24 Products and Technology

CHAPTER
William C. Mann Eric E. Hicks

Old age deprives the intelligent man only of qualities

useless to wisdom.
Joubert, Penses, 1842
OBJECTIVES
By the end of this chapter, readers will be able to: 1. Describe the three ways the built environment can be adapted or modied to benet people with disabilities. 2. Differentiate between accessible design, adaptable design, transgenerational design, and universal design. 3. Dene and describe assistive technology. 4. Differentiate between high-tech and low-tech devices. 5. Describe the devices used for individuals with mobility impairments, including environmental control devices and mobility aids. 6. Describe the devices that may be helpful to individuals with visual impairments. 7. Describe devices that may be helpful to individuals with hearing decits. 8. Describe how the World Health Organizations International Classication of Functioning (ICF) model and Occupational Therapy Practice Framework (AOTA, 2002) can be used to determine the types of devices that may be helpful to a particular individual. 9. Discuss the limitations in the usefulness of technological devices.

Introduction
This chapter provides an overview of how the built environment can be adapted or modied to increase or maintain functional performance for older individuals with disabilities. This is followed by a discussion of how the World Health Organization (WHO) International Classication of Functioning (ICF) model and

culture can impact the appropriate provision of assistive devices. Then, we describe some common assistive technology devices used to compensate for various age-related problems (i.e., mobility, vision, hearing, and cognition) and conclude with a brief discussion of important issues related to technology and older adults. An appendix at the end of the chapter lists resources on assistive technology for older adults.

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Aging and Functional Performance

Recent data suggest that most people over 64 years old are living longer and healthier lives compared to the same age group 10 years ago (Administration on Aging, 2004; Freedman et al., 2004; He, Sengupta, Velkoff, and DeBarros, 2005). However, with advancing age come two major challenges that impact functional performance. The rst is a gradual decline that can result in decrements in hearing, vision, mobility, and cognitive processes. The second is the probability that one or more chronic diseases, such as arthritis, macular degeneration, heart disease, or Alzheimers disease will result in additional disabilities. Figure 24-1 shows a continuum along which individuals may be located as their level of age-associated decline increases and their number of chronic conditions increases. Demographic factors, such as age, gender, race, health, living arrangements, and social support, which have been discussed previously in this volume, contribute to both limitations in functional performance and diversity or heterogeneity of the older population in the United States (He et al., 2005). While facing chronic conditions and age-related functional impairments, Schafer (2000) found that 9 out of 10 seniors 64 and older prefer to live at home. Because most housing and communities are not typically designed to meet the needs and preferences of seniors as they age, various solutions are being implemented in homes and communities to assist older persons in aging

in placeremaining in their homes as long and as independently as possible.

The Built Environment and Functional Performance

Almost everything we do in life is affected by what has been built around us. Our ability to receive an education, nd housing, attend a church or synagogue, shop, bank, recreate, travel, and earn a living are all affected by the built environment. Yet for almost 200 years, our schools, courts, houses, churches and synagogues, stores, banks, theaters, restaurants, public transit systems, and overall workplaces were built with the able-bodied population in mind. Access to these buildings, facilities, and services was only a dream shared by millions of individuals with disabilities. (Peterson, 1998, p. 15)

The concept of designing products and the built environment for people with disabilities did not emerge until the 1960s when the American National Standards Institute (ANSI) established Standard A117.1, Making Buildings Accessible to and Usable by the Physically Handicapped. These standards were followed, over the years, by legislation (e.g., Americans with Disabilities Act and Fair Housing Amendment Act) that increased the rights of people with disabilities to access all public buildings and public and private housing (Kose, 1998; Peterson, 1998; Vanderheiden, 1998). Although these laws improved the

FIGURE 24-1 Disability impact continuum.

