BY LAURA N. GITLIN
Reprinted with permission from Generations,
Journal of the American Society on Aging,
Vol. XIX, No. 1, Spring 1995
Our understanding of why older people choose to accept or reject - use or abandon use of an assistive technology is still rather formative. We know from research and practice that it is a complex matter that may be shaped by a variety of factors. These factors can be categorized as person-based, such as perceived need, functional status, and personal evaluations of disability and devices; as related to the nature of the environment, including the physical and social characteristics of the context in which the device is used and the demands imposed by a particular task; and as involving the device itself, such as its aesthetic quality, durability, ease of use, and fit with the person and environment. Furthermore, the use of an assistive technology occurs within a sociocultural context. Social attributes related to devices and cultural judgments concerning independence and dependence, having or not having a disability, seem to represent powerful influences on whether devices are accepted into a person's daily public and private routines. The independent and joint influences of these multiple factors for facilitating or hindering device use remain under-researched and little understood for different segments of the older population.
FREQUENCY OF USE OF ASSISTIVE DEVICES
What do we know about use and abandonment of assistive technology by older people? Current research has primarily focused on the elderly who experience a physical or cognitive impairment. There is virtually no published literature on the frequency of device use by other segments of the older population, such as care providers or those who begin to experience age-related changes and for whom devices may offset functional decline. The existing research on individuals with an impairment is represented by national large-scale surveys as well as numerous regional small-scale surveys. The large-scale surveys, which include the National Health Interview Survey (LaPlante, Hendershot, and Moss, 1992; Macken, 1986), National Long-term Care Surveys (Manton, Corder, and Stallard, 1993), and the Canadian Health Activity Limitation Survey (Forbes, Hayward, and Agwani, 1993) have consistently demonstrated a trend toward an increase in assistive device use and a decline in the use of personal assistance by older people with varying levels of functional disability and impairment. These surveys have also found that older people often cite the need for additional equipment and use products to help with a wide range of problems.
In an extensive review of the literature on assistive technology and the elderly, only eleven descriptive regional studies conducted in the United States were identified that included a sample of individuals who were 55 years of age or older (Gitlin, 1994). These studies, which differ vastly in sample size, sampling procedures, population groups, and, not surprisingly, in findings, reported averages of 2 to 13.7 devices in the homes of older people and wide variation in use rates. Frequency of use, which ranged among the studies from 35 percent to 82 percent, tended to vary by the type of device considered, the specific functional limitation, and the time of onset of the impairment. For example, people with visual impairments tend to report high use rates, while those with cognitive impairments report the least number of devices in use (Mann, Hurren, and Tomita, 1993). Also, those with a recent-onset condition appear to use devices less than those who have had an impairment for a longer period of time (Van Der Heide et al., 1993).
These findings are consistent with a recent study of 139 older rehabilitation patients who were discharged to their homes with one or more assistive devices. In this study, subjects had an average of eight devices (a receive range of one to eighteen) for home use to facilitate mobility, dressing, bathing, feeding, seating, or grooming. During the first month home, 47 percent of the issued assistive devices were being used on a regular basis. Furthermore, subjects either rejected or abandoned a device or accepted and used it with regularity. Very few used a device on just an occasional or infrequent basis (Gitlin et al., 1994).
FACTORS THAT PREDICT USE
Although there is ample evidence that older people with a disability are device users, it is not yet clear which factors or characteristics distinguish users from nonusers. Given the diversity of the elderly, population, these factors may differ according to which segments of that population, types of impairment, and category of devices are considered. For example, in a recent study of 1,400 community dwelling Canadian elders who experienced mobility impairments, Zimmer and Chappell (1994) found that the most important determinant of the use of a mobility device was the number of mobility problems a person experienced, as opposed to the level of severity, of the problem. People who reported three or more mobility, restrictions were more likely to use a mobility aid than were those who reported fewer difficulties. In another recent study of eighty-six older rehabilitation patients who were first-time device users, with either a stroke, orthopedic deficit, or lower-limb amputation, a different set of predictors was identified (Gitlin et al., 1994). This study involved subjects for whom device need was identified by a health professional, instruction was provided during hospitalization, and people were sent home with their devices with no out-of-pocket costs incurred. Thus, for this group of elderly, neither access, cost, lack of instruction, or lack of knowledge of devices impeded use - all factors that have been identified as potential reasons for the abandonment of devices.
