The influence of personal care and assistive devices on the measurement of disability

Capturing multiple assistive technology use and its impact in later life: lessons learned from distinct measurement approaches

PURPOSE

Assistive technology (AT) use is prevalent in older adulthood and can accommodate activity difficulties to support well-being. However, within the context of multiple activity difficulties and multiple technology use, it is unclear how to best assess their combined effects on older adults' health outcomes. This study proposed four distinct approaches to quantify multiple AT use and examined their respective impact in later life.

MATERIAL AND METHODS

Using data from the 2015 round of the National Health and Aging Trends Study (n = 6,936), we compared four indices to summarize the state of multiple AT use among the U.S. older population: binary, item-specific, cumulative, and accommodative. Separate regression analyses tested the impact of each index on older adults' well-being and restricted participation in meaningful activities.

RESULTS

In 2015, 59.9% of the respondents were identified as AT users. Among these users, 53.8% reported using two or more technologies when performing daily self-care and mobility activities. The implications of multiple AT use for health outcomes varied across the four indices. Approaches that captured elements of person-technology fit provided the most nuanced and actionable insights on the benefits of using AT to support well-being.

CONCLUSIONS

ATs were commonly adopted by older adults in everyday activities. Overall, findings suggest that there are multiple approaches to conceptualize the independent, cumulative, or balanced effects of multiple AT use. Each measurement approach has unique implications for understanding the impacts of using ATs on older adults' health outcomes.

Factors associated with unmet need for support to maintain independence in later life: a systematic review of quantitative and qualitative evidence

BACKGROUND

populations are considered to have an 'unmet need' when they could benefit from, but do not get, the necessary support. Policy efforts to achieve equitable access to long-term care require an understanding of patterns of unmet need. A systematic review was conducted to identify factors associated with unmet need for support to maintain independence in later life.

METHODS

seven bibliographic databases and four non-bibliographic evidence sources were searched. Quantitative observational studies and qualitative systematic reviews were included if they reported factors associated with unmet need for support to maintain independence in populations aged 50+, in high-income countries. No limits to publication date were imposed. Studies were quality assessed and a narrative synthesis used, supported by forest plots to visualise data.

FINDINGS

forty-three quantitative studies and 10 qualitative systematic reviews were included. Evidence across multiple studies suggests that being male, younger age, living alone, having lower levels of income, poor self-rated health, more functional limitations and greater severity of depression were linked to unmet need. Other factors that were reported in single studies were also identified. In the qualitative reviews, care eligibility criteria, the quality, adequacy and absence of care, and cultural and language barriers were implicated in unmet need.

CONCLUSIONS

this review identifies which groups of older people may be most at risk of not accessing the support they need to maintain independence. Ongoing monitoring of unmet need is critical to support policy efforts to achieve equal ageing and equitable access to care.

Longitudinal association between personality traits and homebound status in older adults: results from the National Health and Aging Trends Study

Background

Personality is associated with predictors of homebound status like frailty, incident falls, mobility, and depression. However, the relationship between personality traits and homebound status is unclear. This study aims to examine the longitudinal association between personality traits and homebound status among older adults.

Methods

Using data of non-homebound community-dwelling adults aged 65 years and older in the 2013 and 2014 waves (baseline) of the National Health and Aging Trends Study (N = 1538), this study examined the association between personality traits and homebound status. Homebound status (non-homebound, semi-homebound, and homebound) was determined by the frequency of going outside, difficulty in going outside, and whether there was help when going outside. Personality traits, including conscientiousness, extraversion, neuroticism, openness, and agreeableness were assessed using the 10-item Midlife Development Inventory on a rating scale from 1 (not at all) to 4 (a lot). Ordered logistic regression models were used to examine whether personality traits predicted homebound status in later 3 years with and without adjusting covariates.

Results

The sample was on average 77.0 ± 6.70 years old, and 55% were female. The majority were non-Hispanic whites (76%), and received some college or vocational school education or higher (55%). Homebound participants tended to be less educated older females. Three years later, 42 of 1538 baseline-non-homebound participants (3%) became homebound, and 195 participants (13%) became semi-homebound. Among these five personality traits, high conscientiousness (adjusted odds ratio [OR] = 0.73, p < 0.01) was associated with a low likelihood of becoming homebound after adjusting demographic and health-related covariates.

Conclusions

These findings provided a basis for personality assessment to identify and prevent individuals from becoming homebound.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02771-8.

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map

Background

By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value.

Objectives

This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence.

Search Methods

We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov).

Selection Criteria

Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps.

Data Collection and Analysis

We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist.

Main Results

After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues.

Authors' Conclusions

There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

Examining social determinants in use of assistive technology for race/ethnic groups of older adults

OBJECTIVE

Assistive technologies (AT) can compensate for activity limitations and loss of physical functioning. Little is known regarding how minority older adults differ in AT use as they age. This study examined race and ethnic differences in AT use among a nationally representative sample of older adults in the United States.

DESIGN

Weighted logistic regression analyses were conducted using the 2012 Behavioural Risk Factor Surveillance System (BRFSS), collected annually by the Centres for Disease Control and Prevention (CDC). The study sample included 282,825 non-Hispanic White, African American, Asian and non-White Hispanic older adults. Activity limitation, health care access, overall health status and sociodemographic characteristics were included as variables in the analysis. Interaction analyses were conducted to examine the moderating effect of race/ethnicity on social determinants with AT use.

