149

Adapt:ive Device Use by Older Adults With Mixed Disabilities

Laura N. Gitlin, PhD, Ruth Levine, EdD, OTR/L, Christina Geiger, MS, OTR/L

ABSTRACT. Gitlin LN, Levine R, Geiger C. Adaptive device use by older adults with mixed disabilities. Arch Phys
Medi Rehabil 1993;74:149-52.
l A kev strategy in rehabilitation with the elderly is the selection and training in the use of adaptive devices to improve
the ability to perform self-care and other activities of daily living. Two descriptive pilot studies were conducted to
determine home use of equipment from the perspective of older adults with mixed disabilities and home care therapists.
The first study examined home equipment use over a three-month period by 13 elderly patients discharged from a
hospital rehabilitation unit. The second study surveyed 31 home therapists to evaluate their perceptions of device use by
their elderly clients. The findings indicate that older adults and home care therapists share similar perspectives as to why
devices are not frequently used. Home care therapists perceived that additional training in a person’s home may increase
safety, maximize functional performance, and reduce some caregiver responsibilities. The implications of these findings
for service delivery are discussed.
tZ:i1993 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
RehNabilitation

KEI’ A URDS: .-idaptive device; Geriutric rt~hahilitation: Home curt’

A key strategy in rehabilitation with the elderly with dis-
ability is the prescription of adaptive devices. The goal of
adaptive equipment is to bridge an individual’s functional
limitations with the demands of the physical environment
to reduce the impact of impairment.‘,’ Devices that may
assist the elderly include those for safety (bars and railings),
mobility, seating and positioning, stair climbing, bathing
and toileting, or those designed to assist in the performance
of other self-care activities (grooming, dressing, eating).
The potential role of adaptive devices to promote func-
tion in the home and community is significant in view of
the rapid increase of the number of older persons with di-
minished capacities and multiple chronic disability.3 Never-
theless, thle research literature indicates that only 50% to
80% of issued devices may be consistently used in the
home.4-‘0 #Studies of individuals varying in age and disabil-
ity report a number of reasons for nonuse. These include:
device failure (broken or nonfunctioning devices), incorrect
prescription or fit with individual need, lack of appropriate
instruction.‘Q’6 feelings of embarrassment or awkwardness
in device use, poor aesthetic quality,“-19 and denial of need
or embarrassment over disability.20,21
In light of these findings and given the significant role of
devices in the rehabilitation process,” two descriptive pilot
studies were conducted to further examine home use of
____
From Thomas Jefferson University, Philadelphia, PA.
Submitted f;x publication June 25. 1991. Accepted February 14. 1992.
This research was supported by the Department of Education. National Institute
on Disability and Rehabilitation Research, grant H I33GOO 160.
Previously presented at the American Occupational Therapy Association Meet-
ings, Baltimora:, MD. 1989. and the Gerontological Society of America. Boston, MA,
November 1990.
No commercial party having a direct or indirect interest in the subject matter ofthis
article has or will confer a benefit upon the authors or upon any organization with
which the authors are associated.
Reprint requests to Laura N. Gitlin, PhD, Thomas Jefferson University, Research
Coordinator, (Center for Collaborative Research, 130 South 9th Street, Suite 8 10.
Philadelphia, PA I9 107.
~1 1993 by l:he American Congress of Rehabilitation Medicine and the Amencan
Academy of Physical Medicine and Rehabilitation
ooo3-9993/93/7402-0113$3.00/0
devices from the perspectives of older adults who are dis-
charged from rehabilitation and home care therapists work-
ing with the elderly with disability. The first pilot study
examined frequency of use and reasons for nonuse for 13
older adults with mixed disabilities during the first three
months following hospital discharge. This time-frame was
selected because it may represent a critical period of transi-
tion and adaptation to disability, which may influence how
self-care activities are performed in the home.“-22 The sec-
ond study surveyed 31 home care therapists to determine
their perceptions of device use and reasons for nonuse by
their elderly clients with a range of disabilities.
METHODS
Pilot Study One
In this study, device use was examined for 13 patients
discharged from a hospital rehabilitation unit. Devices con-
sidered in this study included 26 commonly prescribed
items categorized as bathroom. eating, dressing, or hygiene.
