused post office personnel to struggle with sorting and delivering the ever-growing number of mails, resulting in mail receipt and sortation slowing down and causing 10 million pieces of mail to not be delivered on time.
Section 4.2: Why the ZIP code system was not a long term solution to the crisis
Figure 7: Deficit of USPS (in Million Dollars) by year
The increase in deficit, meaning the negative profits, from 1960 to 1962 spurred USPS to implement the ZIP code system. As shown in Figure 7 above, the deficit of USPS decreased from 1963 to 1964 with the implementation of the ZIP code in 1963. However, it was a short term solution as the deficit starts to increase again from 1964 onwards.
With the implementation of the barcode scanning system in 1982 to complement the ZIP code system, deficits started to decrease significantly, especially between 1983 and 1984 when the ZIP code system was improved. This shows that the barcode scanning was a viable solution to counter the increasing deficits experienced by USPS.
Why was the sorting process used by USPS inefficient in sorting the increased volume of mail?
In the year 1963, the five-digit ZIP code was launched to enable USPS personnel to sort the increasing volume of mail according to different states of the nation. However, this method enabled USPS to deliver mail at a rate that was only slightly faster than before and was not efficient enough to handle all the mails that were coming in. As shown in figure 8 , the total area that the ZIP Codes cover is greater than the area of Flint. This will lead to inefficiencies as the workers are unable to accurately locate the receiver, hence wasting time in looking for them.
Figure 8: Geographical map of City of Flint and the region around it
Section 4.3 Similarity between medical non-adherence in the elderly and increase in deficit in mail industry
The increase in deficit in the mail industry that stemmed out of the inefficiency due to massive mail volume is similar to how non-conforming medical non-adherence arises due to polypharmacy in the elderly.
As seen in figure 6, where the amount of mails in the US has been increasing at an increasing rate, there is an increase in demand for mailing services. However, this is met with the inefficient postal mailing system that was unable to meet the demands of the people, leading to clogging of the mailing services, delaying of delivering of the mails, hence reduction in efficiency and loss of profits.
This is akin to our case study where the polypharmacy in the elderly have them consuming multiple types of medicine with different types of prescriptions. As such, they lack the processing ability to sort out and manage the different types of medicine to consume them properly, giving rise to medication non-adherence.
Section 4.4 Difference between medical non-adherence in the elderly and increase in deficit in mail industry
Medical non-adherence in elderly is also due to the decline in their cognitive ability. Cognitive ability of USPS employees is required to be able to memorise the ZIP codes. However, cognitive ability is not the one of the reasons to why the mail industry is losing profits but rather the physical inability and lack of time to deliver the large volume of letters in a day.
Section 4.5 Solution adopted to tackle the problem
In 1982, the first computer-driven single-line optical character reader (OCR) , together with a 9-digit ZIP Code system were introduced which enabled automated sorting to be utilised.
Figure 9: Process of mail sorting in 1970s
The OCR was able to read ZIP Codes and translate them into barcodes, and spray barcodes on letters. Barcode sorters are then employed to read the barcodes and do a detailed sorting. However, OCRs cannot read badly handwritten letters or printed addresses. A function called remote barcoding was implemented to generate electronic images of these letters, and data entry clerks would enter sufficient address information. The processing facility will then match the new information to the letter.
As shown in figure 9, the use of barcode has lead to sharp increase in revenue earned by USPS between the years 1981 and 1982. This proves that the use of barcode has been
effective in improving the inefficient mailing system as with a more efficient mailing system, customers will be more inclined towards using USPS’s service, leading to an increase in revenue.
Figure 10: Total revenue of USPS from 1981 to 1990
Section 4.6 What was learnt from the measure and modifications to the differences
From what was mentioned above, due to the need for identification of letters’ addresses, a barcode reader system was created to accurately read the addresses of the letters. Similar to how there is a need to identify the medications of the elderly and their relevant prescription details such as the time intervals to be taken at and the dosage to be consumed, the barcode scanning system can be used for the creation of the pillbox. With the use of the barcode system, elderly would not need to remember and recognise the different names of the medicine and the prescription, which requires the use of their cognitive ability. Thus, the burden on the elderly’s cognitive state would be reduced, and the chances of errors lessen when the elderly put their medication into the pillboxes, leading to higher medication adherence rate.
However, medical non-adherence is caused by the cognitive decline in the elderly while loss of revenue is due to the physical inability to cope with the large amount of letters. Thus, the pillbox should target the inaccuracy in medication sorting instead of inefficiency.
This is because efficiency is not a significant factor in medication sorting as the elderly do not need to sort their medicine in a limited amount of time and accuracy is needed more to ensure that the medications are sorted correctly.
