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A Survey of Tablet Applications for Promoting Successful Aging in Older Adults

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A Survey of Tablet Applications for Promoting Successful Aging in Older Adults

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‘‘Successful Aging’’ or aging well, as defined by Roweand Kahn, encompasses the following aspects: absence ofdisease, maintenance of physical and cognitive health, andactive social engagement [1].

However, studies have shownthat the majority of older adults (persons aged 65 years andabove) do not meet this criterion of ‘‘Successful Aging’’ [2]for a number of reasons. Firstly, this definition fails toacknowledge older adults with chronic conditions and func-tional disabilities, who self-report aging successfully [3].Secondly, chronic conditions are inevitable with age [4].Therefore, a true definition of ‘‘Successful Aging’’ needs toinclude management of chronic conditions, along with themaintenance of physical, mental health and socio-emotionalhealth (Figure 1).Advances in public health interventions and medicine haveled to a significant increase in life expectancies and thenumber of older adults worldwide. In United States, thenumber of people 65 years and above will approximatelydouble from 38.9 million in 2008 to 72.1 million by 2030 [5].In Europe, the number of people 65 years or older will risefrom being 17.1% of the total population to 30.0% by 2030,and even higher in countries such as Japan and Spain wherelife expectancies are abnormally high [5]. Some challengesassociated with this projected increase are:•Increasing healthcare costs: The healthcare cost asso-ciated with the treatment of an older adult is three to five times higher than that of an average age adult [6], witha projected 25 percent increase by 2030 [7].•Increasing dependency ratio: This ratio describes thenumber of individuals between 15 to 64 years [8] who are available to care for people aged 65 years andolder.•Decreasing number of direct healthcare workers(nurses, home-health workers): This has been linkedto high-stress, low salary, and poor work benefits [9] ofthe existing workforce.•Increasing number of informal care-givers (familymembers providing care). This is the direct conse-quence of the above two factors and has been associatedwith high stress and health decline of informal care-givers. In addition, the caregiving family members sac-rifice wages. In fact, theemployersin the United Statesare estimated toloseabout 33 million dollars due toabsenteeism of these care providers [10].In this era of technological innovation, the potential of tech-nology is being explored to overcome these challenges. Morespecifically, it is being used to bridge the gap between olderadults and the care providers, and to empower the olderadult to take charge of their own health. This advancement ismarked with a gradual increase in the number of older adultsadopting tablet technology [11]. Tablet appeals to them dueto its portability, and absence of external hardware such as amouse and a keyboard [12], [13]. In fact, using technology tosolve their everyday challenges is helping older adults realizethat they can use tablets to stay independently in their ownhomes as long as they can. As a result, applications address-ing more specific aspects of ‘‘Successful Aging’’ are beingdeveloped and studied [14]. Examples include medicationmanagement applications that empower the older adults tomanage their medication intake for improved physical health;and online social networking sites and forums that help olderadults stay socially engaged and connected for better socio-emotional health

A. LIMITATIONS AND OPPORTUNITIESAll the studies evaluating tablet usability amongolder adults [12], [13], [19], [20] were conducted aroundthe same time (2012-2013), with the same tablet technology(iPad) and similar age groups. However, the studies wereconducted in different settings (laboratory, home, home-careand work) and with different sample sizes. Qualitative usabil-ity measures (observations, focus groups and interviews)were used for evaluating the usability of these tablets. Futureresearch can benefit from objective usability metrics: taskcompletion time, number of errors committed, and numberof successful tasks. Research has been conducted to evaluatespecific tasks (dragging, pointing, pinching) on a touchscreenusing these quantitative measures [21], [22]. However, thesestudies were conducted with applications designed specifi-cally for performing study tasks.The existing studies were conducted with earlier versionsof iPads [12], [13], [19], [20]. The tablets have drasticallyevolved since the time these studies were conducted. Theseimply that the disadvantages regarding tablet adoption (heavyweight and screen resolution) could probably be already out-dated. Tablets have become lighter and slimmer, suggestingthe weight issue identified in [13] may have been alreadyresolved. Tablets have become cheaper due to advances intechnology and increase in tablet popularity [11]. The price ofa tablet has been reported to be a challenge in tablet adoptionamong older adults [13], [20]. Further, the memory/storageof a tablet can now be extended with external storage cards(SD cards) countering the storage limitation. However, wemight need to address new challenges due to differencesin tablet specifications [weight, resolution, size], includingimpact on touch sensitivity, font size and various other aspectsof usability. Stronger and effective conclusions about theusability of new releases of tablets could be reached by usinglarger sample, by evaluating performance using quantitativemetrics available for usability evaluation and by compar-ing tablets with different specifications [operating systems(Apple, Android and Windows)].The results should be further analyzed with respect todemographic variables (age, gender, years of education) andexperience using tablet/technology because computer knowl-edge, computer anxiety, and learning ability are found tobe influenced by these factors [28]. Moreover, longitudinaltablet studies could be conducted for capturing any fatiguearising from prolonged usage and for studying the effect ofchronic conditions that affect mobility, visual senses, andbones (finger movements). Code Shoppy The tasks used for evaluation werepredefined for the studies. In longitudinal studies, we caninstall an application for capturing application usage (appli-cation name, and duration of usage for the application) toidentify application usage frequency and popular categoriesamong older adults. Though one of the present studies [20]identified the popular application categories, it was onlybased on the qualitative data (interviews and observations).A combination of qualitative and quantitative analysis canhelp us better understand tablet use among older adults.