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opportunities and independence afforded to those with disabilities, they have not adequately addressed the needs of older adults which in some ways are different from the needs of younger people with disabilities (Kose, 1998). Older adults often experience simultaneous decline in several abilities (i.e., vision, mobility, and hearing) which cannot be addressed solely by removing certain environmental barriers. Three different approaches can be taken to ensure effective interaction with the environment: 1. Change the individual 2. Change the environment 3. Provide individuals with tools they can use (Vanderheiden, 1998) Each approach is seen as equally important and necessary to function effectively in the various environments and situations they encounter on a daily basis (Vanderheiden, 1998, p. 31). Each area is briey discussed in the following sections.

individuals who have to use these features (e.g., ramps next to entrances with stairs). There are three subsets of design that fall under the broad category of accessible design. These are adaptable design, transgenerational design, and universal design. Even though all are considered to be subsets of accessible design, designs may incorporate features from one, two, or all of these subsets. A height-adjustable stovetop, for instance, is an accessible design feature within an environment that incorporates features of both the adaptable and universal design subsets but not the transgenerational design subset because the feature was not specically made to accommodate all of the changes a person might experience as they age.

Adaptable Design
Adaptable design involves making modications to a standard design for the use by a particular individual with a disability, like adding large grips to kitchen utensils to help someone with rheumatoid arthritis (Story, 1998). Similar to accessible design, these features sometimes appear added onto a product or environmental space which may result in the design being stigmatizing and expensive.

Change the Individual

This approach addresses the methods used to enhance the physical, psychological, and social abilities of the individual for accessing and using the environment (Vanderheiden, 1998). These methods include the following interventions: surgery, therapy, training, education, and teaching of compensatory strategies and adaptive techniques. One advantage of this approach is that it improves the innate abilities, skills, and strategies that individuals carry with them.

Transgenerational, or Life-Span, Design

Transgenerational, or life-span, design considers the changes individuals experience as they age (Story, 1998). This type of design does not address the full range of possibilities that can affect individuals throughout their lifetime, such as congenital conditions, injury, illness, gender, cultural background, and literacy level. Grab bars in a bathroom might help both young children and elders but are not specic to particular kinds of conditions.

Change the Environment

In many cases, the impact of disability on functional performance can be overcome or reduced through the design of the places we live, work, play, and worship. This is often referred to as accessible design, dened as design that meets prescribed code requirements for use by people with disabilities (Story, 1998, p. 4). Accessible design is often achieved by providing separate design features for specic disabilities, such as paddle blade handles on large lowered sinks in public restrooms for those with mobility impairments. These solutions can be costly because they are added onto existing designs or new construction at the end of the design process. They can be stigmatizing because they draw attention to the

Universal Design
Universal design is dened as the design of products and environments that can be used and experienced by people of all ages and abilities, to the greatest extent possible, without adaptation (Story, 1998, p. 4). This is the most inclusive and least stigmatizing of the three types of designs because it benets everyoneyoung and old, men and women, children and older adults, small people and large people. Furthermore, universal design solutions are fully integrated into the environmental design before the process begins in order to accommodate a wide range of the populations. The goal of universal design is to

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minimize the amount of adaptation needed by the individual and maximize the individuals natural inclusion into all daily activities. There has been widespread attention to smarthouse designs that incorporate microchip-controlled lights, heating, and appliances, as a mechanism for improving home management for everyone. The Center for Universal Design (1997) in Raleigh, North Carolina, established seven principles that can be used to guide the design process, evaluate existing and new designs, and teach what universal design encompasses. These principles are as follows: 1. Principle one: Equitable useThe design is useful and marketable to people with diverse abilities. 2. Principle two: Flexibility in useThe design accommodates a wide range of individual preferences and abilities. 3. Principle three: Simple and intuitive useUse of the design is easy to understand, regardless of the users experience, knowledge, language skills, or current concentration level. 4. Principle four: Perceptible informationThe design communicates necessary information effectively to the user, regardless of ambient conditions or the users sensory abilities. 5. Principle ve: Tolerance for errorThe design minimizes hazards and the adverse consequences of accidental or unintended actions. 6. Principle six: Low physical effortThe design can be used efciently and comfortably and with a minimum amount of fatigue. 7. Principle seven: Size and space for approach and useAppropriate size and space is provided for approach, reach, manipulation, and use regardless of the users body size, posture, or mobility. (n.p.) There are several advantages of universal design, including reduced need for assistive technology, decreased cost of a device, increased availability of usable designs, increased longevity and reliability and ease-of-repair, increased inclusion of people with disabilities into society, reduced social stigmatism, and decreased amount of personal assistance needed by people with disabilities (Story, 1998). Universal design offers people with disabilities many advantages, but it will not fully replace the need for interventions to enhance the individuals abilities, or the need to provide individuals with tools, or assistive technology. Thus, for some individuals and for some

activities, there will always be a need for devices and personal assistance.