Idea Generation
Section 5.1: Idea: How does it work?
Figure 11: Proposed Idea
Parts (with reference to figure 10):
Section A is a machine with 8 compartments. Each compartment is a cylindrical tube labelled from number 1 to 8 and has a small tube attached to the bottom of each one. Since polypharmacy is the consumption of five or more prescribed drugs per day, 8 compartments are available to store 8 different medications.
Section B is attached at the bottom of section A. It is a pill box with 24 compartments, one for each hour for a total of 24 hours. Each compartment contains all the medications to be eaten for that hour.
Section A has a barcode scanner and an automated dispensing cabinet. Every prescribed medicine has a barcode on the prescription label.
How it works:
First, the barcode of prescribed medicine has to be scanned. The barcode reader will be able to identify the type of medicine, the dosage and the time intervals at which they must be administered to elderly, and store this information.
The elderly will then choose a compartment (1-8) to store that medicine.
Machine will match the information scanned to that compartment number.
Elderly to input the start time of which the first dosage of medicine is going to be administered at. For example, if the start time is 8 A.M., the first dosage of every type of medicine is going to be dispensed at 8 A.M.
Based on the time intervals and dosage of each medicine, each compartment in section A will be rotated and the medication in it will be sort into all the timings that it has to be taken at, through a tube. Section A operates on a rotator mechanism while the pillbox at the bottom is fixed. For example, compartment 1 in section A contains Dabigatran, which needs to be taken every 12 hours. So, section A will rotate till the tube of compartment A reaches the “8 A.M.†compartment in section B and drop the pill into it. Next, the tube will then be rotated to the “8 P.M.†compartment and drop another pill down again. The mechanism to how one pill is dropped at a time is with reference to a candy dispenser[12]. If 2 pills are to be dropped at once, the mechanism will be repeated twice.
This process repeats until all the medications to be taken in 24 hours is sorted out.
A light and alarm mechanism attached to each compartment in section B, lights up and rings at that certain hour to remind elderly to eat their medications.
Thus, elderly will only have to eat all the medication that is in that compartment at that timing.
Each compartment in section B is also detachable and portable.
Section 5.2: How the idea reduces the medication non-adherence rate in the elderly
It helps to plan and sort all prescribed type of medications for the elderly, removing the need to plan out their medication schedule, thus reducing the chances of medication non-adherence since the need to employ the elderly’s declined cognitive ability is minimised.
The issue of small fonts on packaging and language barrier is solved since the barcode scanner reads and stores the information on the prescription label.
Number of compartments in the pillbox increased, allowing for more flexibility in the planning the medication schedule and chances of not adhering to time-critical medications is reduced. Time-critical medications are medications with that have to be taken on time or 30 minutes before/after prescribed timing, if not there will be severe negative impacts on health.
Currently, elderly will have to input compartment number which the medication is going to be put into. However, this means that elderly will have to recognise all their medications so they would not put two different medications into the same compartment. This adds on to the burden they have to face as they will have to remember and differentiate how the pills look like, which is not desirable. To improve it, another section, section A1, will be added at the top of section A, which will help to assign the compartment number to the medicine that was poured in. This section will ensure that different medications will not be stored in the same compartment or different compartments storing the same medication. Thus, the elderly will just have to pour the medication into the only opening of section A1, without having to choose the compartment number. This is reduce the chances of errors arising, leading to greater medical adherence rate.
Secondly, this pillbox will not be suitable for elderly who take more than 8 medications a day as there are only 8 compartments to store 8 different medications for the day. However, [13]a study done by Changi General Hospital in 2016 showed that out of 55 hospitalised patients, aged 65 and above, more than half had nine or more different medications per day. Thus, a more flexible system of allowing elderly to adjust the number the compartments available in section A by adding or taking out tubes from section A according to the number of prescribed medications they have.
Figure 12: Proposed Idea (Final)
Section 5.3: Limitations of idea
With external environmental effects such as scratching and printer marking inconsistency, it might lead to distortion of the barcodes on the medicine packaging and hence render it unreadable by the barcode scanner. Since the only way of setting prescription details of the medicine is through scanning of the barcodes, it will result in the prescription details to be not able to be inputted, resulting in failure of the pillbox.
However, this can be countered by installing an external programme that contains the prescription details of the medicine given to the elderly that was inputted by the hospital staff. That way, should the barcode be damaged, the elderly can input the name of the medicine and the name of medical centre that prescribed the medicine, hence inputting the prescription details of the medicine through the programme.
Another limitation of this idea is that this technology might be too expensive for the elderly as majority of the elderly who are above 65 years old are retired and do not have an income. However, this factor is a secondary concern as our idea’s main objective is to improve medication adherence rate in the elderly for the greater good of their health.