During the first month home, greater frequency of device use was found for those who held a positive orientation toward devices and who during hospitalization expected to use the device upon return home. A positive orientation toward devices included viewing devices as tools for independence as well as a willingness to experiment with different strategies to compensate for functional loss.
The use of devices in the home in month two was best predicted by the frequency of use in the previous month (R^2=.51, p<.000). That is, those who chose to use a device in their home during the first month were most likely to continue to use that device in the following, month.
In month three, the use of devices was best predicted by the frequency of use in month two and by, the type of impairment experienced. Individuals with a lower-limb amputation tended to use their devices with more frequency than either the orthopedic or cerebrovascular patients. Although it was anticipated that orthopedic patients would not need many of their devices by month three, this was not expected to be the case for patients with a stroke. Stroke patients in this study also expressed greater negativity toward their disability and the devices they had been issued. This finding is consistent with previous research that has reported severe disruption in personal identity experienced by stroke patients (Becker, 1993; Kaufman, 1988) and suggests that this group may be at greater risk of abandoning their devices with time.
It was also noted that those who lived alone and those with lower education tended to use devices with more frequency by month three. On an intuitive level, living alone would appear to affect the willingness of an older person to accept an assistive technology. For those who lived alone in this study, sources of support from family, friends, and neighbors may have been exhausted by the third month and thus there was a greater reliance on devices by that month. Finally, there was also a slight trend for those with greater psychological adjustment or lower morale to use devices with greater frequency by month three. Again, this demonstrates the salience of the psychological dimension for shaping the pattern of device use in the home.
The factors that do not predict continued home use in these studies are important to consider as well. The first factor that does not appear to be related to the frequency of use is a person's age. The oldest segment of the elderly population, those 75 years of age or older, are just as likely to use a device as the young old. This point is an important one for product developers and rehabilitation therapists, who evidence reluctance to develop new technologies or issue assistive devices to older patients because of stereotypical beliefs about the elderly.
Gender has also not been found to be a predictor of use; males and females appear to use devices with equal frequency. Functional level may also not affect acceptance and use of a device. Although those with lower levels of function are more inclined to need and hence use a device, other health indicators appear to be more significant in determining actual use; for example, the number and type of difficulties encountered. Finally, the influence of education, income, socioeconomic status, and race on assistive device use remains unclear.
THE USER'S PERSPECTIVE
While many researchers have described the frequency of device use by older people with a disability, less attention has been given to the user's perspective or how individuals come to recognize the need for a technological aid and adapt to its use. It is now recognized that the experience of illness and disability profoundly affects the ways people redefine themselves when their functional abilities become diminished or lost. How individuals proceed through the process of personal recovery and begin to reconstruct a sense of self shapes the ways prescribed therapies or techniques such as the use of a technological aid are accepted.
Although assistive devices are routinely considered by health professionals as objects that promote independence, there is growing recognition that these tools generate a range of subjective responses by users. However, there are only a few investigations concerning these "inner experienced" of assistive technology use. Studies of individuals with postpoliomyelitis (Locker, Kaufert, and Kirk, 1987; Luborsky, 1993) and spinal cord injury (Scheer and Luborsky, 1991) suggest that personal interpretations of technology may involve both positive and negative evaluations and that its use, especially in public, may bring into play or even necessitate cognitive and behavioral coping mechanisms to offset negative social judgments.
Assistive technology may be viewed positively, as a mechanism by which to regain independent performance, or negatively, as a symbol of lost function and abilities. In daily living the use of an aid modifies the way an activity is performed either by altering the physical environment or by serving as an extension of a person's body. The individual may therefore need to adjust to using an assistive device by relinquishing previously valued and preferred ways of carrying out basic living tasks. For example, statements about assistive devices by older people who had been hospitalized for a stroke suggest that the initial use of devices evokes a comparison of one's past to one's present status in which people begin to describe themselves using the language of disability, including terms like "crippled" and "handicapped" (Gitlin, et al., 1994):
'It's not like before. I used to feel sorry for people who had wheelchairs.'
'I am the same person. I just can't walk.'
'I don't like to be dependent on these devices and others. I was very independent before my stroke.'
'My wheelchair makes me a cripple.'
'Glad to have gone outdoors and to have seen people's reactions before I went home.'