RESULTS

Results indicated that 13.5% of older adults reported the use of an AT. African American older adults had the highest percentage of AT use (21.0%), and Asian older adults had the lowest (5.1%). Those who were 85 years and older, reported an activity limitation, were unmarried and in poor health were most likely to use an AT. Having health insurance was significantly associated with higher AT use for non-Hispanic Whites (OR = 1.66, p < 0.001) and non-White Hispanics (OR = 1.98, p < 0.01), but not African Americans and Asians.

CONCLUSION

Health professionals can promote access and address barriers in AT use, particularly in regard to accessibility and acceptability among minority older adults.Implications for rehabilitationAfrican-Americans older adults were most likely to use ATs, and Asian older adults the leastOlder adults who were 85 years and older, reported an activity limitation, were unmarried and in poor health were most likely to use an ATDifferent social determinants to AT use were found among race/ethnic groups, highlighting the need to promote access and address barriers to health care utilization.

Effects of Technology Use on Ageing in Place: The iZi Pilots

In the iZi study in The Hague, use and acceptance of commercially available technology by home-dwelling older citizens was studied, by comparing self-efficacy and perceived physical and mental Quality of Life (QoL)-related parameters on an intervention location of 279 households and a control location of 301 households. Technology adoption was clinically significantly associated with increased perceived physical QoL, as compared with control group, depending on the number of technology interventions that were used. A higher number of adopted technologies was associated with a stronger effect on perceived QoL. We tried to establish a way to measure clinical significance by using mixed methods, combining quantitative and qualitative evaluation and feeding results and feedback of participants directly back into our intervention. In general, this research is promising, since it shows that successful and effective adoption of technology by older people is feasible with commercially available products amongst home-dwelling older citizens. We think this way of working provides a better integration of scientific methods and clinical usability but demands a lot of communication and patience of researchers, citizens, and policymakers. A change in policy on how to target people for this kind of intervention might be warranted.

Racial and Ethnic Differences in Disability Transitions Among Older Adults in the United States

BACKGROUND

Racial and ethnic differences in disability persist and are possibly widening in recent years, but evidence is limited for racial and ethnic differences in disability progression through the entire disablement process and potential influential factors. The objective of this study is to examine racial and ethnic differences in patterns of late-life disability transitions, using a new disability spectrum that incorporates successful accommodation with assistive devices in response to capacity limitations to prolong independence.

METHODS

The study cohort consisted of a nationally representative sample of Medicare beneficiaries aged 65 and older in the United States who were enrolled in the 2011 National Health and Aging Trends Study and followed up annually until 2015 (n = 6,198). First-order Markov transition models were used to determine racial/ethnic differences in transitions among three stages of self-care and mobility limitations (fully able, successful accommodation, difficulty/assistance) and death.

RESULTS

After adjustment for age and sex, non-Hispanic Black and Hispanic respondents had higher probabilities of unfavorable transitions and lower probabilities of remaining in the successful accommodation stage than non-Hispanic White respondents. The racial and ethnic differences in probabilities of maintaining successful accommodation remained statistically significant after adjustment for socioeconomic and health factors (Black: 0.56, 95% CI = 0.52-0.60; Hispanic: 0.53, 95% CI = 0.44-0.61; White: 0.63, 95% CI = 0.61-0.65).

CONCLUSIONS

Successful accommodation with assistive devices may provide possibilities for implementing interventions to enhance older adults' capacities and reducing racial/ethnic differences in late-life disability.

Estimativas de expectativa de vida livre de incapacidade funcional para Brasil e Grandes Regiões, 1998 e 2013

Resumo A expectativa de vida aos 60 anos no Brasil aumentou cerca de 9 anos em pouco mais de meio século. Trata-se de um ganho de sobrevida generalizado, mas que também ocorre de forma heterogênica entre as Grandes Regiões do país. Por outro lado, pouco se sabe, ainda, como os aumentos da expectativa de vida aos 60 anos por região podem ser acompanhados por acréscimos ou decréscimos tanto nos anos vividos com incapacidade, quanto nos vividos livre de incapacidade. O objetivo deste artigo é analisar, para 1998 e 2013, aumentos na Expectativa de Vida Total e suas componentes: Expectativa de Vida Livre de Incapacidade Funcional (EVLI) e com Incapacidade Funcional (EVCI), aos 60, 70 e 80 anos para a população do Brasil e Grandes Regiões. O estudo utilizou informações sobre incapacidade funcional da PNAD de 1998 e PNS de 2013 e empregou o método de Sullivan para estimação da EVLI por sexo e idade. No geral, os resultados mostraram que, entre 1998 e 2013, concomitantemente aos ganhos na EV, ocorreu um crescimento na EVLI. Contudo, os ganhos na EVLI não foram estatisticamente significativos para as regiões Norte e Centro-Oeste. Ou seja, com exceção dessas regiões, além de viver mais, a população idosa de 60 anos poderia esperar viver um número maior de anos com saúde.

Subjective health status of multimorbidity: verifying the mediating effects of medical and assistive devices

Background

This study aimed to verify the mediating effect of using assistive devices as a factor that alleviates the relationship between multimorbidity and subjective health status.

Methods

This study used three-year data (2011–2013) from the Korea Health Panel (KHP). The data were jointly collected by the consortium of the National Health Insurance Service and Korea Institute for Health and Social Affairs.

