U.S. Department of Health and Human Services

Assistive Device Use Among the Elderly: Trends, Characteristics of Users, and Implications for Modeling

Executive Summary

Brenda C. Spillman

The Urban Institute

September 2, 2005

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officers, William Marton and Hakan Aykan, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Their e-mail addresses are: William.Marton@hhs.gov and Hakan.Aykan@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

An intriguing aspect of recent declines in elderly disability is the increased use of disability-related equipment, or assistive devices. Studies consistently have found declines in the overall disability rate among older Americans, with larger decreases in independent living activities, such as meal preparation and shopping, associated with lower levels of disability. Several national surveys also show declines since the mid 1990s in help with personal care activities, such as bathing and toileting, associated with more severe disability. Evidence is less clear, however, when personal care disability is defined to include use of assistive devices, because of the rising prevalence of equipment use. For only one activity, bathing, was an upward trend in the prevalence of equipment use associated with a downward trend in the prevalence of help.

A number of factors argue for the need to better understand the trend in device use and its implications for the growing older population. Research provides evidence that assistive devices may substitute for human assistance under some circumstances, although the full scope and implications of such substitution is not yet known. Nevertheless, if equipment use reduces or removes the need for help from other persons, it may reduce the demands of disability care on both families and public programs, and increase independence and quality of life for elders with disabilities and may have other desirable outcomes. Better understanding of trends may help identify where interventions to promote access to disability equipment may be most effective.

This study has four primary aims:

• To update information on trends in use of disability equipment, using data from the 1984 through 1999 rounds of the National Long-Term Care Survey (NLTCS), which has been a key source of earlier information on trends in equipment use.

• To describe differences in characteristics of equipment users and nonusers.

• To examine differences in the hours of care received by equipment nonusers and by persons using equipment with and without help.

• To discuss implications for multivariate models of the relationship between assistive device use and use of help and impacts of device use on hours of care and other outcomes.

REVIEW OF THE LITERATURE

A number of studies are reviewed that have contributed to understanding of factors associated with use of equipment or help and provided evidence for the intuitive hypothesis that devices may be able to substitute for personal assistance. Much remains to be understood, however, about the scope for potential substitution of device use for personal assistance. This is due in part to limitations in survey data available to address the questions and in part to the inter-relationships between the situation and characteristics of persons with disability and their choices of how to manage their disability. Such inter-relationships complicate both conceptual models and statistical methods required to accurately estimate the relationships between equipment use and hours of care.

Several key issues for modeling were identified from the review:

• It is important to understand how conclusions from global measures of device use may differ from conclusions with respect to particular activities or types of devices. The ability to employ assistive devices may differ depending on the activity, and some devices, notably mobility devices, may have larger impacts because they are used for multiple activities.

• Independent device use for some or all activities intuitively is the place to look for the largest impacts on hours of care, but modeling of potential substitution of devices for hours, needs to take into account the clustering at zero of hours for persons using only equipment and the characteristics that affect the likelihood of being in this group.

• It is important to consider how--and whether--models can differentiate different types of substitution, particularly in cross-sectional data. For example, some types of substitution may not result in reduced hours of care but rather “release” hours of care to other activities.

• Other potential outcomes of device use besides reduced hours of care are important for policy, such as slower functional decline, reduced health care costs, or reduced physical and/or emotional stress on informal caregivers.

• Substitution or supplementation between disability equipment and help occurs at the individual level over time. Equipment may substitute for or supplement help, or the reverse. Whether there is a typical path in choice of disability accommodation and if so what it is remains to be demonstrated. This type of dynamic suggests use of longitudinal models and data to improve understanding of how disability arrangements change as needs change and where policy may be most effective.

DATA AND METHODOLOGY

The NLTCS is a nationally representative survey of persons aged 65 or older designed to identify those who are chronically disabled in one or more activities of daily living (ADLs) or instrumental activities of daily living (IADLs), and to collect detailed data on their disability, service use, family support, and health and demographic characteristics. The survey provides both longitudinal and cross-sectional samples. For this study cross-sectional samples of community residents reporting chronic disability were selected from the four waves of the survey conducted in 1984, 1989, 1994, and 1999.

Disability items included in this study are six ADLs, and eight IADLs. The ADLs are bathing, dressing, getting around inside, getting in and out of bed (transfer), toileting and eating. The included IADLs are shopping, managing money, meal preparation, laundry, light housework, taking medicines, getting around outdoors, and telephoning. Disability data on the NLTCS differ from that on some other national surveys in that disability is defined by use of help, use of disability-related equipment, or reported need for help with ADLs and inability to perform IADLs. There is no universal screen for difficulty in performing or these activities or equipment use. Detail on types of equipment used is collected for four ADLs (transfer, getting around indoors, bathing, and toileting) and for getting around outside, the one IADL for which disability-related equipment use is collected.

The disability information is used to describe trends in use of disability equipment with and without help and trends in the types of devices used. In addition, disability characteristics, human and environmental support, and socioeconomic characteristics are examined for chronically disabled elders in 1999, grouped by whether they used only equipment, only help, or both. Hours of care were examined for persons using help only or help and equipment, and, among those using both help and equipment, for persons using equipment with help and persons performing some activities with only equipment.

MAJOR FINDINGS

Trends in Device Use

• Between 1984 and 1999, the proportion of chronically disabled community residents using equipment, with or without help, for all activities for which equipment use could be measured doubled to nearly 30 percent; the proportion relying solely on help fell to 14 percent. Almost one million more elders were using equipment with at least one activity in 1999 than in 1984.

