Home Adaptation and Equipment

As people get older, two major challenges impact on their ability to engage in everyday tasks. The first is a gradual decline in hearing, vision, and mobility (which includes walking, and movement of the arms and body). The second challenge is a high probability, which increases with age, of having one or more chronic diseases, such as arthritis, cataracts, or heart disease. These chronic diseases often lead to additional impairment. In many cases, the impact of impairment on doing everyday tasks (functional performance) can be overcome or reduced through the design of the places where people live, work, study, play, and worship, and through the use of assistive technology devices (also called assistive technology or assistive devices—all three terms are used interchangeably). Assistive technology is a relatively new term but is now widely used. The Technology Related Assistance for Individuals with Disabilities Act of 1988 defined an assistive technology device as "any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified or customized, that is used to increase, maintain, or improve functional capabilities of individuals with Figure 1. A remote control device with large buttons is easier to use for people who have arthritis or other difficulties with their hands. disabilities." This is a broad definition that includes low-tech devices (i.e., those traditionally recommended by rehabilitation specialists—occupational therapists and physical therapists—such as buttonhooks and reachers). Assistive technology devices also include high-tech devices, which often have microprocessor components, and include computers with voice output, print enlargement systems for persons with low vision, and environmental control units.

Another important concept is universal design. The best device is one that is designed for all people, not just for people with disabilities. Universally designed devices, such as phones and computers, are easier to locate, lower in price, and easier to get repaired. Universal design relates to another simple term, tool. Humans are "tool users," and with the exception of sea otters, which use rocks to break shells, and chimpanzees, which use sticks to dig up insects, no other species uses objects, or tools, to make doing things easier. Humans' tools range in complexity from shovels to space shuttles and from rulers to supercomputers. If we think of assistive devices as tools, as extensions of persons that enhance performance, we can also view disabilities as a set Figure 2. A walker such as this one makes walking easier and safer for millions of elderly persons. of challenges to provide the right tools to overcome the impact of the disabling condition.

While we usually think of assistive devices, or tools, as objects that are held or controlled, we also need to consider our "built" environment—buildings, sidewalks, and landscaped areas—and the things placed or included in them—cabinets, doors, and curb cuts. It is possible to design environments to maximize functional performance by building in features that make it possible for people with disabilities to use the environment in the same way as nondisabled people. The concept of universal design can be applied to the environment, as well as to assistive devices, with the goal of reducing the impact of chronic illness and the declines associated with the aging process.

Many assistive devices are available for older persons with disabilities. Abledata, a computerized database of over twenty thousand assistive devices, is an excellent resource for searching for information on assistive devices. Searches can be conducted by product type, impairment type, and company. Abledata is available on the World Wide Web at www.abledata.com/.

In discussing assistive devices for older people, this entry covers the following categories of assistive devices: devices for persons with mobility and/or motor impairments (including environmental control devices and seating or walking aids, and wheelchairs) and those with vision, hearing, cognitive, and communication limitations. Older adults often have more than one chronic condition and resultant impairments, and may benefit from devices in several categories. Multiple impairments may also require modification of devices. For many of these devices, an occupational therapist or physical therapist should assist with evaluating the person, determining the needs and the best devices, and training and follow-up on the use of the devices.

Devices for persons with mobility impairments. The first type of these devices to be considered is environmental control devices.

Environmental control devices. Some environmental control devices help people who have difficulty moving about. They are also helpful in certain situations for people with cognitive or visual impairments. An environmental control device can increase a person's ability to operate almost any device that runs on electricity—radios, computers, phones, lights, and security systems—and can be used in a home setting, an assisted living facility, or a nursing home. A handheld remote control for a television is an example of an environmental control device that is widely used. However, the remote controls typically sold with television sets are not designed with the needs of older persons in mind. Though they offer many features, the buttons are typically small and the symbols are difficult for many older adults to read. However, there are several universal remote control devices that offer larger buttons and strong color contrast between the symbols on the buttons and the background—a good example of universal design. Figure 1 provides an example of a universal remote control that has useful features for older people.