Results

The mediating effect of using assistive devices was verified, but the direction of the effect was deteriorated subjective health. In other words, in terms of the impact of multimorbidity on subjective health, using assistive devices had a negative impact (−) on subjective health.

Conclusions

The current assessment system for medical devices, narrow scope for choice of assistive devices, and limited scope of health insurance benefits must change to ultimately lead to a positive mediating effect on using medical devices and on subjective health satisfaction of patients with chronic diseases. A system that embraces all ages and generations must be developed. To this end, it is necessary to expand the scope of medical devices and insurance payment in long-term care insurance for elderly users, as well as the active meaning of medical devices in terms of health insurance.

Disability Measurement in the Health and Retirement Study

The Health and Retirement Study (HRS) has provided extensive and detailed national data on disability since it began in 1992, and has been used extensively in studies of disability trends and trajectories. We summarize conceptual frameworks used to characterize disability and review the HRS measures of functioning, work disability, and employer accommodations. HRS survey questions have experienced changes in wording, skip logic, or other design features over the life of the study, and we comment on the analytic challenges posed by those changes. Among our conclusions are (1) work disability and benefit eligibility are important concepts that should be considered for redesign to better reflect current concepts and policy issues; (2) methodological studies of changes in wording or skip logic should be undertaken; and (3) minor additions to survey content in areas such as temporal reference periods or changes in social-participation activities would improve measurement.

Receipt of informal care in the Chinese older population

This paper examines the factors affecting the receipt of informal care among older people in China. It uses the second wave data of the China Health and Retirement Longitudinal Survey, which collected ageing and health-related information on a nationally representative sample of 8,906 older people aged 60 and over in 2013. Apart from the factors that have been examined in the contexts of developed countries, the paper further investigates two factors specific to Chinese society: rural–urban residence and regular financial assistance from children. Based on binary and multinomial logit regression analyses, the research findings are threefold: the determinants of receiving informal care differ remarkably according to the sources of care; disability and living arrangements are the most important determinants; rural–urban residence plays a vital role in the Chinese context, but regular financial assistance from children makes little difference. It is estimated that 53 million older people are receiving informal care each year, a figure equivalent to the entire population of England. With continuous population ageing, Chinese society will face huge pressure to meet the demand for social care among older people in the future. The Chinese government needs to build a well-rounded welfare system that tackles this challenge from multiple dimensions. The formal care services should aim to complement informal care in the short run and reduce inequality in social care in the long run.

Equipment: Is it the Answer? An Audit of Equipment Provision

The provision of equipment and adaptations is a major part of the social services occupational therapist's role and is, therefore, an area that needs investigation to ensure that assessed needs are being met effectively and cost-efficiently. This study was an audit that investigated the longer-term usefulness of equipment and adaptations, provided by social services occupational therapists, in enabling service users to perform daily living tasks. The focus of the audit was whether the service users were still using the equipment and/or adaptations provided, and how useful they were finding them, 18 months to 2 years after provision.

This was a retrospective audit of a random sample of 100 service users during a specified time scale, using a telephone survey for data collection. Fifty-seven telephone questionnaires were completed.

The clearest finding was that the majority (83%) of the equipment and adaptations issued between 18 months and 2 years previously were still being used at the time of this audit, with 69% being used on a daily basis. This suggested that the equipment and adaptations provided were being used as an integral part of daily life and that they had been prescribed appropriately. It was also interesting to note that the satisfaction with the equipment and adaptations being used independently was higher than the satisfaction with the equipment and adaptations used with help from others.

Conclusion

The audit found that 83% of the equipment and adaptations were still being used 18 months after provision, which suggests accurate and appropriate prescription by the occupational therapy service. Small low-cost items, such as grab rails, were seen by the service users to be very useful in helping them to perform activities of daily living, frequently on their own. The audit suggests that people rate equipment or an adaptation as more useful if they are able to use it alone. This link between independent use and satisfaction is an area for further study, because it suggests that equipment can be very important to a person's sense of independence and wellbeing in the community.

The reasons for non-use of equipment were mainly changes in functional ability or personal circumstances, not poor instruction or fitting. This suggests a more appropriate assessment process or more suitable equipment being issued than in the studies reviewed by Mountain (2000).

There was a very high proportion of respondents who would recommend the occupational therapy service to others with similar difficulties; however, most needed prompting to remember that it was occupational therapy staff who had provided the equipment and/or adaptations. Even when prompted, they could remember the staff member but not the name of the service; publicity and clearer information provided to service users at the point of contact may resolve this issue.

Recommendations

Further study is needed to provide more evidence that the provision of equipment and/or adaptations can be effective in enabling independent living in the community. The expertise of community occupational therapists in enabling people to perform daily living tasks is not widely recognised because there has been little or no research in this specialist field. The process of issuing equipment follows a holistic assessment and a practical step-by-step analysis of the problems identified by users and carers. It continues with training and support to use the equipment, with constant re-evaluation of the whole process.

It is interesting to note that although there was a high level of satisfaction with the service provided, there was a lack of clarity over who had provided it. This suggests that more signposting is needed to help service users and the general public to identify occupational therapy as a profession working within social services.

Following on from this audit, there will be a review of systems to ensure that service users and carers are competent in using the equipment issued to them and are aware of how to contact the service if reassessment, repair or return of equipment is needed. This will complement the standard equipment review systems and ensure that as much unused equipment as possible is recovered for recycling. More investigation is also needed to find out how service users are using the equipment and adaptations: are they following the instructions and using them safely? There is some anecdotal evidence that whilst a service user may be using a piece of equipment to perform daily living tasks, this might not be in the manner intended by the manufacturer or demonstrated by occupational therapy staff.