Provide Individuals with Tools

Humans are tool users, and with the exception of chimpanzees who use sticks to dig up insects, and sea otters who use rocks to break clam shells, no other species use objects, or tools, to enhance task performance. Our tools range in complexity from spoons to space shuttles and from can openers to computers. Tools that are used to strengthen, compensate, or provide a better match between a persons abilities and the demands of the environment are called assistive technologies, adaptive devices, or assistive devices. Specically, assistive technology device is dened by the Technology Related Assistance for Individuals with Disabilities Act of 1988 (1994) as any item, piece of equipment, or product system, whether acquired commercially off the shelf, modied or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. (n.p.) This broad denition includes low-tech devices (i.e., those traditionally used by therapists, such as button hooks and reachers) and high-tech devices (which often involve microprocessors and include computer hardware and software, such as voice output and screen magnication software for persons with low vision, and environmental control units). Two advantages of assistive technology are that they can be custom selected and tted to meet the needs of a particular individual, and they can be specically adapted to meet the needs of the individual and the constraints of the environment in which they will be used (Vanderheiden, 1998). Several disadvantages of assistive technology devices are the cost, lack of consumer awareness of products, social stigma regarding use of assistive technology, and that assistive technology advancements cannot keep up with the rate at which mainstream technology is advancing.

Aging in Place
Three areas that should be addressed when helping older adults age in place include interventions at the person level, changes to the environment, and provision of assistive devices. All areas should be taken into consideration when working with a client. Mann, Ottenbacher, Fraas, Tomita, and Granger (1999) demonstrated this

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point by investigating the effectiveness of assistive technology and home modifications in reducing the rate of declined functional status for physically frail older persons living at home. Furthermore, this study documented the cost-effectiveness of an intensive approach to the provision of assistive technology and home modifications. Individuals who receive all the assistive devices and home modifications they need spend less time in hospitals and nursing homes, and average costs associated with institutional care are significantly less. These findings provide strong support for a thorough approach to functional and home evaluation, followed by procurement of needed devices and home modifications, with appropriate training and follow-up. The remainder of this chapter focuses on assistive technology.

and selecting assistive technology, at each classication level for a particular individual given their health or disability, as well as environmental and personal factors. Assistive technology evaluation, provision, training, and follow-up is guided by the environmental factors component of the ICF model. Specifically, the environmental factors component constitutes the physical, social, and attitudinal environment in which people live and includes five areas: 1. Products and technology 2. Natural environment and human-made changes to environment 3. Support and relationships 4. Attitudes 5. Services, systems, and policies (Schneidert, Hurst, Miller, & Ustun, 2003) According to the ICF, assistive technology would be included under the area of products and technologynatural or human made products or systems of products, equipment, and technology in an individuals immediate environment, that are gathered, created, produced or manufactured (p. 591). Selecting and providing appropriate assistive technology devices for a person depends on the number and type of classication levels affected by that persons disease, condition, or disorder. Devices used to compensate for impairments at the body structure/function level include hearing aids, pacemakers, and prosthetics. Technology solutions at the activity level can be low tech or high tech. Some low-tech solutions are utensils with built-up or weighted handles, reachers, and sock aids. Several high-tech examples include environmental control units and specialized computer hardware or software. Assistive technology used to compensate for limitations in participation often overlap with the devices recommended for the body structure/ function and activity levels. For example, a person with a mobility impairment may use a powered wheelchair to compensate for an inability to walk as well as to accomplish specic tasks or actions, such as cleaning the kitchen. In short, the more classication levels impacted by a disease, condition, or disorder will determine the amount and type of assistive technology devices needed to function independently. Many chronic diseases affect hearing, vision, cognition, and movement. Assistive technology is available for people with hearing, vision, memory,