Sample selection criteria included ( 1) an age of 60 years or
older: (2) discharge to a nursing home or home environ-
ment; (3) prescription of one or more pieces of equipment
by an occupational therapist during hospitalization; (4)
cognitive ability to participate in face-to-face and telephone
interviews; and (5) informed consent by the patient. Pa-
tients meeting the selection criteria were identified during
hospitalization by an occupational therapy supervisor and
approached to participate in the study. The final sample
consisted of ten women and three men with a mean age of
73 years (range from 61 to 84 years). Six subjects were
married and living with their spouses and seven were wid-
owed or divorced and lived alone. Six subjects had a pri-
mary diagnosis of orthopedic deficit, four had a primary
diagnosis of cerebrovascular accident., two had multiple
medical complications, and one had rheumatoid arthritis.
Arch Phys Med Rehebil Vol74, February 1993
 150 ADAPTIVE DEVICE USE, Gitlin

Table 1: Summary of Number of Devices During the predischarge interview, all 13 patients re-
ported that the issued equipment was helpful in the hospital
No. of
Devices
and anticipated continued use in the home. However. as
No. of No. of
Subjects Devices in Home Average No. displayed in table 2, by the end of the first month, the eight
Device Prescribed Prescribed Prior to of Devices subjects available for interviewing reported that 45% of pre-
Category Device in Hospital Hospital (SD) scribed equipment was seldom to never used in the home.
In month two, 33% of issued equipment was reported as
Dressing 13 35 6 3.15 (1.46)
Bathroom 12 13 7 I .54 (.88) seldom to never used in the home, and in month three, 42%
Hygiene IO 12 I .08 (.86) of devices were rarely or never used. Use rates fluctuated
Feeding 3 6 : .46 (.88) slightly from month to month, with the lowest rate occur-
Miscellaneous 4 6 I .54 (.97) ring in month two, postdischarge. Devices tended to be
Total 72 (2 = 5.5) 16 (X = 6.8)
“never” or “always” used rather than “seldom” or “fre-
quently” used.
Dressing devices were the most frequently issued cate-
Each subject was interviewed by a trained member of the gory of equipment followed by bathroom devices for this
research team in the hospital one to three days prior to study sample (see table 1). Of 13 bathroom aids reported in
discharge. The interview was designed to assess perceptions the home one month postdischarge, nine devices (69%)
of prescribed devices and future plans to use these devices were used frequently or always. On the other hand, of the
in the home. Eight of the 13 subjects were available for 23 dressing aids, 11 (47%) were reported in frequent or con-
20-minute telephone interviews each month for a three- sistent use. This is significant in that bathroom equipment
month period following hospitalization. Each month, sub- is an out-of-pocket expense for the elderly, although it tends
jects were asked to identify the most valued piece of equip- to be in more consistent use than other device categories.
ment, how often issued devices were used, and reasons for An examination of device utilization on a case by case
nonuse. basis indicated selectivity by individuals. That is, a subject
may have reported frequent use for some devices while
Pilot Study Two
other issued aids were discarded. Also a device reported of
A survey of 3 1 home care therapists was conducted to value to one subject was not necessarily of benefit to or used
evaluate professionals’ perceptions of equipment use by by another. Furthermore, the most valued piece of equip-
their elderly home care recipients. Questionnaires were sent ment tended to change from month to month and different
to directors of seven home care agencies within the county equipment was valued, even for those with the same type of
who then distributed the brief survey to those therapists disability. For example, one woman with an orthopedic dif-
with the greatest concentration of elderly clients. Thirty- ficulty indicated the sock aid as the most valued piece of
one therapists completed and returned the survey. Of those equipment at pre discharge and the grabber at subsequent
who responded, 48% were occupational therapists, 35% monthly interviews. Another female orthopedic patient val-
were nurses, 10% were physical therapists, and 6% indi- ued the grabber at pre discharge and month one, but valued
cated another health profession. Most respondents had the commode and sock aid at interview months two and
worked in home care for three or more years with an esti- three.
mated average of 75% of their time spent in the care of the Four major reasons for nonuse of devices emerged from
elderly. Respondents indicated their primary clientele were open-ended questioning: ( 1) perception of no need: (2)
older adults with a diagnosis of cerebrovascular accident, equipment too “cumbersome” to use; (3) task currently
arthritis, or hip fracture. These professionals were asked to performed by others; and (4) equipment loss or failure.