It would be invaluable to introduce a standardised outcome measure for social services occupational therapy staff to use with all service users. Heaton and Bamford (2001) stated that outcomes are increasingly important in the current policy context, with emphasis on quality, national standards, best value and evidence-based practice. If information could be routinely collected and analysed, it would provide continual statistical data to ensure a strong evidence base to the service. The appraisal of existing outcome measures and their suitability to be used as a tool for community occupational therapy will be a continuing task for the service.

A future audit using the same methodology would enable performance to be measured and reviewed again, ensuring that standards are maintained, and would ascertain whether improvements in service provision have been achieved. The results of this and subsequent audits are vital to ensure that the occupational therapy service meets the challenge of using evidence to underpin practice.

Participation in the Prescription Process of Mobility Devices: Experiences among Older Patients

The aim of this study was to explore older patients' experiences of participation in the prescription process of mobility devices.

The study was conducted in two Swedish municipalities and was a qualitative study, based on the focus group interview methodology of Merton et al (1990). In order to recruit a sample fulfilling both homogeneity and heterogeneity criteria, occupational therapists and physiotherapists in the municipalities identified potential participants, all aged 65 years or older. Twenty-two patients participated in focus group interviews. Each patient participated once in the seven focus group interviews that were arranged.

The participants reported passive participation in the prescription process of mobility devices as the most frequently occurring experience. They also reported non-participation, for example, in discussion about alternative solutions to activity problems.

The study concluded that it was necessary to develop a more client-centred approach in community-based rehabilitation, challenging occupational therapists and physiotherapists to encourage patient participation in the prescription process of mobility devices. The study also highlighted the importance of inviting the patient to discuss alternative solutions to activity problems.

State Rehabilitation Agencies, Aging with Disability, and Technology

Recent federal and state laws have required state rehabilitation programs and Tech Act programs (TAPs) to improve the access of persons with disabilities to assistive technology (AT) and home modifications (HM). A national survey of all 81 state rehabilitation programs, conducted in 1997 and 1998, examined the extent to which state rehabilitation agencies provided services to middle age (51 years-64 years) and older (65 years and older) clients, agency staff awareness of the aging of the disability population, and agency capacity to provide access to AT/HM for persons with disabilities who are older. Findings indicated that agencies for the blind or visually impaired (BVIs) served significantly more middle age and older persons, were more aware of aging, and provided greater access to AT/HM than did rehabilitation agencies (RAs). In addition, RAs having TAPs within their agency were more aware of aging, provided more staff training on aging, and collected more data on middle age and older clients than did RAs without TAPs. These results point to the need for more counselor training in the areas of technology and aging, areas in which the TAPs and the network of agencies dealing with aging issues can play a major role. To meet the challenges of an aging population, rehabilitation agencies may also need a mandate that makes independent living a valued outcome in and of itself. Finally, agencies need more AT/HM funding so they can address the growing population of middle age and older persons with disabilities.

Disability Symptoms and the Price of Self-Sufficiency

Objective: Disability symptoms are tiredness, slowness, and pain doing daily tasks made difficult by health. The authors study factors that increase and decrease disability symptoms, especially effects of equipment and personal assistance. Method: In National Health Interview Survey Disability Supplement Phase 2, people with personal care and household management disabilities were asked about fatigue, taking a long time, and pain when doing tasks on their own and with assistance. The authors study persons ages 55 and older. Results: Poor overall health or disability and severe disability in tasks increase disability symptom chances by 11% to 18%. Assistance users are 19% to 20% less likely to have symptoms than nonusers. Personal help, alone, or with equipment, relieves symptoms better than equipment only, by9%to 13%. Discussion: Equipment-only users are self-sufficient, a highly prized situation. Because they actively engage in tasks, symptoms are still likely. This trade-off of psychological gain with comfort loss may be preferable to personal help.

Factors Influencing the Use of Mobility Technology in Community-Based Long-Term Care

Objectives: This article adapts a framework commonly used to model personal long-term care services to examine factors influencing the use of mobility-related assistive devices, both in isolation and in combination with personal care. Methods: The authors analyze data from Phase 2 of the 1994-1995 National Health Interview Survey Disability Supplements to compare predictors of equipment use with those for personal care and rank the probabilities of using particular combinations according to health needs, access, and personal and family characteristics. Results: The authors find that underlying health needs are the dominant factor related to the type of care arrangement used. The typical person with a mobility-related disability is most likely to use equipment alone; only at younger ages or at greater levels of severity are other arrangements expected to dominate. Discussion: Research on the dynamic acquisition process, with attention to age and trajectories of disability severity, is needed to fully understand the integration of technology and personal care.

Care Challenges in the Bathroom: The Views of Professional Care Providers Working in Clients' Homes

In home care, bathroom activities-particularly bathing and toileting-present a unique set of challenges. In this focus group study, professional home care providers identified factors that increase the danger and difficulty of assisting their clients with bathing and toileting. These included small restrictive spaces, a poor fit between available equipment and the environment, a reliance on manual handling techniques (but insufficient space to use optimal body mechanics), attempts to maintain normalcy, and caring for unsteady and unpredictable clients. Specific elements of each activity that care providers found difficult included multitasking to support client stability while performing care below the waist (dressing/undressing, providing perineal care) and helping clients to lift their legs in and out of a bathtub. Participants did not feel that available assistive devices provided enough assistance to reduce the danger and difficulty of these activities.