Assessing the Need for Assistive Technology

The heterogeneity of those 64 and older makes it difcult to predict a persons level of functional performance and need for assistive technology (He et al., 2005; Schafer, 2000). For example, one person may experience only the effects of the normal aging process, such as decreased hearing and vision, but another person may have several medical conditions or age-related diseases that can significantly impact independence. The WHOs ICF (2001) model, as discussed previously in this book, provides practitioners with a systematic way to assess and select appropriate assistive technology devices to accommodate the needs of their clients (Jette, Haley, & Kooyoomjian, 2003; Perenboom, & Chorus, 2003; Ustun, Chatterji, Kostansjek, & Bickenbach, 2003). The ICF model not only depicts the person and his or her performance of tasks or activities in a state of health rather than disability, but it also delineates and conceptualizes functional performance into three classication levelsbody structure/function, activity, and participation prior to adding in disease or disorder. Any resulting impact caused by disease, disorder, condition, and personal and environmental factors on one or more classication levels is viewed as unique to the individual and is not always in a direct oneto-one relationship. Thus, the ICF model can be used as a guide for the provision of medical and therapeutic intervention, including evaluating

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communication, and movement impairments. The overview of assistive technology in the next section focuses primarily on high-tech devices, assuming that the reader is familiar with the range of low-tech devices that have been available for many years. It is important to point out that high-tech is not synonymous with complicated. In fact, high-tech devices may be easier to use than traditional devices designed for the same purpose. That is, they may be smarter and save the user steps. A good example of this is the Beyond Smart Microwave Oven that features a built-in scanner that reads the bar code label on the food package and automatically sets the time and temperature controls for the correct cooking of the food product. The electronics for this oven are complex, but the process of cooking is simplied for the user; if the user has a visual or cognitive impairment, independent cooking may be possible only with such a device. The Beyond Smart Microwave Oven will have a much broader market than older persons with cognitive and visual impairments and could be considered a universally designed product.

purchase a cane. For those with more serious gait impairments, perhaps as a result of stroke or Parkinsons disease, a variety of canes and walkers are available to make mobility easier and safer. Walker types vary in design and functionality. They range from regular walkers and canes to ones with built-in seats that allow a person to sit and rest when tired. Wheelchairs offer another option for independent mobility, as well as making assisted mobility possible. Advances in wheelchairs have led to lighter, more comfortable designs. Depending on the needs of the person who will use the wheelchair, therapists must make recommendations involving cushions, armrests, wheels, tires, hand rims, and power. Therapists also make recommendations for wheelchair accessories including transfer boards, lapboards and trays, safety belts, clothing guards, and bags and pockets. Several references provide detailed information on wheelchairs, useful for therapists working with older adults who may need a wheelchair (Cooper, 1998; Giannini, 1998).

Environmental Control Units

Assistive Technology for Older Adults

There are over 20,000 products listed in Abledata, a computerized database of assistive devices. In discussing products that might be useful for older adults, this section will cover the following categories of assistive devices: devices for persons with movement impairments (including walking aids, environmental control devices, and robots) and those with vision, hearing, cognitive, and communication limitations. It is important to keep in mind that older adults often have more than one chronic condition and resultant impairments and may benet from devices in several categories. Multiple impairments may also require modication of devices.

Devices for Persons with Mobility or Motor Impairments

Walking Aids and Wheelchairs
Walking aids are among the most common of all assistive devices. The cane, second only to eyeglasses in popularity and numbers, is also one of the oldest assistive devices. Persons experiencing some loss of balance may decide on their own to

Environmental control devices are designed primarily for persons with physical disabilities, although they often benet people with cognitive or visual impairments as well. For older adults, whether living at home or in a nursing home, an environmental control device can increase ability to operate almost any device that runs on electricity: radios, computers, phone, lights, and security systems, to name just a few. Handheld remote controls for televisions could be considered an environmental control device, one that reaches a much broader market than people with impairments. Originally, handheld remotes were designed for young people with excellent ne motor control, excellent vision, and a love for bells and whistles because of the small size of the buttons, the small print on or under each button, and the various complicated features. However, there are several handheld remotes now that incorporate universal design features like larger buttons, more room between buttons, more simplied layouts, and easy-to-read print. Haataja and Saarnio (1990) identied ve components that make up an environmental control device: 1. A switch that provides the user a means to operate the device

