42% of older adults have unmet need for assistive bathing, toileting devices
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A nationally representative cohort study estimated that 5 million older adults in the U.S. who have difficulty performing self-care tasks or are at risk for falls lack access to grab bars, shower seats and other assistive devices.
“In an older population, the evidence for non-pharmacological interventions like home modification, occupational therapy and physical therapy is robust. They prevent falls, improve quality of life, and reduce hospitalization — with effects that are more meaningful than things like vitamin D or aspirin, even though that's what we are typically trained to discuss in our visits with patients as clinicians,” Kenneth Lam, MD, a clinical fellow at the University of California, San Francisco, told Healio Primary Care. “Despite this evidence, I believe most older patients walk out of PCP appointments thinking about aspirin and vitamin D and not about how they might change up their home for the sake of their health and wellbeing.”
Describing the unmet need for assistive devices in the US
Lam and colleagues conducted a nationally representative observational cohort study using data from the U.S. National Health Trends and Aging Study on 2,614 older adults (mean age, 80.5 years; 62% women; 60% white) who live in communities, not retirement homes or institutional facilities, representing 12 million individuals in the U.S. Among the study population, 40% had an educational level beyond high school, 33% lived alone, 47% had an income level in the lowest quintile and 34% had three or more health conditions.
Participants discussed health, function, living environment and finances and completed an objective assessment of physical performance with an interviewer once annually in person. The study’s main outcome measure was the unmet need for bathing equipment, including bath grab bars and shower seats, or toileting equipment, including toilet grab bars and raised seats, and the cumulative incidence of equipment acquisition during the 4-year follow-up period. The researchers wrote that they selected this outcome “owing to the high prevalence of conditions that require their use, ease of installation and low cost relative to other equipment such as ramps or stair lifts.”
The researchers estimated that 42% (95% CI, 39-44) of older adults had an unmet need. After the 4-year follow-up period, 35% (95% CI, 30-40) of older adults still had an unmet need for bathing equipment, 8% (95% CI, 6-11) of whom died before receiving the equipment. In addition, 52% (95% CI, 47-57) of older adults still had toileting equipment needs, including 17% (95% CI, 14-21) who died before receiving this equipment.
Lam and colleagues adjusted the analysis for age, sex, race and ethnicity and found that unmet need was associated with several factors, including younger age. There was an unmet need in 49% (95% CI, 44-54) of those aged 65 to 74 years, 37% (95% CI, 33-41) of those aged 75 to 84 years, and 29% (95% CI, 25-33) of those aged 85 years and older.
Race and ethnicity were also factors. Forty percent (95% CI, 36-44) of white participants had an unmet need, compared with 51% (95% CI, 45-56) of Black participants, 54% (95% CI, 46-62) of Hispanic participants and 55% (95% CI, 47-64) of participants who indicated “other.”
There were multiple clinical characteristics associated with unmet need, including fewer health conditions (55% among those with none vs. 39% among those with three or more), not having a regular physician (61% vs. 42%), no recent hospitalization (46% vs. 37%) and no prior knee or hip fracture or surgery (46% vs. 35%), according to the researchers.
How primary care providers can address older patients’ unmet needs
Lam said that 95% of the study population saw a doctor regularly, creating an opportunity for PCPs to address assistive technology with older patients.
“I believe a visit focused on addressing these issues would be better than time spent discussing more pills,” he said.
Lam offered the following suggestions for PCPs to incorporate into regular practice:
- monitor older adults for disability, particularly recurring falls or poor balance, “not just because it’s a risk for them, but because there’s something you can do about it;”
- incorporate questions about patients’ personal experiences as they age and whether they feel more limited;
- propose the idea of making changes around the home, if indicated, because “it might well help them stay at home longer rather than spending a bunch on a nursing home;” and
- partner with other health care providers in the area, including occupational therapists, physical therapists and home modification groups.
“Think of it like writing a prescription then asking them to go to the pharmacy — only here, the evidence-based intervention is equipment,” Lam said.
However, there are often systemic obstacles to obtaining assistive devices. In an invited commentary, Brian E. McGarry, PT, PhD, assistant professor at the University of Rochester, and Jason R. Falvey, PT, DPT, PhD, assistant professor at the University of Maryland, pointed out that “Medicare only covers equipment that is deemed medically necessary,” which excludes “many forms of equipment that improve safety and reduce risk for falls, including grab bars, handrails, toilet seats, and shower chairs.”
Ultimately, the lack of coverage means that older adults are subject to not only an out-of-pocket expense, but also frequently must navigate identifying, purchasing and installing assistive equipment themselves, according to McGarry and Falvey.