Empirical redefinition of comprehensive health and well-being in the older adults of the United States

The World Health Organization (WHO) defines health as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Despite general acceptance of this comprehensive definition, there has been little rigorous scientific attempt to use it to measure and assess population health. Instead, the dominant model of health is a disease-centered Medical Model (MM), which actively ignores many relevant domains. In contrast to the MM, we approach this issue through a Comprehensive Model (CM) of health consistent with the WHO definition, giving statistically equal consideration to multiple health domains, including medical, physical, psychological, functional, and sensory measures. We apply a data-driven latent class analysis (LCA) to model 54 specific health variables from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of US community-dwelling older adults. We first apply the LCA to the MM, identifying five health classes differentiated primarily by having diabetes and hypertension. The CM identifies a broader range of six health classes, including two "emergent" classes completely obscured by the MM. We find that specific medical diagnoses (cancer and hypertension) and health behaviors (smoking) are far less important than mental health (loneliness), sensory function (hearing), mobility, and bone fractures in defining vulnerable health classes. Although the MM places two-thirds of the US population into "robust health" classes, the CM reveals that one-half belong to less healthy classes, independently associated with higher mortality. This reconceptualization has important implications for medical care delivery, preventive health practices, and resource allocation.

[Live longer and better? Estimates of healthy life expectancy in the Brazilian population]

This study analyzed differences in healthy life expectancy in the elderly based on three health dimensions in Brazil from 1998 to 2008: disability-free life expectancy, healthy life expectancy based on self-rated health, and chronic disease-free life expectancy. The Sullivan method was used, combining life tables from the Brazilian Institute of Geography and Statistics (IBGE) and interval estimates of the prevalence of functional disability, self-rated health, and chronic diseases according to the Brazilian National Household Sample Survey (PNAD, 1998 and 2008). Besides the increase in life expectancy, the study showed significant and similar increases in disability-free life expectancy and healthy life expectancy based on self-rated health at almost all ages. Women had higher life expectancies than men, but expected to live longer with poor health, regardless of the indicator used to measure health. Although the studies measured health differently (making comparisons difficult), women showed a consistent disadvantage in healthy life expectancy.

Epidemiology of the Homebound Population in the United States

IMPORTANCE

Increasing numbers of older, community-dwelling adults have functional impairments that prevent them from leaving their homes. It is uncertain how many people who live in the United States are homebound.

OBJECTIVES

To develop measures of the frequency of leaving and ability to leave the home and to use these measures to estimate the size of the homebound population in the US population.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional data from the National Health and Aging Trends Study collected in 2011 in the contiguous United States. Participants were a nationally representative sample of 7603 noninstitutionalized Medicare beneficiaries 65 years and older.

MAIN OUTCOMES AND MEASURES

We defined homebound persons as those who never (completely homebound) or rarely (mostly homebound) left the home in the last month. We defined semihomebound persons as those who only left the home with assistance or had difficulty or needed help leaving the home. We compared demographic, clinical, and health care utilization characteristics across different homebound status categories.

RESULTS

In 2011, the prevalence of homebound individuals was 5.6% (95% CI, 5.1%-6.2%), including an estimated 395,422 people who were completely homebound and 1,578,984 people who were mostly homebound. Among semihomebound individuals, the prevalence of those who never left home without personal assistance was 3.3% (95% CI, 2.8%-3.8%), and the prevalence of those who required help or had difficulty was 11.7% (95% CI, 10.9%-12.6%). Completely homebound individuals were more likely to be older (83.2 vs 74.3 years, P < .001), female (67.9% vs 53.4%, P < .006), and of nonwhite race (34.1% vs 17.6%, P < .001) and have less education and income than nonhomebound individuals. They also had more chronic conditions (4.9 vs 2.5) and were more likely to have been hospitalized in the last 12 months (52.1% vs 16.2%) (P < .001 for both). Only 11.9% of completely homebound individuals reported receiving primary care services at home.

CONCLUSIONS AND RELEVANCE

In total, 5.6% of the elderly, community-dwelling Medicare population (approximately 2 million people) were completely or mostly homebound in 2011. Our findings can inform improvements in clinical and social services for these individuals.

Trends in healthy life expectancy among older Brazilian women between 1998 and 2008

OBJECTIVE To analyze conditional and unconditional healthy life expectancy among older Brazilian women. METHODS This cross-sectional study used the intercensal technique to estimate, in the absence of longitudinal data, healthy life expectancy that is conditional and unconditional on the individual's current health status. The data used were obtained from the Pesquisa Nacional por Amostra de Domicílios (National Household Sample Survey) of 1998, 2003, and 2008. This sample comprised 11,171; 13,694; and 16,259 women aged 65 years or more, respectively. Complete mortality tables from the Brazilian Institute of Geography and Statistics for the years 2001 and 2006 were also used. The definition of health status was based on the difficulty in performing activities of daily living. RESULTS The remaining lifetime was strongly dependent on the current health status of the older women. Between 1998 and 2003, the amount of time lived with disability for healthy women at age 65 was 9.8%. This percentage increased to 66.2% when the women already presented some disability at age 65. Temporal analysis showed that the active life expectancy of the women at age 65 increased between 1998-2003 (19.3 years) and 2003-2008 (19.4 years). However, life years gained have been mainly focused on the unhealthy state. CONCLUSIONS Analysis of conditional and unconditional life expectancy indicated that live years gained are a result of the decline of mortality in unhealthy states. This pattern suggests that there has been no reduction in morbidity among older women in Brazil between 1998 and 2008.

