Medicine Reminder for Elderly People

A project case to explore Human Centered Design methods

Johannes Andersson Sefat Chowdhury Bin Han

Interaction Design and Technologies Chalmers University of Technology, 2012

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Abstract
This paper describes the use of human centered methods in order to design a medicine reminder for elderly people. Among the methods used were Interview Guide, Personas and Scenarios.

Introduction
To design for elderly people is a special task. One does have to take into account both mental and physical constraints, as well as diseases, that comes with old age. The objective here is to propose and describe a method for designing for elderly, as well as to produce a design proposal. The subject of design is a medicine reminder, to help elderly remember and take their medication. The project were to be conducted in cooperation with the DEVICE project.

Problem definition
This project was initiated as a course project in the course Human-Centered Design at Chalmers Institute of Technology. This gave a initial scope of the project, to investigate and utilize the human-centered methods. The design was specified to center around elderly couples, who might have a hard time remembering taking their medications. It was also suggested that the design should consider the communication between the couple as a factor.

The DEVICE project

The scope of the design project takes place under the DEVICE project. DEVICE stands for DEsign for Vulnerable generatIons: Children and Elderly, and is funded by the EU. The purpose of DEVICE is to bring together, evaluate and promote the methods of Human Centered Design. It focuses on the age groups specified in the name, the youngest and the oldest. The goals of DEVICE includes documenting the current best-practice and give guidelines for future design projects. They will also make the knowledge gained available to the public, to spread the word of the benefit of usability and ergonomics. (DEVICE, 2012)

Methodology
The methodology used during this design project was Human Centered Design, or HCD, as the case often is, the methodology were strongly adapted to the constraints of the project, and in turn, the end users of the product to be designed. The Human-Centered Design Toolkit of IDEO (IDEO, 2009) were used to get an overall picture of the Human Centered Process and its methods. Through this framework we get an abundance of methods and concepts applicable to most design processes. With this framework as a base an overall project plan and timeframe were set, to give a scope in which further refinement of the methodology can be applied. The specific human centered activities of the process were not defined within this timeplan, but were to be further specified as the literature study, and other related tasks, progressed. The structure of the design process were divided into three steps; Context of Use Analysis, Requirements Engineering, Ideation and Design and Evaluation.

Context of Use Analysis

A meeting were set up with the representatives from the DEVICE project to get a discussion going and to get a feeling for the project goal, aside from the design itself. Along with the discussions a set of related papers, organisations and projects to study were proposed by the DEVICE representatives, to work as a basis for the literature study.

Literature Review
With this initial set of papers a literature study were conducted to get a firm idea on how to best apply the Human Centered Design methods to this project. The main purpose of the literature study was to answer the question of what particular methodology within HCD and what specific activities to conduct. Further the literature study surveyed existing products within the field of medicine reminders. Studies were also made to find to what extent physical and mental constraints, as well as age related diseases, affected the elderly people. The literature study were mainly consisting of data and papers from scientific databases, mainly through the databases available through the Chalmers Library. In addition to this knowledge were gathered from company practices and product

demo videos from less scientific sources, to get a deepened view of the feeling of the existing products.

Requirements Engineering
After the Context of Use Analysis the project moved into Requirements Engineering. This is an important step in the design process, to specify what will be developed. This is naturally in the interest of both the developers, to see to it that they keep on the right track, and the external stakeholders, so they know what properties the end product will have (Maguire, 2001). To find the requirements many methods were used including interviews, personas and existing systems analysis.

Interview Guide
Before the start of the design process a short pilot study was conducted. This was done to get some early idea of if and how the users would use the future product. Some of the questions included was age, how many pills they take per intake occasion, and how many occasions per day, etcetera. This resulted in a dataset and some reflections from the interview subjects. The interview questions, conduction and results are described more closely later in this paper.

Personas
Based on the results from the early literature study along with the results from the Interview Guide sessions personas were created to help the design process. Two persona couples were specified, Mr. and Mrs. Smith, and Mr. and Mrs. Johansson, who both are described in further detail later in this paper.

Scenarios
To give the personas a more sharp application to the design, a scenario were invented for each of the personas. This added to the personas in shining light on some of the areas we suspected trouble would arise,

Existing product analysis Existing product analysis is an approach to requirements engineering. It is used to look at what products are out on the market, or proposed as design suggestions, and see what possible requirements can be extracted from its key features and design points. The strengths and weaknesses of the products already in the market are the target of this analysis in order to inform the design criteria.