These comments reflect an underlying concern with negative social appraisals and suggest that social stigma may be an important construct for understanding acceptance, continued use, or the abandonment of assistive technology by older people, especially for those who experience disability for the first time. It has been noted that even taking medication may be governed by the degree to which an older person feels more stigmatized or dependent by following the prescribed regimen (Zola, 1986).
Despite its liberating aspects and even when it is necessary to sustain life, the use of technology appears to present dramatic compromises in social activities, role definition, and self-identity. Conversely, there is evidence to suggest that those who are willing to experiment with different ways of managing functional loss in order to adjust to disability and who value independent performance may be less concerned with social appraisals and more motivated to use devices (Bruno, 1993; Gitlin et al., 1994).
REASONS FOR ABANDONING ASSISTIVE DEVICES
Abandoned devices are those that are owned by older people but are not in use. For example, a person who switches from a walker to a cane is considered to have abandoned the walker. Similarly, devices that remain in the closet or under the bed or that become broken or lost are considered as abandoned as well. Regardless of the reason, the abandonment of an assistive device represents an ineffective use of limited resources, including the funds used to purchase the device and the time a health professional spends instructing a client in its use. Perhaps by understanding the reasons for abandonment, we can construct more effective and cost-saving services.
REASONS FOR DEVICE USE AND ABANDONMENT
REASONS FOR DEVICE ABANDONMENT
A variety of reasons, which are listed in Table I, have been reported as to why older people abandon assistive devices. A careful examination of these reasons reveals, however, that each can be addressed through the enhancement of the assistive technology services that are offered to older people or by the modification and improvement of the technology itself. For example, consider the following reasons for nonuse: (1) improvement of client's functional stability, (2) nonuse of one device because its use depends upon use of another (perhaps abandoned) device, (3) lack of knowledge about how to use the device, (4) poor fit between a device and the physical environment, and (5) broken or lost device. Situations 2 through 5 above could be remedied through a flexible service delivery system that allows periodic opportunities for health professionals, particularly occupational therapists, to re-evaluate the continued use of a particular device as its owner's needs and environment change (Gitlin and Levine, 1992).
These reasons for abandonment also suggest that the method of instruction and the context in which it occurs need greater attention to ensure appropriate prescription and maximize proper use. Older people learn to use new technologies best when the task is broken into component parts, the skill is learned in the context in which it will be used, and learning sessions are kept short and interspersed with practice opportunities (Czaja and Barr, 1989). In particular, older people appear to benefit from short training, periods with many, opportunities for practice, experimentation, re-evaluation, and modification of the assistive device or the environment, if necessary. Also, older adults, especially first-time device owners, may become more successful users if such strategies are introduced within the context of a valued activity and/or if instruction occurs in the home. Furthermore, instruction should include information as to where to obtain other technologies and how to repair or replace broken or lost devices (Gitlin, Levine, and Geiger, 1993).
Another reason for device abandonment is, as discussed earlier, that devices symbolize a change in competencies that is associated with negative social judgments. A state of psychological readiness or a certain level of motivation appears to be required if a person is to become a successful device user. Sensitivity to how a disabled person feels about his or her changing self and knowledge of the person's level of motivation are important in a helping professional, particularly when the client denies the need for technological assistance. People in this group may need extended exposure to assistive devices and opportunities to practice activities that are relevant and meaningful to them.
When clients have concerns associated with the appearance of assistive devices and their awkwardness, these feelings may be alleviated in part by the use of universal-type designs. Universally designed technological products enable the professional to portray device use as normal and to minimize the social stigma some older adults associate with these tools. This, coupled with marketing strategies that emphasize the positive aspects of assistive technology, may begin to provide a societal framework for supporting its use.
Yet another reason for device abandonment cited by older people is the preference for relying on a family member or other source of personal assistance to perform a task. Family members provide close to go percent of the support for older people with long-term chronic conditions. Older adults and their caregivers demonstrate great resilience and adaptability to functional decline and develop their own creative solutions to complex care problems. Nevertheless, their solutions can sometimes pose new safety risks, such as falls or unsafe practices in the home, which could be minimized through the appropriate use of an assistive technology. The way in which caregivers manage and participate in elders' daily routines may influence how and when assistive devices are introduced and used in the home. Also, family members themselves may benefit greatly by using a device in the care of their elder. Nevertheless, caregivers receive limited instruction, if any, in the use of devices and usually have limited knowledge as to their potential benefit. Furthermore, caregivers are rarely consulted in making decisions as to what types of devices would assist in their caregiving tasks.