“This is a complex process, and the arbitrary distinction between equipment that is for safety rather than medical in nature often leaves older adults without the equipment they need to stay in their homes,” McGarry and Falvey wrote.
They also offered suggestions for PCPs.
“Every clinical encounter should be treated as an opportunity to screen older adults for changes in physical function, particularly those associated with activities of daily living,” they wrote.
They added that physicians can screen for assistive equipment needs at annual wellness visits or assess the home environment via telehealth video visits.
Physicians can use the CDC’s “Check for Safety” questionnaire, part of its Stopping Elderly Accidents, Deaths and Injuries toolkit, and incorporate “questions about activities of daily living (eg, toileting, bathing, getting in/out of the house) that focus on reports of difficulty, need for assistance, and subjective concerns, like a fear of falling, can identify potential equipment needs,” McGarry and Falvey wrote. Physicians can also use “simple measures of physical capacity, such as gait speed,” which they wrote “have been shown to predict fall risk.”
After identifying a need for equipment, older adults will likely require help determining what equipment to obtain and how to install it in their homes. According to McGarry and Falvey, there are several options that range from local vendors who advise, sell and install equipment; direct online retailers, which may have a lower cost but often require older adults to select their own equipment and coordinate installment; and community “loan closets,” which “may be particularly important for low-income patients.”
Health care providers should follow up with patients to ensure that the adaptive equipment “has been installed safely and patients feel comfortable using it,” they wrote.
“The findings of Lam and colleagues make clear that there is substantial room for improvement when it comes to meeting the adaptive equipment needs of older adults,” McGarry and Falvey wrote. “Most patients want to stay in their homes; we should help them.”
References:
- Lam K, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.0204.
- McGarry B, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.0398.
Perspective
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The findings don’t surprise me because having worked with the elderly population for my entire professional career, bathroom equipment is always an issue because it is not covered by Medicare Part B. Many times, patients and/or family members can’t afford it, particularly when they’re having to make other modifications to the home, so that’s an issue.
From a clinical standpoint, it certainly gives us some qualitative data to think about the number of people who are truly being affected by not having that assistive device. When you consider the implications of further falls and further problems, it’s almost like we’re playing catch up. If you look at what a fall costs Medicare, particularly if someone breaks a hip, and if we could prevent 10% of falls that occur in the bathroom with some bathroom or toilet assistive devices, then the money could be saved from not having to replace hips and surgically repair hip fractures. Instead, as the system is set up today, we just play catch up.
On a federal level, we need legislation. We should really look at articles like this and show our legislators what the implications are and how many falls could actually be prevented.
As a physical therapist, I’m trained to ask patients, “What’s your home environment like? How many steps do you have going into your house? Do you have throw rugs?” This is discharge planning. Even in an outpatient setting, when I have somebody at fall risk, I do a verbal screen with them and their family members to assess home environments, but I’m not sure every elderly person is evaluated by a physical therapist or occupational therapist to asked about their home and access to home equipment. I think what would be beneficial is if PCPs, nurse practitioners or physician assistants could entertain the policy, particularly with somebody over the age of 65, to automatically refer them to physical therapy or occupational therapy for a comprehensive screen, so that those of us who are trained to ask those questions, can ask those questions. If we’re really looking at quality of life, we have to ask: “What does your home environment look like? Are you having trouble with bathing or toileting? What assistive equipment is available to you?” We have a handout here that we give people that shows how to order some of these pieces of equipment out of the Home Depot and Lowe’s catalogue.
When former patients pass away and their family members offer to donate equipment like a bedside commode, a set of handrails or an extra walker, I take it and store it. So, if I know someone needs an elevated toilet seat and they can’t afford one, I’ll go see what I have in our storage area. I think both local and state-wide programs to repurpose some of this equipment would be extremely beneficial. I know we do it here at LSU Health, because the populations we primarily work with are economically disadvantaged, and many times, I know for a fact cost is an issue.
Patient and family education is also important. Many times, I believe there are patients’ family members who would do what they could to provide the assistive devices and equipment if they understood the need for it, so we need to educate them. Now, who does that? Is it the primary care clinician? I know we do it as physical therapists and occupational therapists, but there’s so many times we don’t get that chance unless they have an issue. They are referred to rehab after the fall and they’ve broken a leg.
The way the system works now, we don't usually have that preventative educational opportunity. If we did, would we be able to prevent that first incident? I don’t know, that’s a great question, but I would certainly like the opportunity to try!
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