Fig: Human Centered design process for medication reminder

Ideation and Design

For initial ideation we used critical brainstorming based on literature, existing product analysis, personas and scenarios, interview results etc. The ideas were continuously checked with our personas and scenarios, to see if any conflicts arose. The ideation progress were generating series of questions, to answer for each design, which in turn lead to new designs. Initially only whiteboards were used to sketch the prototype concepts. Later paper sketches were introduced, and finally photoshop. Existing product analysis helps us to understand and figure out the advantages and potential problems of the products in the market. Thus we can adapt some advantages, and overcome the problems while designing our concept.

Literature review
For the initiation of the project we looked at usability as a design goal. According to the ISO standards definition of usability of a product, it consists of three components; effectiveness, efficiency and satisfaction. These factors denote in turn: whether or not the product does what it is supposed to do, how good it performs and the users feeling of satisfaction with using the product, according to the ISO 13407. The usability factor in a design is important for a number of reasons including reduced launching cost , or rollout, cost of the product, increased acceptance of the product and growth of company.

Design methods and activities

The human centered design HCD paradigm is meant to produce designs tailored to humans., however there are several ways to achieve or implement HCD. The goal for this design project is to find and utilize an advantageous design method in designing for elderly. And even though the elderly are represented among the humans that HCD intends to design for, the different methods are more or less suited to this demographic. Therefore this literature review focuses on how HCD can best be applied with elderly users as target user group. Since this is a subject that is not well studied. (Newell et.al 2011) The in designing for elderly a longer time is needed for them to adapt to the design process concept and to feel comfortable.This theory is a basis for Empathic Design giving the elderly and the designers empathy for one another. (Demirbilek and Demirkan 2004) One other good reason to bring in the users in the design process is to avoid Design biases, because the user knows what the application of the product will be, what the best practises is without the product etcetera.

Universal Design
Universal design is a design paradigm focused on producing products usable for everyone, no matter age group, disabilities and other potential problems. (Demirbilek and Demirkan, 2004)

Limitations of elderly people

The first topic of review is the physical and psychological impairments of elderly. The sensitive nature of elderly people implies that not all standard HCD or UCD methods of submethods are suitable. The MIT AgeLab was created to creatively translate technologies and insights from behavioral sciences into practical solutions to improve the quality of life of older people and those who care for them. As part of that work, the AgeLab has created the Age Gain Now Empathy System, or AGNES, a suit that when worn mimics the physical restrictions of age. For example, elastic bands, knee-pads, wrist guards and a neck collar restrict movement in ways that mirror arthritis and spinal problems. Earplugs reduce hearing, yellow glasses diminish sight, and gloves hinder touch. The goal of AGNES is to help product and system designers, who are often in their 20s and 30s, gain insight into how older people negotiate the world (AGNES, 2012). This so-called silver tsunami stems from a seemingly unstoppable increase in longevity, driven in part by improvements in medical technology. American demographer James Vaupel has shown that human life expectancy in most advanced nations has increased in a linear pattern, rising by about three months a year for the past 170 years. Some experts think this trend will flatten out, but as yet it shows no signs of doing so (Silver Tsunami). Joseph Coughlin, director of the MIT AgeLab, said The baby boomers have moved from the once referred to generation gap in their youth, to an expectations gap in their later years. There are going to be far more older people in the future. Elderly people can be at increased risk from medicines for various reasons: The ageing body can be more susceptible to the side effects of medicines. Elderly people with multiple diseases can often end up taking multiple medicines at the same time. With multiple medicines, there is an increased chance of side effects, interactions between different medicines and problems taking them correctly. The physical effects of ageing, such as arthritis and failing eyesight and memory, can also cause issues in taking medicines the way your doctor intended. Medicines often have more than one name: generic name for the active ingredient of the medicine, and brand name which a manufacturer gives to the medicine. And once patents no longer protect the medicine, competing companies usually makes their own versions, which can lead to even more confusion in naming.

Existing Product Analysis

Existing products analysis comes to support, enlarge or contradict what is already accounted for. The strengths and weaknesses of the products already in the market are the target of this analysis in order to inform the design criteria. Nowadays, medication reminders can be classified into three categories: electronic reminder devices, telephone-based reminders, and reminders which integrated with personal emergency response system services. In this section, we will introduce three existing medicine reminder product, one example for each category.