Thus, assistive devices may not necessarily, be considered by caregivers searching for solutions to care difficulties. Again, these issues indicate the need to develop a different service delivery system that involves the older person and his or her caregiver as partners in developing effective approaches to long-term care that include assistive technologies.
REASONS FOR USE OF ASSISTIVE DEVICES
The reasons older people choose to use assistive devices remain understudied but are just as important to understand as the reasons for device abandonment. These reasons (also listed in Table I) emphasize the ease and comfort involved in using the device, the sense of physical safety and emotional security), gained by using it, and the value of devices for accomplishing desired goals or activities and for enabling greater independence and mobility.
These reasons highlight the importance of evaluating the personal goals of individuals as a basis for determining an appropriate assistive technology. That is, older adults use assistive technology when it enables them to perform activities that they identify as personally meaningful and satisfying. Personal goals may include dressing independently, climbing stairs safely, or "smaller" but important actions like picking up objects from the floor. These smaller personal goals (Ory and Williams, 1989) may differ from those of health professionals, who often place greater emphasis on functional gain (Gitlin, 1993; Hasselkus, 1988; Becker and Kaufman, 1988). Some people prefer to use a mix of both personal assistance and assistive devices, depending on the particular activity, the expenditure of energy required, and their personal level of comfort with each form of aid.
Although we tend to think of assistive technology as primarily for those with functional limitations and for the purposes of maintaining independence, there may be other reasons to use a device. For example, assistive technology may "buffer" the effects of a physical environment that places high performance demands on individuals with declining levels of competence (Verbrugge and Jette, I994). That is, use of an assistive device may enable older people to freely move among environments that offer different levels of support. Conversely, an assistive technology such as a grab bar may protect against injury and thus serve as a health-promoting self-care instrument.
Potential device users can be categorized into five groups: (1) individuals who are caring for a family member and for whom select assistive technologies may decrease the burden of care, (2) older individuals for whom device use may promote safety or reduce the risk of injury, (3) individuals who experience age-related changes or functional decline and for whom technologies would enable independent performance and minimize disability, (4) those who have a first-time disability or experience multiple chronic conditions and who may require numerous assistive devices to perform personal care activities, and (5) individuals who are aging with a disability and who may use assistive technologies over the long term to sustain daily activities.
Each of these groups may differ as to how they perceive assistive technology, define its benefits, obtain knowledge of the range of available assistive devices, and acquire devices. Systematic research involving comparisons across these five groups as well as within them would be necessary to fully comprehend the conditions under which older people become technology users and the circumstances under which they choose to abandon that particular approach to performing a daily activity.
On a final note, as the elderly population continues to increase, so too will the importance of assistive technology as a vital strategy to enable continued independence in daily functioning Thus far, there is little understanding as to the characteristics of individuals who use assistive devices in the home. The population of older people is characterized by extreme heterogeneity. The issue of use or nonuse should be evaluated in light of the full range of older persons' life circumstances and varying needs for and access to assistive technologies.
To fully examine use and abandonment we also need to consider the impact of the healthcare system in which a device is acquired. Many older persons' initial introduction to the use of an assistive technology occurs during hospitalization for a chronic disabling condition. How assistive devices are offered to older patients in various medical settings, when devices are introduced in the course of recovery, and the context of instruction in use of a device all hold unknown consequences for a person's decision to accept a device and continue its use over time. Finally, it is important to recognize that the personal goals and device needs of individuals and especially of those with a chronic disability change over time as health, functional status, and life roles improve, decline, alter. This reality has significant implications for the development of effective assistive technology services that enable older people greater access to these tools for living.
Laura N. Gitlin, Ph.D., is associate professor in the Department of Occupational Therapy and assistant director and director of research, Center for Collaborative Research, Thomas Jefferson University, Philadelphia, Pa.
This paper is an outgrowth of research supported by the Department of education, National Institute on Disability and Rehabilitation Research (grant no. H133GOO160), and by the National Institute on Aging (grant no. AG10947).
Becker, G. 1993. "Continuity After a Stroke: Implications of Life-Course Disruption in Old Age." Gerontologist 33(2): 148-58.
Becker, G., and Kaufman, S. 1988. "Old Age, Rehabilitation, and Research: A Review of the Issues." Gerontologist 28(4): 459-68.
Bruno, R. 1993. The Reinforcement Motivation Survey. Hackensack, N.J.: Harvest Press.