Activity limitations, use of assistive devices or personal help, and well-being: variation by education

OBJECTIVES

This study examined the associations among self-care or mobility limitations, use of assistive devices or personal help, and well-being while giving special attention to 3 dimensions of well-being and older adults' educational attainment.

METHOD

The analysis was based on 4,456 community-dwelling older adults with self-care or mobility limitations who completed interviews in the first round of the National Health and Aging Trends Study. Path models were estimated to examine the associations among limitations, use of assistive devices or personal help, and 3 dimensions of well-being (positive affect, self-realization, and self-efficacy) for different educational groups of older adults.

RESULTS

Self-care or mobility limitations had a negative association with 3 dimensions of well-being. The use of assistive devices was positively related, but the use of personal help was negatively related to well-being. Older adults with more education demonstrated weaker associations between assistive devices and well-being and stronger inverse associations between personal help and well-being than those with less education.

DISCUSSION

The use of coping strategies to address self-care or mobility limitations is not necessarily associated with better well-being, and education does not seem to play a protective role once limitations develop. More research is needed to unpack population heterogeneity in the association between coping strategies and well-being.

Expansion of morbidity: trends in healthy life expectancy of the elderly population

Objective: to analyze the changes in life expectancy (LE) and disability-free life expectancy (DFLE) in São Paulo's elderly population to assess the occurrence of compression or expansion of morbidity, between 2000 and 2010. Methods: cross-sectional and population survey, based on official data for the city of São Paulo, Brazil, and data obtained from the Health, Well-Being and Aging Survey (SABE). Functional disability was defined as difficulty in performing at least one basic activity of daily living. The Sullivan method was used to calculate LE and DFLE for the years 2000 to 2010. Results: from 2000 to 2010, there was an increase in disabled life expectancy (DLE) in all age groups and both sexes. The proportion of years of life free of disability, at 60 years of age, decreased from 57.94% to 46.23% in women, and from 75.34% to 63.65% in men. At 75 years of age, this ratio decreased from 47.55% to 34.54% in women, and from 61.31% to 56.01% in men. Conclusion: the expansion of morbidity is an ongoing process in the elderly population of the municipality of São Paulo, in the period of 2000-2010. These results can contribute to the development of preventive strategies and planning of adequate health services to future generations of seniors.

Estimativas de expectativa de vida com doenças crônicas de coluna no Brasil

As doenças crônicas de coluna, entre elas as deformidades e as dores musculares, são importantes causas de morbidade entre adultos e idosos. O objetivo deste estudo foi estimar a expectativa de vida de brasileiros com doenças crônicas de coluna, por sexo e idade, nos anos de 2003 e 2008. Empregou-se o método de Sullivan, combinando a tábua de vida e as prevalências de doen ças crônicas de coluna. Foram utilizadas as tá buas de vida publicadas pelo Instituto Brasileiro de Geografia e Estatística e as prevalências de enfermidades crônicas de coluna da Pesquisa Nacio nal por Amostra Domiciliar (PNAD), dos anos selecionados. Os principais resultados indicam que, no Brasil, ao nascer em 2008, um homem poderia esperar viver 69,1 anos, 15% dos quais com doenças crônicas de coluna. Já as mulheres que nasceram neste mesmo ano, apresentavam uma expectativa de vida de 76,7 anos e espera riam viver um quinto de sua vida com problemas crônicos de coluna. No período analisado, concomitantemente aos ganhos na expectativa de vida, ocorreu um crescimento na expectativa de vida saudável, ou seja, nos anos de vida livre de doenças crônicas da coluna, tanto em termos absolutos como relativos.

The potential for technology to enhance independence for those aging with a disability

Technologies of all kinds can sustain and accelerate improvements in health and quality of life for an aging population, and enhance the independence of persons with disabilities. Assistive technologies are widely used to promote independent functioning, but the aging of users and their devices produces unique challenges to individuals, their families, and the health care system. The emergence of new "smart" technologies that integrate information technology with assistive technologies has opened a portal to the development of increasingly powerful, individualized tools to assist individuals with disabilities to meet their needs. Yet, issues of access and usability remain to be solved for their usefulness to be fully realized. New cohorts aging with disabilities will have more resources and more experience with integrated technologies than current elders. Attention to technological solutions that help them adapt to the challenges of later life is needed to improve quality of life for those living long lives with disabilities.

Assistive technologies in caring for the oldest old: a review of current practice and future directions

Our aging populations have led to concern as to whether existing care provision will cope with the predicted future demand. The oldest old (those over 85 years) are a particular challenge; they are the fastest growing sector of our population and have high rates of comorbidity and cognitive impairment. Assistive technologies provide one possible solution to promote independence for older individuals, but are often underutilized in routine care. In this perspective, we consider how assistive technology can support the future care of the oldest old. First, we summarize the evidence on the health of the oldest old and their current use of assistive technology with a review on the evidence to date on the effectiveness, and potential benefits, of assistive technology. We then discuss the ethical issues associated with the use of assistive technology in this population and, finally, identify key directions for future research and service development in this field.