GlowCaps (electronic reminder device)

GlowCaps (GlowCaps) is an electronic medicine reminder that produced by Vitality (see figure GlowCap). They fit popular prescription bottles available at drugstores and other retail pharmacies. Inside the GlowCap is a wireless chip that enables four services. GlowCaps use light and sound to signal when it is time to take a pill. When the bottle is opened, GlowCaps will sense and use wireless to relay bottle status to Vitalitys secure network. If the user does not take the medicine, which means not open the bottle after a scheduled dose, Vitalitys secure network will remind the user with a telephone call. GlowCaps can also call the user to refill pills when pills are deplete. Furthermore, Vitalitys secure network will send an weekly email report to the user, family member or caregiver about summarizing progress. The user and doctor will also receive a printed report every month.

Figure: GlowCap
GlowCaps provides sound and light feedback, as well as telephone call services to remind the user to take medicine. But there are still several potential problems for this product. First, this device only sense status of the pill bottle cap. But this status can not ensure the user has taken pills, or whether taking pills with correct quantity. Second, a telephone call after two hours is too late, especially for some

acute diseases. Third, one GlowCaps can only be used on one pill bottle, which means if the user need to take many different pills, several GlowCaps is needed.

CARE (telephone-based reminder)

CARE (Call Reassurance) is a community calling program provided by Database Systems Corp. (DSC). This program is used to contact home alone children, homebound residents and senior citizens, to ensure their well-being. CARE can deliver medication reminder calls to the user with a recorded message, reminding the user to take prescription medication. The reminder calls will greet the user with a recorded message in the beginning. Then the user is instructed to press 1 button on the phone to acknowledge customized information. These information include name, medication type, prescription dosage, number of times per day etc. If the user does not answer the phone or acknowledge the call for several times, CARE will automatically call the designated contacts with an alert message, and send alert email as well. CARE also provides a complete log of activity including the status of each call and schedule changes. Comparing with the telephone service of GlowCaps, CARE provides more detailed information, such as medication type, prescription dosage, and number of times per day. But elderly people usually have different distractions like hearing, seeing, memory, or sensing. Telephone-based reminders can only give the user sound feedback, which will be an issue for those elderly people with hearing problem. Furthermore, if the user has answered and acknowledge the phone call, but does not remember the reminded information detail for some reason, the program will assume the user has already taken the medication correctly. This may be a potential risk for the user.

Response LINK (personal emergency response system service)

There are some medication reminders which integrated with personal emergency response system service. These services are usually as wearable products, e.g. pendants and watches. One example of this kind product is Response LINK (Response LINK). Response LINK includes two parts: Medical Alert Pendant and Medical Monitoring Panel. The Medical Alert Pendant (see figure MAP) is used to send an emergency signal to central monitoring station. The user only needs to press the button on the pendant if emergency situation happens. There are four major buttons on Medical Monitoring Panel (see figure MMP): A) Emergency Button - sends an emergency signal to central monitoring station; B) Call Button - Calls central monitoring station for non-emergency events; C) Check Button - Used to respond to medication reminders, answer phone, announce time; D) Speed Dial / Direct Link Automatically dials programmed phone number.

Figure MAP

Figure MMP

Among the above three existing medication reminder products, Response LINK probably has the weakest functionalities since medicine reminder is just a subsidiary function of this product. It will only give the user sound alarm, lacking of enough information detail and other feedbacks. Thus as a medicine reminder, Response LINK has most of the potential problems of the other two products.

Interview
To explore the reality of the problem, as well as possible solutions, an interview were conducted. The interview were conducted in the form of a guided interview (IDEO, 2009). This means that the base for the interviews were a questionnaire, and that the target of the interview never saw the actual questions, they were rather filled in by the interview leader while he had a more free-formed discussion with the subjects. This was done because of the age of the subjects, it was suggested[] that the use of surveys might give a lower response rate. Another reason to do this is the obvious opportunity to tailor the questions to get extra value from the interview from the subject ad-hoc. This can, if not due consideration is given to the possibility of affecting the subject, give a skewed response profile.

Realisation
The questions asked were about three different areas of interest. The first was about age and how that related to disabilities. The second area concerned medication, how many different medications they were taking, how many times per day they were taken, etcetera. And thirdly, how often they forgot to take their medication, and if,

and how, they reminded themselves about their medications. The interviews were conducted at Hjalmar Brantingsplatsen on a Wednesday afternoon. These circumstances were chosen from the estimation that the availability of interview subjects of the right age group, with the time to participate would be good. In addition to this it is both a shopping area and a public transportations connection point. This would give a broad variety of people with different backgrounds generating a fair base of subjects, we argue. The subjects were asked randomly to participate in the interview. The random subject requests resulted in five interviews, out of twenty-five inquiries.