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2. A control device that provides a means for transmitting commands, through sound waves, infrared light, or hard-wired connections 3. A target device such as a lamp or radio that is actually turned on or off 4. Connections such as the sensors that pick up the infrared light signal 5. A feedback device that lets the user know the status of the system One recent study employed a cross-sectional design with 15 experienced users of electronic aids to investigate the impact of continued use of a device and to identify the functions the device assists with or performs for an individual (Ripat, 2006). Device use was found to make participants feel more competent. Their well-being was stable over a long period compared with new users of electronic devices. Furthermore, participants noted that environmental control units were used to perform the following functions: increase and maintain independence, control devices for entertainment, and communicate basic needs. An X-10 environmental control device is pictured in Figure 24-2. Environmental control devices range in price from $24 to approximately $10,000, and their functions vary from simple onoff of one or a few appliances to computerbased control of the total home environment, the computer, and telecommunications. A table listing different environmental control units, a brief description of each, the manufacturer, and the cost is available from Abledata. In helping a person select an environmental control device, Dickey and Shealey (1987) offer several questions to consider: Will the system be difcult

(how difcult) to operate? How reliable and durable is the system? How will the system be installed? How easy is it to install? How portable is the system, especially if it will need to be moved? Who is the manufacturer, and will the manufacturer be in business when support or repair is required? Are the features of the device appropriate for the intended user? How much training will be required to ensure that the user will be successful with its operation?

Robots
Environmental control devices operate on the electrical environment. An environmental control device could be used to operate a mechanical device such as a lift (Figure 24-3), but the combination of electronics and mechanical functions falls into the area of robotics. Robots have been developed to assist people with performing industrial, military, personal, and medical tasks (Davenport, 2005). Personal robot research and development has lagged behind the advances made with industrial robots because personal robots have to operate in a semiautonomous to autonomous state in changing

FIGURE 24-2 An X-10 environmental control device

system.

FIGURE 24-3 Overhead lift operated by remote

control device.

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environments while industrial robots function in xed environments (p. 76). However, development of personal robots is expected to increase in the near future due to less-expensive robotic components, recent advances in power consumption, and better sensor technology. Current personal robot use and development is in the following areas: mobility devices, exoskeletons, powered wheelchairs, entertainment, household assistance, and monitoring.

Devices for Persons with Vision Impairments

Vision loss is common among older persons. In fact, age-related vision loss and blindness affect 5.5 million noninstitutionalized Americans who are 55 years and older (American Foundation for the Blind [AFB], 2006). Additionally, about 1.8 million noninstitutionalized older adults state they have difculty performing basic activities of daily living (ADL), like bathing, reading, and dressing, due to a severe visual impairment (Desai, Pratt, Lentzner, & Robinson, 2001). Visual loss may be caused by diabetic retinopathy, cataracts, glaucoma, and macular degeneration, as well as normal aging. A discussion of visual loss can be found in Chapter 5. Vision loss among the elderly is associated with a decrease in outdoor mobility. A recent study of 404 older adults determined that vision signicantly affects the performance of activities of daily living outside the home (Wahl, Heyl, & Schilling, 2002). They also found that vision impairment affected a participants ability to engage in outdoor activities. Those who participated in outdoor activities reported a higher level of life satisfaction than those who did not engage in outdoor activities. Eyeglasses are the most common assistive device, and they are typically provided by an optometrist. For individuals who require other devices or devices that provide stronger magnication, occupational therapists often participate in providing assistive devices. The following are some basic guidelines for assisting persons with visual impairments who do not necessarily require an assistive device: 1. In speaking with a person with a visual impairment, do not increase your speaking volume 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. Allow the person to hold your arm and follow a few steps behind when guiding a person with a severe vision loss. 4. When providing assistance 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 closer to the objects involved in the task. 6. Increase the amount and intensity of light, but at the same time reduce glare. 7. Provide contrasting colors (e.g., dark objects on a light surface). This may require placing a cloth on the table for activities (AFB, 2006, n.p.). There are a wide variety of low-cost, simple assistive devices for persons with visual impairments. These include magnifying glasses, pens that write with a bold line, and writing guides. Materials prepared in large print are available in many bookstores and libraries. Banks can print checks with large characters, and games can be bought with enlarged boards. Most electronics stores carry phones with large buttons and large numbers. Thermometers, clocks, watches, and blood sugar monitors are all available with either large-print or voice-output features. Figure 24-4 pictures a thermostat with enlarged numbers and marks. Today, various hardware and software solutions and video-based technology have increased the number and type of products available for persons with visual impairments. The features offered by these devices make them very appropriate for older adults. These products are categorized by the features they offer.