Czaja, S. J., and Barr, R. A. 1989. "Technology and the Everyday Life of Older Adults." Annals of the American Academy of Political and Social Science 503: 177-37.
Forbes, W. F., Hayward, L. M., and Agwani, N. I993. "Factors Associated with Self-Reported Use and Non-Use of Assistive Devices Among Impaired Elderly Residing in the Community." Canadian Journal of Public Health 84(1): 53-57.
Gitlin, L. N. 1994. "Technology and Self-Care: What Can Social Science Research Contribute to an Understanding of Technology Use and Aging?" Paper presented at Conference on Research Issues Related to Self-Care and Aging and the Administration on Aging, Washington, D.C., May 26-27.
Gitlin, L. N. 1993. "Therapeutic Dilemmas in the Care of the Elderly in Rehabilitation." Topics in Geriatric Rehabilitation 9(1): 11-20.
Gitlin, L. N., Levine, R., and Geiger, C. 1993. "Adaptive Device Use in the Home by Older Adults with Mixed Disabilities." Archives of Physical Medicine and Rehabilitation. 74: 149-52.
Gitlin, L. N., and Levine, R. E. 1992. "Prescribing Adaptive Devices to the Elderly: Principles for Treatment in the Home." International Journal of Technology and Aging 5: 107-20.
Gitlin, L. N., Luborsky, M., Burgh, D. Y., and Schernm, R. L. 1994. "Older Persons with Stroke Speak About Their Assistive Devices." Paper presented at Conference on Cognition and Aging, St. Louis, Mo., Jan. 10-11.
Gitlin, L N. et al. 1994. "Factors Predicting Assistive Device Use in the Home by Older Persons Following Rehabilitation." Paper presented at Conference on Design for Maturity, American Society on Aging, Washington, D.C., June 19.
Hasselkus, B. R. 1988. "Rehabilitation: The Family Caregiver's View." Topics in Geriatric Rehabilitation 4(1): 60-70.
Kaufman, S. R. 1988. "Stroke Rehabilitation and the Negotiation of Identities." In S. Reinharz and G. D. Rowles, eds., Qualitative Gerontology. New York: Springer.
LaPlante, M. R., Hendershot, G. E., and Moss, A. J. 1992. Assistive Technology Devices and Home Accessibility Features: Prevalence, Payment, Need and Trends. (DHHS Publication No. PHS-92-1250.) Hyattsville, MD: National Center for Health Statistics.
Locker, D., Kaufert, J., and Kirk, B. 1987. "The Impact of Life Support Technology Upon Psychosocial Adaptation to the Late Effect of Poliomyelitis." Birth Defects 23 (4): 157-71.
Luborsky, M., 1993, "Sociological Factors Shaping Adaptive Technology Usage: Fulfilling the Promise." Technology and Disability 2(l): 71-78.
Macken, D. L. 1986. "A Profile of Functionally Impaired Elderly Persons Living in the Community." Health Care Financing Review 7(4): 33-49.
Mann, W C., Hurren, D., and Tomita, M. 1993. "Comparison of Assistive Device Use and Needs of Home-Based Older Persons with Different Impairments." American Journal of Occupational Therapy 47(11): 980-87.
Manton, K. G., Corder, L., and Stallard, E. 1993. "Changes in the Use of Personal Assistance and Special Equipment from 1982 to 1989: Results from the 1982 and 1989 NLTCS." Gerontologist 33(l): 168-76.
Ory, M., and Williams, T E 1989. "Rehabilitation: Small Goals, Sustained Interventions." Annals of the American Academy of Political and Social Science 503: 60-71.
Scheer, J., and Luborsky, M. 1991. "The Cultural Context of Polio Biographies." Orthopedics 14(11): 173-81.
Van Der Heide, A., et al. 1993. "Self Report Functional Disability Scores and the Use of Devices: Two Distinct Aspects of Physical Function in Rheumatoid Arthritis." Annals of the Rheumatic Diseases 52: 497-502.
Verbrugge, L., and Jerre, A. I994. "The Disablement Process." Social Science and Medicine 38(1): 1-14.
Zimmer, Z., and Chappell, N. L. 1994. "Mobility Restriction and the Use of Devices Among Seniors." Journal of Aging and Health 6(2): 185-208.
Zola, I. K. 1986. "Thoughts on Improving Compliance in Elderly Arthritics." Geriatrics 41(8): 81-83.