Assistive devices in context: cross-sectional association between challenges in the home environment and use of assistive devices for mobility

PURPOSE

A primary goal for aging policy is to optimize independence in later life. We estimate the cross-sectional association between physical and social challenge in the home environment and use of assistive devices (AD) for mobility in the home, controlling for lower extremity physical performance (short physical performance battery [SPPB]) and other factors.

DESIGN AND METHODS

Data are from the Women's Health and Aging Study I, a prospective study of the factors related to physical disability in a sample of moderately to severely disabled older women. We describe these associations in the baseline sample overall and also within subsets who do and do not have both a baseline and a 3-year follow-up observation.

RESULTS

On average, physical challenge in the home environment is inversely associated with level of AD use (p < .05) in the overall sample, independent of SPPB, living alone, and other factors. We do not find a significant (p < .05) association between social challenge and the level of AD use in the overall sample. Findings by follow-up responder status were similar (with minor variability).

IMPLICATIONS

Future cohorts who are better educated and more receptive to technology may confront challenges in the home environment that limit their ability to age in place. Our findings suggest that the physical challenges of the home are significantly related to AD use. Future analyses that explore the mechanisms of the home environment as a source of challenges to independent functioning could help in the design of future interventions for these cohorts as they age.

The association between chronic disease and physical disability among female Medicaid beneficiaries 18-64 years of age

BACKGROUND

Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population.

OBJECTIVE

This study described the prevalence of chronic disease among adult (18-64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005.

METHODS

Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability.

RESULTS

Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts.

DISCUSSION

Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the long-run.

A quality-of-life scale for assistive technology: results of a pilot study of aging and technology

BACKGROUND

In an aging society, it is increasingly important to understand how assistive devices can be used by older people to maintain quality of life despite chronic disabilities. Assistive technology is a mainstay of physical therapist practice, but the potential for device use to affect psychosocial well-being is not yet understood at the population level.

OBJECTIVE

The objective of this study was to develop a parsimonious indicator that can be used in population-based surveys to represent the effect of assistive technologies on quality of life for older people, separate from personal assistance.

DESIGN

This study was a cross-sectional survey.

METHODS

/b> The methods used in this study were psychometric scale development and structural equation modeling.

RESULTS

The results indicated that a parsimonious, valid, and reliable scale reflecting quality of life related to assistive device use can be created from 3 questions designed to measure improvements in safety, control, and participation due to technology. The findings also suggested that assistive technology may more effectively improve quality of life for people with greater levels of functional limitations.

LIMITATIONS

The data were derived from a cross-sectional survey conducted by telephone. The use of personal assistance, on average, was low; thus, the applicability to a population with more profound care needs has yet to be confirmed.

CONCLUSIONS

Determining the broader impact of assistive technology on quality of life with population-level measures may provide insight into how best to leverage technologies to prevent dependence in aging adults.

Incident preclinical mobility disability (PCMD) increases future risk of new difficulty walking and reduction in walking activity

PURPOSE

This study examines whether and how report of a change in walking behavior, incident PCMD, predicts subsequent reduction in walking activity.

MATERIALS AND METHODS

Data are from a prospective study of 436 community-dwelling women age 70-79 years. Outcome measures include subjective and objective measures of walking ability at 3 years.

PRINCIPAL RESULTS

Incident PCMD is associated with the loss of walking abilities at 3-years, regardless of baseline physical impairment. Compared to women without, women with incident PCMD at 1.5 years after baseline were 2.7 (95%CI 1.4-7.2) times more likely to report that they no longer walk outdoors at least 8 blocks and 4.9 (1.9-13.1) times more likely to report new difficulty walking. Incident PCMD was also associated with declines in objective outcomes. Incident PCMD is an independent marker of subsequent decreased walking activity.

MAJOR CONCLUSIONS

Incident PCMD appears to be a target for programs to prevent declines in walking activity in older adults.

Validation of new measures of disability and functioning in the National Health and Aging Trends Study

BACKGROUND

Measurement gaps continue to hamper fuller understanding of late-life disability trends and dynamics. This article reports findings that validate the self-reported components of the disability protocol to be used in the new National Health and Aging Trends Study. The protocol was designed to redress existing measures by attending to environmental aspects of disability, capturing a broader range of capacity to perform tasks and including participation restriction items.

METHODS

We undertook an in-person validation study to determine the reliability, validity, and initial measurement properties of the National Health and Aging Trends Study self-reported disability protocol (n = 326). A random subset (n = 111) was readministered the protocol within 2-4 weeks. The interview and reinterview included new self-reported measures of physical capacity, activity limitations, and participation restrictions, as well as established performance and cognitive tests. We calculated percent agreement and kappa between interviews for all self-reported items and summary measures. We also assessed the construct validity of summary measures through correlations with demographic characteristics, frailty, memory, and performance-based mobility and confirmed whether activity limitations and participation restrictions were distinct domains.

RESULTS

New items and derived summary measures demonstrate robustness over a short time period, with kappas for retained/recommended items in the .60-.80 range. The summary measures correlate as expected with age, sex, residential status, and established performance-based constructs. Two factors, representing activity limitations and participation restrictions, were confirmed.

CONCLUSIONS

The National Health and Aging Trends Study protocol preserves the ability to examine more traditional measures of functioning while offering new insights into how activities are performed and preserving key conceptual distinctions.