A study of older adults living in nursing homes compared two groups, one of which was given handheld environmental control devices connected to their radio and the other was not. Participants in both groups had radios, but the group with the environmental control devices used their radios significantly more than the group who relied on nursing home staff, or themselves, to operate their radios (Mann). This study used the simple X-10 type of handheld environmental control devices, available for under $35 at most consumer electronics stores. This study illustrates how designing the environment with the right tools results in more independent interaction with the environment.

Other examples of low-cost environmental control devices include (1) a touch-lamp device that allows a person to turn a lamp on or off simply by touching any metal part on the lamp; (2) voice-activated wall switches that simply require the person to say "on" or "off" rather than physically manipulate the switch; (3) movement detection switches that will turn lights on or off by sensing movement (or lack of movement) in the room. For a person who has difficulty getting up to turn lights on or off, these devices can make the task much easier.

In choosing an environmental control device there are many considerations, but simplicity of operation is perhaps the most important. The examples cited above are all relatively easy to install and to use. Reliability and durability are also important considerations. Are the features of the device appropriate for the intended user? Some environmental control devices require training in their use, especially those that are integrated into a computer system. The amount of training required to ensure that the user will operate it successfully is another important consideration.

Mobility devices. About 6 percent of noninstitutionalized people over sixty-five years old have difficulty walking, and almost 8 percent have difficulty "getting outside," according to the National Health Interview Survey (Prohaska, et al.). Canes, crutches, and walkers are examples of mobility devices that are used to assist with walking and getting outside by providing support and balance. Mobility devices are used by more people than any other category of assistive device. The cane is one of the oldest assistive devices and is second only to eyeglasses in popularity and numbers used. People who experience some loss of balance may decide on their own to purchase a cane. For those with more serious mobility impairments, a variety of canes and walkers are available to make walking easier and safer. Some of the newer walker designs come with a built-in seat, which allows the person to sit and rest when tired. Figure 2 illustrates a walker that has both a seat and a basket to carry items. Usually when people go from one place to another, they are carrying something. If they have to use both hands to grasp a walker, a basket or bag or tray is needed to carry items.

Though canes and walkers are widely used, many people have difficulty using them. Almost half of the identified problems relate to difficulty and/or risk with the use of the cane. A primary physician, often through a referral to a physical therapist, can play an important role in identifying problems people are having with walking and using the cane and walker For those who might benefit from a cane or walker, a careful evaluation should be performed, in the setting where the person will most frequently use the device (Mann, et al.).

The wheelchair is another category of assistive devices that can provide independent mobility and make assisted mobility possible. Advances in wheelchair design have led to lighter, more comfortable products. There are many considerations in selecting an appropriate wheelchair, including type of cushions, armrests, wheels, tires, hand rims, and power. It is important to have a trained professional, typically a physical or occupational therapist, involved in evaluating and recommending the most appropriate wheelchair. Therapists also make recommendations for wheelchair accessories, which include devices for transferring into and out of the wheelchair, trays, safety belts, clothing guards, and bags and pockets. Several references provide detailed information on wheelchairs (Mann and Lane; AARP).

Reachers. Reachers are assistive devices that extend a person's reach and enable grasping and movement of objects at a short distance—but a distance longer than would be possible without the device. Reachers are inexpensive and very useful for many older adults with disabilities. They can be helpful for people with lower back problems, arthritis, and heart conditions. People who use wheelchairs find that a reacher can make it possible to pick up things they could not access while in the wheelchair. With a reacher people do not need to bend over or stretch up as much, which can reduce the possibility of causing further physical impairment. Unfortunately, many older people practice the unsafe procedure of standing on a chair or stool to reach into high cabinets or other places; reachers can help eliminate the need to do this, and thus reduce the potential for a fall. In a study of older people with disabilities who were living at home, 20 percent of participants owned and used a reacher, and almost 10 percent considered their reacher their most important assistive device. Another study of reachers determined the tasks for which older persons used reachers, and tested performance of these tasks using three reachers selected for their potential to meet the needs of older persons with disabilities most satisfactorily. The criteria for evaluating reachers were developed by older persons who used reachers, and included adjustable length, one-hand use, lifetime guarantee, lock system for grip, forearm support, light weight, and lever-action trigger. The Winchester Reacher was rated highest by consumers who tested three reachers that best met the consumer criteria (Chen, et al.).

