U.S. Department of Health and Human Services

Evaluation of New Measures of Assistive Technology and the Home Environment from the 2005 Pilot Study of Technology and Aging

Executive Summary

Vicki A. Freedman
University of Medicine and Dentistry of New Jersey

Emily M. Agree
Johns Hopkins University

Jennifer C. Cornman
University of Medicine and Dentistry of New Jersey

September 27, 2006

This report was prepared under contract #HHS-100-03-0011 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officers, William Marton and Hakan Aykan, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Their e-mail addresses are: William.Marton@hhs.gov and Hakan.Aykan@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

Although not exclusively targeted at older adults, assistive technologies appear to be increasingly important in the daily lives of older adults and even may be linked to the decline during the 1990s in personal care use by older persons. These trends, along with projected increases in the number of older persons with disabilities and shortages of long-term care providers, have spurred interest among policy makers regarding how to best leverage technological solutions to reduce dependence among adults as they age. Yet there has been limited nationally focused information to guide these discussions. With current surveys it is not possible to identify groups at-risk for disability because of an environmental barrier or lack of modification to the home, to track the contributions of environmental changes to declines in late-life disability, or to assess the extent to which technology enhances the lives of older adults.

To begin to fill this void, the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services funded the 2005 Pilot Study of Technology and Aging in cooperation with the National Institute on Aging and the National Center for Health Statistics. The purpose of that project was to develop and disseminate a set of questions on assistive technology use and the home environment for national surveys on health and aging. The project involved a review of existing measurement approaches, consultation with stakeholders in policy and national surveys, discussions with technical advisory group members, cognitive testing, and a pilot test with 360 people ages 50 and older. The final recommended instrument was designed as a series of brief modules that can be adopted into a computer-assisted telephone interview.

This report highlights the analytic properties of the new instrument. We address three distinct but complimentary questions:

• How do questions that combine several environmental features or devices (“global measures”) compare with more detailed items?

• How can measures of the home environment be combined with measures of functioning to enhance understanding of disability?

• Can a valid and reliable scale be created from questions that link technology use of quality of life measures?

Analyses provide several useful insights into measurement issues relevant to discussions of policies on disability and aging. First, questions about assistive technology use that combine items into a single question provide modestly lower estimates than more detailed measures. Importantly, our analyses suggest that the single-item in the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System to assess assistive technology use, which names cane, walker, special telephone, and special bed as examples of special equipment used because of a health problem, may under-estimate use by as much as 50%.

Second, we demonstrate at least two ways to combine information about the home environment with measures of functioning to identify groups of interest to policy makers, particularly those interested in furthering declines in late-life disability prevalence. In doing so, we find that potentially as many as one in four adults ages 50 and older might be targeted for an environmental modification in their home because they have a severe lower body limitation, a physical barrier in their home, and no existing modification. We also find that approximately 27% of adults ages 50 and older currently are able to fully accommodate their personal care activities with device use. Incorporating this type of information into national surveys that track late-life disability would provide important insights into the role of environmental factors in current trends.

Third, our analysis suggests that a valid and reliable scale reflecting the effectiveness of technology can be created from three questions designed to measure improvements in safety, control, and participation due to technology. However, for two of the three questions, over 20% of respondents in our study required clarification, suggesting that further improvement in question wording may be useful.

These analyses suggest several next steps for integrating measures of assistive technology and the home environment into national surveys. Global items that combine multiple items into a single measure generally under-estimate use and should be avoided with one exception. A global item that combines the most commonly used mobility devices into a single measure has good measurement properties. Existing national surveys, such as the NHIS and the Behavioral Risk Factor Surveillance System, may well consider a more focused mobility-related item in place of the current approach. We further recommend the use of a list-driven set of questions to identify the existence, addition, and use of “fixed” assistive technologies (e.g., grab bars, railings, and ramps). Such technologies are quite prevalent in the homes of older persons and are used as frequently as, and in some cases more often than, portable mobility devices. The 2-3 minute module in the Appendix serves as a useful, succinct approach, while allowing analytic flexibility to identify those who have, have added, and use environmental modifications. Finally, with respect to measuring the effectiveness of assistive technology, this analysis highlighted the need to recognize the influence of technologies on other domains beyond dependency that matter for quality of life in aging. Additional pilot testing may be helpful to expand upon this approach.