The historical increases in use of assistive devices continued between 1999 and 2004, so that in 2004, nine in ten elders with disabilities were using at least one device. This represented an increase of nearly a million elders using devices, roughly equivalent to the increase in the 15 years between 1984 and 1999. What was different between 1999 and 2004 was that most of the increase was in the proportion using both personal assistance and devices. Across the 1984-1999 period, independent use of devices for all disabilities had driven the increases.
This change in the driver of assistive device use trends may be related to the increasing rate at which those with even high levels of disabilities are remaining in community settings. A number of factors may contribute to the higher rate of community residence and, thus, indirectly to greater demand for assistive devices. These include the greater array of supportive settings other than nursing homes available for the older population (Spillman and Black 2005), evolution in nursing homes toward a more seriously impaired and medically frail population (Decker 2005), and the increased availability of community care options through the Medicaid program (Eiken et al. 2011). However, although Medicare is a third party payer for many assistive devices through its coverage for durable medical equipment (DME), coverage policies have not changed substantially over the 20-year period of rising device use, so the increases in device use cannot be attributed to deliberate policy efforts to improve access (Wolff, Agree, and Kasper 2005). More aggressive marketing to an aging population, Medicare provider behavior, and other market factors related to the DME benefit may have contributed, however (Reschovsky et al. 2012).
Those who use both help and devices to accommodate their limitations represent nearly two in three community-residing elders, and they have higher levels of disability than elders managing all disabilities with either devices only or help only, making them an important potential target for long-term care policy. Descriptive findings indicated that within this important group using both help and devices, those who were able to accommodate limitation in at least one activity with devices alone received significantly fewer hours of care per week. Multivariate analysis confirmed that a significant association of independent device use with lower hours of care persisted after controlling for disability level and other characteristics. This was also true within the subset of persons using devices independently for at least one activity. Moreover, despite the lower weekly hours of care, use of devices only for at least one activity was not associated with higher rates of reported unmet need.
This result suggests the potential that interventions designed to assist elders and their caregivers in identifying and acquiring appropriate devices might be able to increase independence, reduce hours of formal and informal care needed, and reduce informal caregiver burden, without increasing unmet need. In addition, subsidiary findings suggest that home modifications may be an important part of such interventions.
The results presented here are cross-sectional associations, and as such cannot be interpreted as causal. They also cannot shed light on factors associated with adoption or abandonment of assistive devices, initiation of help, and the relationship between the two. Understanding these dynamics would require longitudinal data capable of observing changes in accommodations in response to changes in health and functioning. The NLTCS, with its 5-year cycle, cannot meet that need. New data collected in the National Health and Aging Trend Study are specifically designed to better understand both trends and trajectories of disability and accommodations, with a one year cycle and retrospective information about events since last interview (Kasper and Freedman 2013). This new data source will provide a platform for better understanding not only the potential for improving outcomes through interventions to support independence and informal caregivers but also when in the disability trajectory such interventions might be most effective.