report the extent to which they believed equipment was These findings confirm the research literature, which sug-
used in the home by their elderly clients, to list the most gest that social and psychological issues, device-specific or
frequently used pieces of equipment, and those they be- mechanical factors, and presence of attendants or care-
lieved were least likely to be used consistently. Finally, they givers may influence rate of use and perceived need in the
were asked to provide their perceptions of reasons for non- home.
use and suggestions for hospital-based professionals in issu-
ing equipment. Pilot Study 2: Therapists Perceptions of Use
Of the 31 therapists surveyed, 90% perceived mobility
RESULTS
and bathroom equipment to be most frequently used by
Pilot Study 1: Older Adults in Rehabilitation
Table 1 presents a summary of the number of subjects Table 2: Device Use After Discharge (n = 8)
issued a device, number of devices per category prescribed Month I* Month 2 Month 3
during hospitalization, number of devices per category in (49 devices) (6 1 devices) (61 devices)
the home prior to this hospitalization, and mean number of
devices per subject. A total of 72 devices or an average of 5.5 Never 19 (39%) 19 (31%) 22 (36%)
devices per patient were issued during hospitalization for Seldom 3 (6%) I (2%) 3 (5%)
Frequently 7 (14%) I I (18%) 9(150/n)
the 13 subjects. An additional 16 devices were reported as Always 20 (41%) 30 (57%) 27 (44%)
present in the home prior to the hospital experience. Thus,
a total of 88 or 6.8 devices per patient were reported. *n=7.
Arch Phys Med Rehabil Vol74, February 1993
 ADAPTIVE DEVICE USE, Gitlin
their clients 60 years of age or older. On the other hand.
77% perceived that grooming or hygiene equipment was
seldom used and 58% perceived that dressing equipment
was also seldom used. Therapists cited six major reasons for
nonuse of elquipment in the home. Thirty-five percent per-
ceived lack of knowledge as to appropriate use and what to
do with broken or defective devices as the major cause for
discarding a device. Nineteen percent expressed cost as a
reason: 19% felt clients denied need: 10% indicated inappro-
priate selection of equipment for the environment; 10% in-
dicated that clients perceived equipment to be too time
consuming or “too much trouble”; and 6% expressed that
the assistance of a family member minimized a client’s use.
Finally. therapists were asked to provide advice to hospi-
tal-based personnel in selecting and training in adaptive
devices for the older patient. Five major themes of advice
emerged from open-ended questioning. They included the
need of rehabilitation therapists to (1) develop innovative
instructional strategies: (2) empower clients through educa-
tion; (3) solicit individual need and values: (4) involve care-
givers: and (5) understand complexity of home environ-
ment.
DISCUSSION
Device use appears to be a complex issue that may
change over time as patients adapt to their home environ-
ment. Pilot study 1 suggests that in transition from hospital
to home, patients may adapt different strategies in self-care
and hence, change their perspective as to the value and
frequency of use of the devices. Strategies for performing
basic self-care activities may differ in the home from those
initially used in the hospital. This may account for the ini-
tial enthusiasm expressed for devices during hospitalization
but the low use rate and fluctuations in use that occurred
over the three-month period in the home.
.4lthoughi in this study device use remained low each
month, it should be noted that 47% of devices were reported
in use in th;e home over the three-month period. Further-
more, an average of 6.8 devices per subject was reported.
The large number of devices per person may in itself pre-
clude the ability for older adults to consistently use each.
.4nother important finding is that although bathroom
equipment was perceived as helpful, and reported by both
patients and home care therapists as most frequently in use,
this device ‘category is not reimbursed by private insurance
or Medicare. Thus, financial limitations may prevent wider
distribution and use of this category of equipment. This is a
critical reimbursement and health policy issue given the
potential role of equipment in the prevention of injury due
to falls in bathrooms.
In Pilot study 2, the experiences of home care therapists
indicate relatively little to no coordination between inpa-
tient rehabilitation training approaches and home care
training in adaptive devices. Their comments suggest that
health professionals would greatly benefit from knowledge
of the home during a patient’s hospitalization in order to
construct a more realistic and contextual experience for the
instruction in self-care techniques. The value of a home
evaluation as part of the geriatric assessment process has
been documented in the research literature as a critical com-
ponent to assessment and delivery of effective care.23 Fur-
151
thermore, a home evaluation may be a cost-effective prac-
tice. It may minimize the need to retrain individuals in
their home and allow the home care therapist to concen-
trate efforts on reinforcement and refinement of skills.