Reachers can be purchased from durable medical suppliers (listed in the Yellow Pages under "Medical Equipment and Supplies"), catalogs of special products, and, more recently, in some department stores. In hospital or rehabilitation programs, occupational therapists often recommend reachers for elders.

Phones. More and more is being said about universal access to the Internet. It is easy to forget how relatively recently another important communication device became available. Phones are in virtually every home and office in America, but it has been only a century or so that they have been available at all, and now the phone is considered a necessity for work and leisure. For older people with disabilities, phones provide opportunities for talking to other people when it is difficult to get out of the home. More than 30 percent of people over sixty-five years old live alone, and over 50 percent of people over age seventy-five live alone. For elders with disabilities the phone also represents a safety device, a tool for calling for help if they have fallen, if they are ill, or if someone is trying to intrude into their home.

There is a wide range of special features available on phones today that assist elders with sensory, physical, or cognitive impairments. Many people with disabilities are easily able to use phones with such features as large buttons, single-button dialing, and, more recently, voice-activated operation. Phones are a good example of a device available in the larger marketplace that can help people with disabilities (as opposed to many assistive devices that are targeted at a much smaller segment of the population). Having a larger market results in lower prices. Most of the special phone features that can be helpful for a person with a disability can be found on phones sold in electronics and department stores.

Assistive devices for the visually impaired. Vision declines with age, and many elders have significant vision impairment. In fact, one out of five elderly persons has difficulty reading as a result of vision impairment. One out of twenty people over sixty-four years of age cannot see words or letters on a page (U.S. Bureau of the Census). Vision loss can result from a number of conditions, such as diabetic retinopathy, cataracts, and macular degeneration. Vision loss is also related to a decrease in mobility: people with severe vision loss tend to get out of their homes less than those without vision loss (Long).

Many people with vision loss use eyeglasses. In fact, eyeglasses are the most common assistive device, and are typically provided by an optometrist. For people who require other vision devices or devices that provide stronger magnification, occupational therapists often participate in providing assistive devices. In addition to assistive devices, there are some general rules that should be followed when with a visually impaired person:

1. In speaking to a person with a visual impairment, don't talk more loudly than usual unless the person also has a hearing impairment. Be sure to tell the person who you are. Tell the person when you are leaving.
2. Ask the person if assistance is needed; do not wait to be asked.
3. When guiding a person with a severe vision loss, allow the person to hold your arm and follow a few steps behind.
4. When assisting with setting up activities, provide larger images when possible. For example, you can set the enlargement feature on a photocopy machine to increase the size of print or pictures.
5. Position the person close to the objects involved in the task.
6. Increase the amount and/or intensity of light, but at the same time reduce glare.
7. Provide contrasting colors, for example, dark objects on a light surface. This may require placing a cloth on the table for activities.

There are many low-cost, simple assistive devices for people with vision impairments: magnifying glasses, pens that write with a bold line, and writing guides. Bookstores and libraries carry materials in large print. Checks can be printed with large characters, and games are available with enlarged playing boards. As discussed above, stores carry phones with large buttons, large numbers, and backlit displays. Thermometers, clocks, watches, and blood sugar monitors are all available with either large-print or voice output features.

Since the 1980s, computer and video-based technology have made it possible to develop a number of special products to assist people with visual impairments. The features offered by these devices make them very appropriate for older adults. Stand-alone print enlargement systems increase the size of any written material or picture. The systems include a monitor (usually fourteen to nineteen inches) and a viewing table where the book or other material is placed. Some viewing tables are automated and can be controlled with a foot pedal. For older adults with visual impairments, a print enlargement system often makes it possible to read newspapers and books. In fact, a study found that reading was one of the two activities that visually impaired elders most missed doing (Mann, et al.).

Braille provides a way for people who are blind to read print on paper. Software is available that, together with a Braille printer, permits Braille printing of text produced on a computer with a word processor. Refreshable Braille displays are available on a device called the Navigator. Available in twenty- or forty-character-long strings, tiny pins move up and down to produce the Braille characters, representing a portion of the computer screen. While a smaller percentage of visually impaired persons is now learning Braille, a significant portion of older adults who have been blind since their youth are benefiting from these computer-based Braille output devices.