Demographic profile of older adults using wheeled mobility devices

The purpose of this study was to determine whether the use of wheeled mobility devices differed with respect to age, gender, residential setting, and health-related factors among older adults. A total of 723 adults ageing 60 and older are representing three cohorts, from nursing homes, the Center for Assistive Technology, and the wheelchair registry from the Human Engineering Research Laboratories. Wheeled mobility devices were classified into three main groups: manual wheelchairs, power wheelchairs, and scooters. Our results found factors including age, gender, diagnosis, and living settings to be associated with differences in use of manual versus powered mobility devices. Differences in use were also noted for subtypes of manual (depot, standard, and customized) and powered (scooter, standard, and customized) mobility devices, on demographic, living arrangements, and health-related factors. Consideration of demographic, health-related, and environmental factors during the prescription process may help clinicians identify the most appropriate mobility device for the user.

Medical and Everyday Assistive Device Use among Older Adults with Arthritis

This research compared older adults' use of medical assistive devices (ADs) with their use of everyday ADs as a means of managing chronic physical disability. The study also examined whether predisposing, need, and enabling factors were associated with device use in three domains of activity: personal care / in-home mobility, household activities, and community mobility. Participants were 248 adults, aged 55 years and older, with a wide range of disability levels as a result of osteoarthritis. All participants were administered an in-depth, structured questionnaire, as part of a larger study examining older adults' independence and adaptation to chronic physical illness. The results revealed that respondents actively adapted to their disabilities and used a wide range of medical and everyday devices, with everyday devices being reported more than twice as often as medical ADs and the fewest devices overall being reported for community mobility. In general, medical devices were used when subjective and objective need for ADs was considerable. Everyday devices were reported earlier in the trajectory of the disease, at mild and moderate disability levels, and were associated with a broader pattern of adaptation that included planning to avoid problems, exercise, and pacing activities.

[Healthy life expectancy to Brazilian elders, 2003]

The increase of the percentage of elderly population in Brazil and the increase in longevity incite a demand for information on the quantity of years spent in good health. The aim of the present study is to measure the life expectancy for the elderly of 60 years and above, by sex and age, in the year of 2003. The Sullivan method was used, which combined the life-table with the current experience of mortality and the self-perceived health. The mortality information was obtained from the life tables published by the IBGE (Brazilian Institute of Geography and Statistics), 2003. The self-perceived health was used and it was dichotomized in good and bad. This information came from the National Research of Household Sample (PNAD), 2003. The results indicate that women live longer, but spend a higher number of years perceiving their health as bad, as compared to men. The results also highlights to the need of considering the differences between sexes in relation to the demand for health care. It is also important to consider the need to have policies designed to allow the increase in the number of years that the elderly can live in good health conditions.

Ambulatory assistive devices in orthopaedics: uses and modifications

Ambulatory assistive devices (eg, canes, crutches, walkers) provide advantages such as stability, augmentation of muscle action, and reduction of weight-bearing load. Although they are often prescribed, a detailed understanding of these devices is often lacking, which can lead to detrimental consequences. Comprehension of normal gait cadence, as well as the gait patterns used in both reciprocating and swinging gait, allows the orthopaedic surgeon to understand the limitations of the patient with gait abnormalities. Appreciating the types of assistive devices, their modifications, associated gait patterns, physiologic demand, proper fitting, and indications for use is essential in prescribing the proper device.

Promoting independence in older persons through the internet

New communication technologies provide hope for promoting independence in older persons. Today the Internet provides opportunities to socialize with others, participate in educational and spiritual activities, and assist with some of the instrumental activities of daily living. This is important in terms of quality of life for older persons as well as reducing expenditures for long-term care. This article discusses the growth in use of the Internet by the elderly and evaluates its ability to meet both various general needs of the population as well as needs specific to older persons.

A conceptual framework of outcomes for caregivers of assistive technology users

OBJECTIVE

To develop and validate the content of a conceptual framework concerning outcomes for caregivers whose recipients are assistive technology users.

DESIGN

The study was designed in four stages. First, a list of potential key variables relevant to the caregivers of assistive technology users was generated from a review of the existing literature and semistructured interviews with caregivers. Second, the variables were analyzed, regrouped, and partitioned, using a conceptual mapping approach. Third, the key areas were anchored in a general stress model of caregiving. Finally, the judgments of rehabilitation experts were used to evaluate the conceptual framework.

RESULTS

An important result of this study is the identification of a complex set of variables that need to be considered when examining the experience of caregivers of assistive technology users. Stressors, such as types of assistance, number of tasks, and physical effort, are predominant contributors to caregiver outcomes along with caregivers' personal resources acting as mediating factors (intervening variables) and assistive technology acting as a key moderating factor (effect modifier variable).

CONCLUSIONS

Recipients' use of assistive technology can enhance caregivers' well being because of its potential for alleviating a number of stressors associated with caregiving. Viewed as a whole, this work demonstrates that the assistive technology experience of caregivers has many facets that merit the attention of outcomes researchers.

Assessment of physical functioning: a conceptual model encompassing environmental factors and individual compensation strategies

Commonly studied physical functions include activities such as walking and climbing stairs. Despite the acknowledged role of environmental factors and behavioral strategies to compensate for reduced performance capacity or environmental barriers in characterizing physical functioning, most assessments do not take these factors into account. This article presents a new conceptual model for assessment of relevant physical functioning while accounting for habitual environmental factors and compensation strategies.