• Most of the increase in equipment use was in independent use without human help. Nearly one-quarter of disabled elders managed all chronic disabilities with only equipment in 1999, and almost two-thirds used equipment independently for at least one disability.

• Bathing was the only activity with a strong upward trend in independent use of equipment and a similarly strong downward trend in sole use of help, but significant increases in independent use of equipment occurred for all four mobility-related ADLs--bathing, getting around inside, transferring, and toileting--and for getting around outside.

• Increases in equipment were not the result of proliferation of complex assistive technology. Simple devices for mobility, bathing, and toileting--walkers, canes and crutches, tub or shower seats, and raised toilet seats--continued to be most common and saw the largest increases, although wheelchairs and scooters also nearly doubled in prevalence.

• When walkers, canes, crutches, wheelchairs and scooters were combined, 70 percent of disabled elders in 1999 were using one of these mobility aids, 50 percent with at least one other device. Only about 16 percent of chronically disabled elders were using only other devices without one of these mobility aids.

Characteristics of Users and Nonusers of Equipment

• In 1999, 1.3 million persons age 65 or older, about one in four chronically disabled community residents, used only equipment for all disabilities; three million, or nearly 60 percent used a combination of help and equipment; and only about 15 percent reported using only help with all chronic disabilities.

• Persons managing all chronic disabilities with only equipment were significantly less disabled than persons using both help and equipment on all measures, particularly with respect to mobility and the frequency with which accommodation was needed.

• The minority who used only help for all chronic disabilities were far less disabled than both groups using equipment. Nearly two-thirds were disabled only in IADLs, only 12 percent reported needing help most of the time with any ADL, and about 4 percent reported needing help most of the time for transfer or indoor mobility.

• Sole reliance on equipment did not indicate greater unmet need for help. Essentially none of the group using only equipment for their chronic disabilities reported any unmet need for help with ADLs, compared with about one in five persons using a combination of help and equipment, and about one in ten persons receiving only help.

• Persons managing all disabilities with equipment were most likely to live alone, and to live in some type of senior housing; persons using both equipment and help were most likely to live in an explicit community residential care setting, such as assisted living.

• Persons using only help were most likely to live with a spouse and far less likely than persons using equipment, with or without help, to have any environmental accommodations, such as railings or raised toilet seats, or to consider them desirable.

• Both groups using equipment were relatively similar in age and gender distribution, although persons using a combination of help and equipment were more likely to be age 85 or older.

• Persons relying solely on equipment had higher education and higher income than either group using help.

Hours, Equipment Use, and Independent Equipment Use

• As expected, hours of care received in the last week rose with disability level and generally were higher for the more disabled group using both help and equipment than for the group using only help.

• Frequency of need for help or equipment and frequency of need specifically for mobility or transfer were important; need for accommodation to perform any ADL most of the time more than doubled the hours of help received.

• Within the group using both help and equipment, persons with three or more ADLs who used equipment with help received far more hours of care than persons performing at least one activity only with equipment; they also received more hours than similarly disabled persons receiving only help.

• Even controlling for the total number of ADL disabilities and the number of activities performed with equipment, all persons with at least three ADLs who used equipment with assistance received significantly more hours of help than did persons who managed at least one activity with only equipment.

• Within each disability level hours rose as the number of activities performed with both equipment and help increased, and fell as the number of activities performed independently with equipment rose.

IMPLICATIONS FOR CONCEPTUAL AND EMPIRICAL MODELING

Better understanding of the relationship between assistive device use and use of help and impacts of device use on hours of care may require longitudinal analyses, more narrowly focused cross-sectional analyses, and more information on health status and changes in functional and other characteristics than have been typical in the literature to date. Studies to date have not determined whether exclusive use of one type of accommodation is most likely to be a transitional situation in a typical progression of accommodations used over time as functional status declines, or whether substantial heterogeneity exists. Longitudinal analyses may be able to provide insights into whether there is a typical ordering of the adoption of accommodations and what factors are associated with changes in accommodations or different orderings.

Analyses focusing on the majority of disabled elders who use some combination of help and equipment, abstracting from the probability of being in this group, may yield important insights into the scope for potential interventions to promote more independent function and into factors associated with greater or lesser hours of care when equipment is used with help. Such a focused analysis also reduces--but does not eliminate--the importance of empirical complexities such as endogeneity of living arrangement and choice of accommodations.

The ability to link Medicare claims history with the NLTCS can help control in either longitudinal or cross-sectional models for unobserved factors that may affect the ability to use equipment alone, such as differences in health and events, such as hospitalization for hip fracture or stroke, or use of post-acute care, and provide additional information on chronic conditions. In either cross-sectional or longitudinal modeling, it also may be important to consider the role of particular disabilities, notably mobility disability, in the accommodations used.

Finally, other outcomes than hours of care are important in studies of assistive device use, including unmet need, impacts on caregiver health, changes in functional status, and health and long-term care costs. The 1999 NLTCS includes a supplemental interview of primary informal caregivers which may support analysis of caregiver outcomes for different patterns of accommodation. Recently, additional years of Medicare claims as well as assessment data have become available to federal contractors. These data offer the opportunity to examine the impact of choice of accommodations on outcomes such as nursing home admission, use of home health use, hospitalizations, and Medicare spending, as well as changes in functional status for persons who have assessment data as a result of either nursing home or home health care.