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EVIDENCE-BASED RATIONALE

Evidence-Based Rationale

Navjeet K. Lehal & Lou N. Luis

School of Occupational Therapy, Pacific Northwest University of Health Sciences

OTH 535: Environment, Technology, and Occupation

Dr. Wendell Nakamura

April 9th, 2024

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EVIDENCE-BASED RATIONALE

Evidence-Based Rationale

Intervention Plan

The interventions for our client to address her concerns have been prescribed the

LiveFine® Frosted Automatic Pill Dispenser (LFAPD) and a mindfulness checklist. The client's

largest concern was managing her medication, specifically taking her pills on time with the right

dose. The LFAPD has many features that will address the client's concerns. The pill dispenser

has a capacity of up to 28 compartments with rings that can indicate the number of dosages,

which can go up to nine. The client takes her pills twice a day so her medication will be pre-set

for two weeks at a time. She will choose when the alarm will be set twice a day at the which will

cue her to take the medication. The device will be addressing her deficits in her process skills of

sequencing, organizing, and planning to participate in successful medication management. The

client will need fine motor skills like pincher grasp and palm-to finger translations to manipulate

the medication. Additionally, she will need upper extremities strength to lift the pill box. Lastly,

she needs a functioning neuromuscular system to have control and precision of her wrist to

pronate the pill out of the dispenser and into her hand.

The second intervention will be a mindfulness-based checklist focused on cooking. It will

consist of different tasks meant to be completed around the time of cooking. Mindfulness will

help the client stay in the present moment while she is completing the tasks. The mindfulness

checklist is the size and shape of a standard paper. It will be marked off for breakfast, lunch, and

dinner. It is color coded, yellow for breakfast, green for lunch, and blue for dinner. There are 12

rows that should be checked off every day while completing the cooking task. There are columns

for Monday-Sunday. The tasks include turning off all appliances that need to be turned off,
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donning safe clothing, handling hot dishes with care, and knowing where the fire extinguisher is

and how to use it. We will use her input to determine the location of the mindfulness checklist to

best fit her routines. We want to place it in a location where she would be reminded to use it.

This intervention will address the concern of safety awareness around cooking. The intervention

will assist the client in being more mindful while cooking which will increase her safety

awareness.

A performance skill that the mindfulness checklist compensates for is sequencing. The

steps for aspects for the process of cooking are stated in plain language and in a logical sequence.

The device also compensates for the termination of the task. The mindfulness checklist reminds

the client what steps they need to complete during and after cooking. The client will

notice/respond to any steps that she missed. The client will still need to notice/respond to the

mindfulness checklist and recognize that she needs to complete it after cooking. She needs to be

able to use and grip a pen or pencil that will be used to complete the mindfulness checklist. She

will need to know where she last left the mindfulness checklist so she can complete it for the

next meal (American Occupational Therapy Association [AOTA], 2020).

Human Activity Assistive Technology (HAAT) model

Human

Employing the HAAT model means considering the client’s physical, cognitive, and

somatosensory functions when deciding between various devices that are the most appropriate

for the client. To use the pill dispenser the client must show ability in a few functions. The

client's auditory and visual capabilities remain unaffected. Throughout the assessment there were

no signs of hearing impairment. However, the client needed to bring her face closer to the paper

to read extremely small text subjectively. Apart from this, her visual abilities remain unaffected.
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Neuromuscular functions required for operating the electronic pill dispenser are present. During

the evaluation, the client demonstrated proficiency in utilizing precise tip-to-tip pinch and palm-

to-finger translation techniques while handling the mock medication, in this case beads. The

client's dysfunction remains in her cognitive function, which is why a typical pill dispenser is not

probable for this client (Cook et al., 2020).

Additionally, to utilize the mindfulness checklist the client must have some intact body

functions. Her mental functions are affected by the mild cognitive impairment, but she can

complete simple tasks. This is clear from how she completed the Cognitive Performance Test

(CPT). She will be able to visually see her mindfulness checklist as well as read and understand

it. She may need some further clarification if she is not sure what the task is asking her to do. Her

voice, hearing, and neuromusculoskeletal functions are unaffected to use the mindfulness

checklist (Cook et al., 2020).

Activity

Utilizing the HAAT model means an activity analysis is done to ensure that the

intervention addresses the why, how, temporal, and where (Cook et al., 2020). The client takes

medication that assists with her diagnosed hypertension. She needs to maintain her scheduled

medication to ensure that her blood pressure remains at a normal level. The client states that she

has an unreliable support system so 90% of the time she will be sorting her medication on her

own. Her medication requires her to take her medication twice a day, once in the morning and

once before bed. The client states that she keeps her medication in the master bathroom, and it

stays on the counter. The client's capacity to participate in this activity means that she can be

independent and live in her own home to take care of herself.