There exist many direct and indirect measures of medi-cation adherence [36]. Some of the direct methods includemeasurement of biological markers in blood and direct obser-vation therapy. While these direct methods provide accurateestimation of medication adherence, they are quite expen-sive and could be invasive. The indirect methods includeelectronic medication dispensers and pill counting. Thesemethods are fairly inexpensive and can act as a good proxyfor estimating medication adherence. However, these have adependency on the reliability of the users because there isneither tracking of the actual intake of the medication nor anyinvolvement of direct physiological measurement.Prior to the introduction of iPad in 2010 and the subse-quent popularity of tablets, mobile phone applications weredeveloped for medication management. The majority of theseapplications were standalone with no integration with the careproviders. Text-based mobile-based medication remindershave been proven to be effective in improving medicationadherence [37]. One of the earliest smartphone applicationfor medication management developed for older adults isUbiMeds [38]. Its design was based on the literature reviewof the issues associated with medication non-adherence. ThisiPhone-based application provides automated reminder withan image of the medication, directions, dosage and a buttonfor confirming intake. If a medication is missed, it informsthe physician. The application is linked to the user’s personalhealth record (PHR) where prescription/medication infor-mation can be directly updated by the clinician. Further, itprovides information on side effects and additional dosageinstructions for the prescribed medications. The applicationwas not evaluated for usability and effectiveness in improvingmedication adherence.A few tablet-based medication management applicationshave been specifically developed for older adults [39]–[41].The majority of these applications have been developed usingan iterative, user-centered design approach with the olderadults as the target users. For example, prior to the develop-ment of Mediframe [39], a quantitative study with 360 olderadults and a qualitative study with nine older adults wereconducted for identifying the issues with medication adher-ence [42]. These studies have found that forgetting to takemedication, lacking knowledge about a medication and notgetting support from a care provider are some of the importantchallenges in adhering to medication regimens. The primaryfeature for these applications is to provide reminders whena medication is due. Some of these applications allow usersto customize these reminders [39]. Usually, these remindersprovide a list of the medications due at a particular time, alongwith the dosage information, image of the medication andwarnings (if any). The user is required to confirm the intakeof a medication.Only one application (ALICE) has been evaluated for itseffectiveness in improving medication adherence [40]. Arandomized control trial was conducted for 3 months with 102older adults, equally divided into experimental and controlgroups. The participants having multiple chronic conditionsand taking multiple medications, and capable of managingtheir medications by themselves, were included in the study.The participants filled out a custom questionnaire for evalu-ating the rate of missed does and medication errors, 4-itemMorisky Medication Adherence Scale (MMAS-4) [43], andperceived health status at the beginning and at the end ofthe study. The participants in the experiment group receivedthe ALICE application installed either in a Wi-Fi enabledAndroid or iPad tablet. The participants in the control group,on the other hand, only received information on the risks asso-ciated with their medications and the common medicationerrors.Even though the majority of the participants requiredassistance in navigating ALICE despite initial training, theyfelt that using ALICE has improved their medication intakehabit. The study found an increase in treatment adherence(as measured by MMAS-4) and a decrease in number ofmissed doses among the participants in the experiment groupat the end of the study. However, there was no statisticallysignificant difference in the reduction of medication errorsfrom the beginning of the study, when compared to that at theend of the study for both experimental and control groups.Further, a statistically significant difference in cholesterollevels were observed, even though there was no change in thelevels of glycated hemoglobin, blood pressure and perceivedhealth status for all the participants at the end of the study.A positive and significant correlation (Pearson’s) measuringpatient compliance was observed between MMAS-4 and themedication reminders generated by ALICE.A few applications, specifically for older adults have beendeveloped for minimizing medication errors and improv-ing knowledge about medications. Studies have shownthat if a person has knowledge about his/her medications,he/she would take medications as directed, thereby adher-ing to his/her medical regimen [36]. One such applica-tion for minimizing medication errors is Colorado CareTablet (CCT) [44], [45]. CCT, a tablet-based application formedication management during care transitions, was devel-oped using an iterative, participatory design approach forminimizing medication errors. A user can enter medicationsby scanning the barcode for the medication, manually usingthe code or selecting recently picked ones from the pharmacy.The user can easily access information related to a medication(retrieved from National Library of Medicine’s MedlinePlus).The application can generate memo (containing the list ofcurrent medications and related potential questions that theuser may ask) for promoting effective communication withthe physician. Further, it can generate notifications for criticalcare assistance.Tumedicina (YourMedicine), a smartphone-based and tab-let-based application, allows older adults to scan the EAN-13(barcodes) and QR codes on the medication packaging [46].Upon scanning, the application displays the name, dosage,instructions for use, warnings if any, expiration date and thenext visit to the physician. This information is also avail-able in audio format. A study with 61 older adults (average age of 68 years) was conducted for user evaluation of thisapplication. The participants found Tumedicina easier to useand verbal messages simple and clear. There was no differ-ence in satisfaction between participants with no or previoustechnology experience. The application was best valued byparticipants who had used pillbox or packaging notes formanaging their medications