Evaluation
Some of the negative answers are, naturally, based on lack of time and a slightly negative attitude towards being bothered. But from some of the more expressive negative responses, we found that medication was a subject not willingly discussed with a stranger, the interview conductor. Analogous with the statements of Demirbilek and Demirkan (2004), about elderly users needing time to be incorporated in the design process, the resulted in a quite small sample size, from a statistical point of view. The type of data gathered was, on the other hand, more qualitative, with statements and examples from the subjects' lives. The fact that the questions were answered in a discussion format gave more qualitative data, both in the actual answers, but also in the interviewers, albeit subjective, view of the subjects attitude and feeling of the questions asked. The main conclusion from the interviews was that people, to a relatively large extent, thought of reminders for medication purposes were unnecessary. This came from the fact that all but one of the interview subjects stated that they always remembered to take their medication on time, and that they relied solely on routine to do so.

Personas and Scenarios

In this section, we will introduce more detail about personas (Mr. and Mrs. Smith, and Mr. and Mrs. Johansson) and the scenarios which we arranged for them. In order to distinguish our personas, we designed them in different characters, experience, backgrounds, hobbies, restrictions, and diseases etc. The scenarios are also set in different scenes.

Persona 1:
Mr. and Mrs. Smith have been living in their own apartment for the last 6 years in Gothenburg, Sweden. Mr. Smith will reach his 70 in the next December and Mrs. Smith just had her 68th birthday celebration few months back. Mr. Smith used to be a banker and Mrs. Smith worked in the city museum of Gothenburg. Now that they are living their retired life, Mr. and Mrs. Smith spend a lot of time staying home and watching tv, running errands and doing chores. They stopped travelling abroad and hardly travel to other swedish cities. Sometimes they attend the community events and activities to socialize with the people from the neighbourhood. Mr. and Mrs. Smith are always interested in new technologies, products and they are proficient with using computer software and internet. Recently, Mr. Smith has been diagnosed with diabetes and mild hearing loss. He is also having problems with remembering small things such as taking medicine in time, news highlights from morning tv show, following diet plans as per the physicians advice or going for any outdoor tasks unless Mrs. Smith reminds him about it. So, whenever Mrs. Smith is outside the house sometimes, she worries about Mr. Smith specially when it is about taking the right medicine at the right time. Moreover, Mrs. Smith also encounter minor common aging problems at times and she also follow some medication plan for that. Sometimes they wish there was a product that could help them reminding about each others medication schedule.

Scenario 1:
On a sunny summer morning, Mrs. Smith went out for buying groceries and household items. She met one of her colleagues after so many years while parking her car outside Coop Forum. Her Colleague invited Mrs. Smith for lunch and she would really insist if Mrs. Smith wants to return to her place as soon as possible as Mr. Smith might forget to take his medicine. So, she calls up Mr. Smith to remind him about the medicine and also to tell him that she is going to be late before she

returns home. Mr. Smith assures her that he is not going to forget to take medicine. Mrs. Smith also reminds him about which medicine to take and how those look like as there are a variety of pills and Mr. Smith might mess it up. After an hour or so, Mrs. Smith calls again to check out whether he took the right medicine in right time?

Persona 2:
Mr. and Mrs. Johansson are a couple in their mid 70's living in Malm, Sweden. And lived their entire lives in the south of Sweden, and don't like traveling too much. They had three children in their late 30's who are now having started families of their own. Lately Mr. and Mrs. have started suffering from old age, lowering their mobility and eyesight. In spite of this they still have cared much to their home, a self-contained house in the outskirts of the city, with activities like gardening and cleaning gutters. This makes them quite active, and makes their schedule inconsistent. One of their few fixed activities is viewing the SVT show "P Spret". They have a computer, that they got from one of their children, which have never been used. They are not tech savvy at all, and will never buy smartphones, they don't even like the digital thermometer they have in the window, and will never replace their old plastic egg-timer with a digital one. They are both retired, he from driving a cab for Taxi Malm and she from being receptionist at an office. They don't take a lot of medicine, and haven't taken medicine for very long and because of this they sometimes forget to take the medications. She takes medication for her eyes every morning and night. He doesn't take any medication except from vitamins, which only are preemptive, but he still would like reminders to take them every day.