Based on the perceptions of both home care therapists
and older adults in these two pilot studies. it appears as if
home use may be influenced by three interrelated factors.
First are those factors that are person-centered and include
both an individual’s physical abilities and personal prefer-
ences and values. Although physical abilities. such as
strength, balance, and coordination. may determine the
type of device an individual may be able to use, personal
preference and style of managing one’s care is an equal, if
not greater, influence. Researchers have argued that formal
providers often impose a medical model approach without
considering the real concerns and issues that the elderly and
their caregivers themselves express as primary or impor-
tant.14 Furthermore, cultural and ethnic background have
also been identified as influential factors in the use of a
range of technologies and health care services.“-” There is
a growing body of literature that indicates the importance
and potential cost effectiveness of client-driven therapeutic
approaches in rehabilitation. That is, the inclusion ofethnic
and cultural considerations and client-identified goals and
values in the development of intervention strategies may
lead to more effective treatment planning and implementa-
tion.‘S-“1
The second factor that may influence home use is envi-
ronmental considerations, including the physical and social
characteristics of the home. As the survey of home care
therapists indicated, equipment is often prescribed by the
rehabilitation therapist without adequate knowledge of the
physical dimensions and properties ofa client’s home. Inap-
propriate prescription increases the likelihood of a client’s
misuse or nonuse of the technology. The social dimension
of the client’s environment refers to the presence of care-
givers and other family members in the home that may
influence the use of equipment. Family members provide
up to 90% of the direct care of the elderly in the home and
there is a growing body of literature that indicates that care-
givers directly effect rehabilitation outcome3’,3’ and use of
devices.34 However, there is minimal research documenta-
tion as to the extent to which caregiver instruction in device
use occurs in rehabilitation and the home and how thera-
pists include family members in therapeutic practice.
The third factor that may influence home use is the char-
acteristics of the devices themselves. Comments from older
adults in Pilot study 1 such as “I do it another way,” or “it is
too cumbersome to use,” suggest that ease of use of a device
and how it fits into the personal lifestyle and care manage-
ment plan of the individual directly effects frequency of
use. Other researchers have identified an embarrassment
factor and the lack of aesthetic appeal as also influencing an
individual’s level of comfort in using a device.”
As the home increasingly becomes the context for contin-
ued rehabilitation and instruction in the use of assistive
technologies. inclusion of the above considerations be-
comes particularly significant in the care of the elderly with
disability. These factors indicate the need to move from a
medical model framework that prescribes equipment based
on pathology, to an ecological approach. In an ecological
approach, an individual’s own goals, cultural values, and
Arch Phys Med Rehabil Vol74, February 1993
152 ADAPTIVE
the physical and social characteristics of the home are inte-
gral components that shape therapeutic decisions regarding
assistive technology.35
CONCLUSION
Health professionals have the unique opportunity to em-
power the older adult and the caregiver in device use in both
the rehabilitation and home care setting. Patient education
regarding the range of available technologies, how to evalu-
ate change in equipment need, and where to purchase and
repair equipment, provide the older rehabilitation patient
and caregiver with the necessary knowledge to fully exploit
the potential benefit of devices to promote quality of life.
Recent legislation in support of assistive technology36 un-
derscores the necessity of deriving multiple service delivery
strategies to enhance the potential of technology for the
older user.
These two pilot studies suggest that older rehabilitation
patients may represent a new category of device users who
need varied and distinct instructional approaches. Such ap-
proaches may involve ( 1) greater knowledge and specificity
of the physical and sociocultural characteristics of the pa-
tient’s home; (2) inclusion of caregiver in the training pro-
cess; (3) use of shorter training sessions that occur over
longer periods of time; and (4) more practice opportunities
in the home, or a simulated environment. Further research
is needed to test these principles and their cost effectiveness.
Acknowledgment: The authors gratefully acknowledge the editorial
and methodological assistance of Dr. Kevin Lyons, Associate Dean. Col-
lege of Allied Health Sciences, Thomas Jefferson University; and the li-
brary and organizational assistance of Desiree Burgh, Project Coordinator,
Thomas Jefferson University.
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