Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Assistive technology and environmental interventions helped slow functional decline in frail elderly adults

ACP J Club. 1999 Nov-Dec;131:71. doi:10.7326/ACPJC-1999-131-3-071


Source Citation

Mann WC, Ottenbacher KJ, Fraas L, Tomita M, Granger CV. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly. A randomized controlled trial. Arch Fam Med. 1999 May/Jun;8:210-7. [PubMed ID: 99266357]


Abstract

Question

In elderly persons with physical disabilities but normal cognition, does the use of assistive technology (AT) devices and home environmental interventions (EIs) improve functional independence and reduce overall health-related costs?

Design

Randomized, single-blind (outcome assessor), controlled trial with 18-month follow-up. Blinding was not maintained.

Setting

A county agency, a visiting nursing association, and hospital rehabilitation programs in western New York, United States.

Participants

104 elderly adults (mean age 73 y, 70% women, 53% lived alone) who had a score ≥ 23 on the Mini-Mental State Examination and had difficulty with ≥ 1 aspects of the Functional Independence Measure (FIM) motor section. 38% of participants reported poor or fair vision, and none was totally blind. Follow-up was 87%.

Intervention

Elderly adults were allocated to receive AT-EI services (n = 52) or standard care (n = 52) for 18 months. AT-EI services comprised comprehensive functional assessments of the person and home; recommendations for, provision of, and training in the use of AT devices (e.g., canes, walkers, and bath benches) and EIs (e.g., removal of throw rugs); and continued follow-up. Standard care included medically directed services after hospitalization and rehabilitation, nursing directed services, and services provided through the Office for Aging agencies. These services included assistance with shopping and personal care.

Main outcome measures

Physical ability (FIM, the Older Americans Research and Services Center Instrument, and the Craig Handicap Assessment and Reporting Technique), pain (Functional Status Index), and costs in U.S. dollars.

Main results

Both groups showed a decline in FIM total and motor scores, but the decline was smaller for the AT-EI group than for the control group (mean score change 4.0 vs 11.5, P = 0.01 for total score; 2.5 vs 8.6, P = 0.01 for the motor section). The control group but not the AT-EI group had an increase in pain scores (mean score increase 2.1, P = 0.05). The groups did not differ on other outcome measures. The AT-EI group had lower costs for institutional care (mean cost U.S. $5630 vs $21 846, P < 0.01) and nurse visits (mean cost $426 vs $842, P < 0.01) but higher costs for AT-EIs (mean cost $2620 vs $443, P < 0.001) than did the control group. Overall costs did not differ.

Conclusion

In frail elderly adults, assistive technology devices and environmental interventions led to a decrease in some measures of functional decline without increasing costs.

Sources of funding: National Institute on Disability and Rehabilitation Research of the Department of Education; Department of Health and Human Services; Andrus Foundation of the American Association of Retired Persons.

For correspondence: Dr. W.C. Mann, Rehabilitation Engineering Research Center on Aging, University at Buffalo, 515 Kimball Tower, Buffalo, NY 14214, USA. FAX 716-829-3217.


Commentary

Inattentive readers of this carefully worded report could surmise that the provision of AT devices and home modification benefited elderly persons with physical disabilities but no cognitive impairment. Careful readers will note that blinding of the outcome assessment was not maintained and that the intervention had little clinically significant benefit. Statistically significant differences in outcome were found for few of the variables examined, and no convincing clinical benefit was shown overall.

Failure to show benefit from the interventions may result from many factors, including the possibility that the interventions did not work or that they did work but the outcome measures could not show it. For example, could the outcome measures have detected benefits of car door openers, hand railings, a garage door opener, or the other diverse interventions that were used in this study? These interventions may have reduced handicap rather than impairment or disability (as defined by the World Health Organization [1]), but the outcome measures do not reflect handicap well. The structure of the FIM may also have contributed to the negative outcome; the use of an AT device to do a task is penalized on the FIM (score 6 out of 7), even if the person attains full independence through use of the aid.

For physicians and other health care service providers who are committed to community-based preventive care, this study will be disappointing. But absence of evidence of benefit does not mean evidence of no benefit, and we concur with the investigators' conclusion that further research is needed. Such research must use appropriate outcome measures; if not, real benefit could be missed and false conclusions could be drawn, and this would have unfortunate consequences for health care delivery to elderly adults.

Peteris Darzins, BM, PhD
Robyn Smith, MPHNational Ageing Research InstituteParkville, Victoria, Australia


Reference

1. World Health Organization. International classification of impairments, disabilities, and handicaps; a manual of classification relating to the consequences of disease. Geneva: WHO; 1980.