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EVIDENCE-BASED RATIONALE

The client will complete the mindfulness checklist by marking it on the paper after she

has completed cooking for breakfast, lunch, and dinner. The four aspects must be checked off to

be complete. She will be using her fine motor skills to grasp the pen and check off the boxes. Her

mild cognitive impairment may impact her ability to remember to complete the tasks. The

mindfulness checklist's placement will be important to cue her to follow through on completing

the cooking task. Her self-efficacy will determine her ability to complete the mindfulness

checklist. The client will have occupational satisfaction when she follows the mindfulness

checklist (Cook et al., 2020).

Assistive

The classification of the electronic medication dispenser includes mainstream technology, low-

tech, and hard technology. The client stated disinterest in a device that was too hard to

comprehend which translated to little human/technology interface (HTI) and an easy processor

interaction (Cook et al., 2020). The LiveFine® Frosted Automatic Pill Dispenser provides more

HTI during the set up and alarm setting then there is little interface.

The mindfulness checklist is easy to understand, use, and learn. The device is efficient,

and it will be easy to remember how to use it once we decide on a location that fits the client's

routines. If the client makes an error, they may self-correct. We will do short- and long-term

follow-up to ensure she can use the low- tech. We will keep up on her goals by asking about

satisfaction and psychosocial impact (Cook et al., 2020).

Context

Incorporating the electronic medication box and mindfulness checklist allows the client

to remain in her home longer as she values her independence. The physical context that affects

the client for the mindfulness checklist is the layout of her home. If we decide to place it in a
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spot she normally does not access, she may forget to use the device. It should be placed in a spot

that she comes across naturally and frequently. The social context does not impact her greatly;

she rarely visits people from her church. If people do come by, they may be able to remind her to

use the devices. The cultural context may influence how often she interacts with the device

(Cook et al., 2020). She does not like to use devices that are “too techy” as stated during the

home visit.

Addressing Occupational Performance Deficits

Performance patterns

The electronic medication box intervention helps patients manage their medications by

establishing routines for organizing and taking their doses. The new routines will be embedded

into pre-established routines by choosing the times the alarm goes off and the location of the

box. The mindfulness checklist initiates the habit of checking off the items for cooking. She will

always turn off the appliances she used after seeing it on the checklist. She will wear safe

clothing and handle all hot dishes with care.

Performance skills

Reiterating the client's concerns were (1) wanting to take the right dose of her medication

at the right time of day and (2) improved safety awareness in the kitchen. The electronic pill

dispenser improves participation by having her medication prepped every two weeks and allows

choosing what to take an easier task. Then the pre-set alarms (done during intervention) initiate

the client to take medications on time and prompt them to where the medication box is in the

house. The performance skills that the mindfulness checklist addresses are sequencing, attends,

handles, notice/responds, and termination. The mindfulness checklist addresses the sequence of

steps needed to practice safety awareness around cooking. She attends to and handles hot
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dishware and utensils. She notices/responds to any danger that is sensed such as a fire starting in

the kitchen or accidentally touching a hot item. The checklist terminates the process of cooking,

it is the last step to be completed (American Occupational Therapy Association [AOTA], 2020).

Client factors

The client factors addressed by the electronic pill dispenser and mindfulness checklist are

mental and sensory functions. She needs to use her attention and memory to attend to the task

and remember to use it. The client needs awareness of self and time to recognize the alarm to cue

her to take her medication and to complete the mindfulness checklist while cooking. She needs

the energy to cook and take her medication. Her visual functions must be intact to look at the

mindfulness checklist and mark off for the meal she just prepared and find her electronic pill

box.

Environment

Considering the client lives in a two-story apartment, the prescribed device needs an

alarm system loud enough to be heard across the home. It’s an important feature so the client can

be reminded of it in any part of the home. Furthermore, we need to decide the placement of the

mindfulness checklist with the client, so it is in a location that is easily accessible by her. The

type of food she cooks will determine if she needs to check off some of the boxes. An example

of this is if she made a cold sandwich, she would not need to turn off appliances. The number of

times the church community and meals on wheels comes by will influence how often she cooks

in the kitchen.

Evidence-based Practice
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Being evidence-based in practice ensures that the clients have the most updated and

effective treatment, as it is one of the principles of occupational therapy practice. Patel et al.,

(2020) focused on the usability and workload of electronic medication adherence products by

older adults. The LiveFine® system demonstrates moderate usability, as indicated by the system

usability scale (SUS) score of 46.50 (SD 27.38; range 10-85) falling a little below the mid-range

and the NASA-TLX score of 65.21 (SD 21.32; range 32.50-99.17) suggesting a moderate to high

task load. The workload of 18 minutes and 22 seconds indicates the average time required to

complete tasks, while the error rate of 17% suggests room for improvement in accuracy.