Scenario 2: In vacation environment

Mr. and Mrs. Johansson from are going to their youngest son's wedding in Denmark. This means that they will have to take all their medications with them and leave home for the three day feast. They will take a train and arrive Copenhagen at 1 pm in the first day. Their son will pick them up at the railway station. They will go to the hotel first, check in and leave with their baggages. After that, they will visit several famous scenic spots in Copenhagen, e.g. Little Mermaid Statue. Mr. and Mrs. Johansson are looking forward to take some photos with it. In the evening, they will have meal with their son and bride. The second day is the wedding day, and will be a very busy day. The wedding ceremony is at 2 pm in church. Mr. and Mrs. Johansson will help to prepare the wedding ceremony a bit in the morning. After wedding ceremony, they will go to the hotel together with all guests and have dinner. The dinner party will last until 10. In the last day, Mr. and Mrs. Johansson planned to have a picnic with some relatives in a park. They will take a train back to Sweden around 6 pm.

Design
Unlike children, it is difficult to find stereotypes amongst elderly people as this user group has a comparatively longer age range and higher standard deviation in their behaviour and activities. Some elderly people are still as active as their late youth where as some of them really struggle to keep up the physical and mental fitness. However, elderly people are comparatively more vulnerable in general than any other age group. So, it is crucial to understand their feelings towards products, their needs and desire. We started off with analyzing the core tasks that a medicine reminder must perform and reflecting on that. At this point core tasks were identified as below: 1. Remind the user about taking medicine using sound/ light and vibration 2. Supplying the pills to the users as they set it up 3. Performing functions when the user forgets to take medicine. Core tasks helped us with providing a starting point of brainstorming about the design decisions we made for the final product. The device should help a couple to remind each other about taking medicine. However, it is not necessary to involve both of them for the operations to run. We decided to design it as an independent device as it would be mostly used in home environment as found from context of use analysis. Reminding each other about medicine is a cross functional activity for the user and at the same time they have to take their own medicine which might overwhelm the users. We decided to design them as independent device and leave the function of reminding each other on the users. In allocating what features the reminder should have, we chose to have the product do only reminding about the medicine, and be programmed to set the reminders. This concept was combined with an existing design for a medicine organizer. This was done to keep the users mental model as close to the currently most common way of storing medication. Since most users, during the interview, expressed scepticism towards a technical solution, we chose to let the medicine be stored in a

static way, contrary to some of the existing products that by rotation or other mechanics dispense the medications. In our prototype, we decided on designing two digital interfaces, one being the programmable for setting reminder, medication plan etc. and the other always shows the time remaining for the next medication. The second interface is set by the side of the device which is visible only from a side view. The reason for that is to always provide the user an estimation of time before the next medication, no matter what part of a room (s)he is at any given moment. The exact amount of time might not always be important for the user, however, it works as an ubiquitous notifier of medication obligations. Beside that, the device has both sound, light and vibration signal to support accessibility(vision, hearing problems etc). The user has complete control over customizing the device with preferred notification type. The medication device can keep records for missing doses that a caretaker can check anytime later . As a connected device, it can also send message to the caretaker if the user misses a dose and in that case the caretaker calls the user to remind about it. The form of the medication device were inspired from the popular non-digital medication container called dosette. The other reason behind designing dosette like device is to using the users existing mental model of a medication reminder box.

Fig: The Prototype for medicine reminder and the side view on the right

The functionality thought around the designed reminder has been kept simple. There are slots to keep pills for one whole week. And the slots are divided into four different times of the day. The caretaker or the user keeps pills first as per the prescription of the doctor. Then they have to set alarm type and medication time using the keypad and interface(detail keypad design has been avoided as it is outside the course scope). a subtle green glow indicates the user which slot to take pills from. The indicator moves according to the program set through the interface.

When there is an alarm, the user approaches the device, just turn off the arm and the pill slot comes out like a CD tray.

Conclusion
The interviews did not give as much data as we hoped. The most likely reason for this was that the participants did not feel that the interviews were intrusive. As suggested by the Empathic design paradigm, the subjects need more time adjusting to participate in a design process. The number of sessions with each participant would be increased to get a more deeply rooted connection to the design process, but due to time and personnel constraints, and the unwillingness among subjects to participate on scheduled occasions at predefined locations without extra motivation. For the level of physical and mental constraints, along with age related diseases, we recommend Universal Design. That bases the accessibility and usability to the worst case scenario, rather than defining hard constraints on the elderly. Also, longer contact with the users should be made. To bring the design to be more empathic.

References
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