The majority of these applications provide no connec-tivity with the care providers/clinicians [39], [41]. Thiscommunication is very important to gather reasons for non-adherence. Moreover, this communication is becoming par-ticularly crucial with the increase in older adults [5] andcontinual decrease in the number of care providers [8], [9].Only ALICE reports the number of missed doses and med-ications taken to the clinician and the care provider, listedby the user using 3G service at the end of the day [40].However, it does not provide any reason for the missed dosesor medications. Moreover, these applications do not providealternate functionality for providing responses to a medica-tion reminder, in case this reminder is overridden [47]. Themajority of these applications require the medication list tobe entered by the older adults themselves [39], [40]. However,the participants in the study for evaluating ALICE had theirprescription information preloaded in the application at thebeginning of the study. S4S Medical Assistant [41] created athird party service for allowing care providers to enter thislist. This medication entry is a complex and cumbersomeprocess, given the complex medical regimen for older adults.This process could demotivate the older adults from using theapplication. These medication management applications donot provide offline usage functionality, which could becomean important limitation when deploying these applications ina low socioeconomic group.The majority of the studies evaluate the usability of theapplications [38], [39], [44], [46]. However, there is onlyone study that evaluated the effectiveness of the applicationin improving medication adherence using experimental andcontrol groups [40]. The study demonstrated a potential forusing tablet-based applications for medication management.There was an improvement in treatment adherence and reduc-tion in medication errors at the conclusion of the study.However, the study only measured unintentional medicationerrors. As there is no gold standard for measuring adher-ence [48], a combination of different methods should be usedfor measuring this adherence. Moreover, people, sometimes,do not take the prescribed medications purposefully, evenwhen they do remember to take the medication. The power oftechnology (scanning barcodes or QR codes) or even submit-ting pictures of the intake could be employed as secondarymeasures for measuring adherence. In addition, physiolog-ical measures could be used for evaluating the effective-ness of these applications in improving/maintaining medi-cation adherence. Few such measures including cholesteroland blood pressure were used in the evaluation of ALICE.However, these measures cannot be generalized because theydepend on an individual’s chronic conditions.

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