However, the mean unassisted task completion rate of 70% and the mean completion rate of 90%

indicate that most tasks were completed successfully, with some assistance needed in certain

instances. Overall, there is potential for enhancement in usability and efficiency, particularly in

reducing errors and improving task completion rates without assistance. While the results aren’t

optimal, a limitation of this study is that the participants had no prior exposure or training to each

device. Our client will receive training on the device to ensure their understanding.

Tellier et al. (2020) found when utilizing a similar electronic pill box, the DoPill® found

that after a 12-week training program, medication adherence was over 80% with participants

with mild Alzheimer's. The DoPill® is like the LiveFine® and has 28 available compartments

with an alarm system. The main difference is that the LiveFine® uses batteries whereas the

DoPill® has a connector for a power outlet. When training is administered adherence rates are

within an optimal range for participants with mild cognitive impairment. For older adults who

used an electronic pill dispenser for 3 or more years found has the potential for long-term use by

older adults with Alzheimer's who do not have moderate or severe cognitive impairment (Patel et

al., 2020).
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EVIDENCE-BASED RATIONALE

Lastly, mindfulness is a practice that increases wellbeing and psychological symptoms. It

promotes focusing on the present moment rather than being in the past or future. Additionally, it

has been supported by growing evidence in literature for older adults with mild cognitive

impairments. Newer studies have integrated mindfulness as an intervention for psychological

well-being for individuals with cognitive decline. After the intervention, it was noted that clients

showed substantial progress in anxiety, stress, and quality of life (Rose Sin Yi et al., 2023).

Mindfulness-based interventions created positive changes in brain structure and greater

interaction between different parts of the brain. Additionally, it increased global cognition (Leow

et al., 2023). A 9-week mindfulness training program led by occupational therapists decreased

anxiety levels in older adults (Tran et al., 2023). Although these studies did not show significant

results, they showed notable improvements in areas such as anxiety, wellbeing, and stress. This

is why we are implementing the electronic pill box along with the mindfulness checklist. Using a

combination of methods will make the intervention stronger.

References

American Occupational Therapy Association. (2020). Occupational Therapy Practice

Framework: Domain and Process—Fourth Edition [none]. American Journal of

Occupational Therapy, 74(Supplement_2), 7412410010p1-7412410010p87.

https://doi.org/10.5014/ajot.2020.74S2001
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Cook, A. M., Polgar, J. M., & Envarnacao, P. (2020). Assistive technologies: Principles &

practice (5th ed.). Elsevier.

Kamimura, T. (2019). Older adults with Alzheimer's disease who have used an automatic

medication dispenser for 3 or more years. Clinical Gerontologist, 42(1), 127–133.

https://doi.org/10.1080/07317115.2017.1347594

Leow, Y., Rashid, N. L. B. A., Klainin‐Yobas, P., Zhang, Z., & Wu, X. V. (2023). Effectiveness

of mindfulness‐based interventions on mental, cognitive outcomes and neuroplastic

changes in older adults with mild cognitive impairment: A systematic review and meta‐

analysis. Journal of Advanced Nursing, 79(12), 4489-4505.

https://doi.org/10.1111/jan.15720

Patel, T., Ivo, J., Faisal, S., McDougall, A., Carducci, J., Pritchard, S., & Chang, F. (2020). A

prospective study of usability and workload of electronic medication adherence products

by older adults, caregivers, and healthcare providers. Journal of Medical Internet

Research, 22(6), Article e18073. https://doi.org/10.2196/18073

Rose Sin Yi, L., Jing Jing, S., Hammoda, A. O., & Jonathan, B. (2023). Effects of mindfulness‐

based interventions on neuropsychiatric symptoms and psychological well‐being on

people with subjective cognitive decline and mild cognitive impairment: A meta ‐analysis.

International Journal of Geriatric Psychiatry, 38(8), e5986.

https://doi.org/10.1002/gps.5986

Tellier, M., Auger, C., Bier, N., & Demers, L. (2020). Use of an electronic pillbox by older

adults with mild Alzheimer's disease: Impacted on medication administration and

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adherence. Gerontechnology, 19(1), 66–76.

https://doi.org/10.4017/gt.2020.19.1.007.00

Tran, T., Finlayson, M., Nalder, E., Trothen, T., & Donnelly, C. (2023). Occupational

Therapist-Led Mindfulness Training Program for Older Adults Living with Early

Cognitive Decline in Primary Care: A Pilot Randomized Controlled Trial. Journal of

Alzheimer's Disease Reports, 7(1), 775-790. Https://doi.org/10.3233/ADR-230006