Voice output with a computer allows a person to write into a word processor, spreadsheet, or database file and then check the accuracy and content of the file. Existing files and E-mail messages can be spoken by the computer for the visually impaired person. Together with a scanner, which takes text that is already printed and converts it into a computer file, printed material becomes available to the person with a visual impairment. For elders with severe vision loss, a talking computer may make it possible to continue work, leisure reading, and carrying out household tasks that require writing and reading.

Devices for persons with hearing impairments. Like vision, hearing declines with age. Many older people have difficulty hearing, and background noise becomes more of a problem as people age. About one-third of people age sixty-five or older have some hearing impairment and the figure increases to almost half in persons over age eighty-five (Hotchkiss). While many older adults accept hearing loss as a normal part of aging and do nothing about it, there are assistive devices that can improve hearing for some people.

Tinnitus is a significant hearing problem for over 90 percent of persons over age sixty-four (U.S. Public Health Service). With tinnitus people experience a ringing sound in their ears. There is no cure, but "maskers" are sometimes used to provide a more acceptable sound than that produced by the tinnitus. Hearing aids are used to offset the effect of the hearing loss that often accompanies tinnitus. Surgery is sometimes employed to reduce tinnitus, as are drugs, relaxation techniques, and biofeedback.

Hearing aids. The most common assistive device for hearing loss is the hearing aid, typically prescribed by an audiologist. Many older people have difficulty using hearing aids due to vision impairment and loss of dexterity in the fingers: they have difficulty replacing batteries, positioning the device, or adjusting the controls. Of all assistive devices, hearing aids have the highest rate of dissatisfaction among people who own them. This is due in part to the fact that many people get their hearing aids without an audiological assessment.

Assistive listening devices. When hearing aids do not provide adequate sound amplification, assistive listening devices (ALDs) may be used. Some people use both a hearing aid and an ALD, depending on the situation they are in. The components of an ALD include a microphone for the person(s) speaking, an amplifier to capture and "enlarge" the sounds, and, for the person with the hearing loss, a headset. ALD systems are hardwired or use either FM radio waves or infrared signals. Churches and theaters are installing ALD systems, usually FM and infrared systems. The hardwired system is more often used in a home.

Telecommunication devices for the deaf (TDDs). For people who are deaf, TDDs are designed to provide the means to use the telephone. They are actually small microprocessor-based devices that have a screen, keyboard, and modem. With a TDD at both ends of a telephone line, messages can be typed in and read at each end. Relay services are available in every state so that a person with a hearing impairment can type in a message to an operator, who in turn provides the final receiver with the spoken message. TDDs are now available in public places such as airports.

Amplification and other signaling devices.

There are a number of assistive devices that provide amplified sound. Electronics and phone stores carry phones that offer amplified sound and devices that can be added to an existing phone in order to provide amplification. Closedcaptioned television provides text at the bottom of the screen on television sets equipped with a special decoding device. All new televisions have this feature installed. Other devices include smoke detectors that provide a visual alert, such as a flashing light. A number of these low-cost devices can make it possible for older adults with hearing loss to continue their involvement in important life roles.

Devices for persons with cognitive impairments. Persons with cognitive impairments can benefit from devices that assist with writing and retaining information, and performing simple household chores.

Note writing and electronic notebooks.

Memory loss can occur as a result of a number of diseases associated with aging, including Alzheimer's disease. One low-tech solution to memory impairment is to write reminder notes on paper and post them in appropriate places. An alternative, high-tech solution is to use a small electronic notebook. Many digital wristwatches now offer features such as alarms that can be used as reminders for taking medications.

Other devices. Other helpful devices include automatic turn-off switches for stove burners, automatic timers for lights, movement-sensitive light switches that turn lamps on when a person enters a room, and security systems that sound an alarm when someone attempts to open a secured door.

Assistive devices can help older people remain independent. Many of these devices are simple to use and/or install, and can be purchased at neighborhood stores. Others, such as mobility and hearing aids, require professional assistance in evaluating the need, recommending the most appropriate device, and providing training and follow-up in their use.