Screen Enlargement Software

There are many software programs that magnify the image on the computer screen, making it possible for a person with low vision to read what is on the screen. Prices range from under $100 to $600. All of the current Microsoft operating systems provide free limited magnication of the computer screen through its accessibility options. There are also many software programs, such as Microsoft Word, Microsoft Excel, and WordPerfect, which have free

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limited character enlargement features by increasing the viewing size of the page. These free built-in features found in Microsoft Windows and Ofce applications are also another example of universal design. A list of screen enlargement software can be obtained from Abledata.

Closed Circuit Televisions (CCTVs)

These devices increase the size of any written material or picture. The systems include a monitor, anywhere from 14 to 26 inches, and a viewing table where the book or other materials are placed. Some viewing tables are automated and can be controlled with a foot pedal. For older adults with visual impairments, a CCTV could make the difference in being able to read the newspaper and books. In fact, one study found that reading was one of the two activities that visually impaired older participants missed doing most (Mann, Hurren, Kuruza, & Bentley, 1993). Figure 24-5 illustrates a stand-alone print enlargement system.

processor. Refreshable braille displays attach to the computer and use tiny pins that move up and down to produce braille characters that represent a portion of the computer screen. Various refreshable braille display models exist and are available in 20-, 40-, and 80-character-long strings. Although a smaller percentage of visually impaired persons are now learning braille, a signicant portion of older adults who have been blind since youth are beneting from these computer-based braille output devices. However, those who acquire vision loss later in life often have difculty learning to read braille due to sensory loss in the ngers. Figure 24-6 shows a refreshable braille display.

Screen Reading Software

Screen reading software can be added to a computer which will allow the words on the computer monitor to be read out loud through the computer speakers. This allows a person to navigate the computer desktop, access les and documents, and use various word processing, scheduling, and spreadsheet software. Existing les can be read to the visually impaired person. Together with an optical character recognition system (described in the following section), which takes text that is

Braille Output Devices

Most of us are familiar with braille printed on heavy paper. Software is available that, together with a braille printer, permits braille printing of text produced on a computer with a word

FIGURE 24-4 Thermostat with large numbers.

FIGURE 24-5 Print enlargement system.

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FIGURE 24-6 Refreshable braille display on the navigator.

already printed and converts it into a computer le, virtually any printed material becomes available to the person with a visual impairment. For older adults with severe vision loss, a talking computer may make it possible to continue working, leisure reading, and carrying out household tasks that require writing and reading.

Optical Character Recognition System

Optical character recognition systems use a computer scanner that is similar to a photocopy machine in that you place a printed page on the copying surface to get a second copy. The difference is that the scanner produces a computer le that can be saved or read (with screen reading or enlargement software). Computer systems with screen reading capabilities and a scanner have become much more affordable in the past few years, and they provide virtually complete access to printed materials.

assistants (PDAs) have been developed to provide the same functionality and programs for people with visual impairments as off-the-shelf PDAs provide to those without visual impairments. These PDAs have various input (standard or braille keyboard) and output (refreshable braille display or audio) methods. A global positioning system can also be attached to many of these PDAs, making it possible for a person who is visually impaired to navigate around the community. Development of portable CCTVs and optical character recognition (OCR) scanners has improved access to printed materials in the home and community and has reduced the reliance on the larger desktop models of the same products. These mobile devices have provided those with visual impairments an increased independence and freedom in both the home and community environments that was unheard of even 5 years ago.

Mobile Devices
Recent technological advances have made the development of mobile devices for people with visual impairments possible. Cell phones can be programmed with voice-output software that will enable users to access the various menus and dialing features of their phone. Personal digital

Devices for Persons with Hearing Impairments

Hearing impairment is common among older adults: One out of three persons over age 65 have some hearing impairment; this increases to almost one out of two persons over age 85 (Desai et al., 2001). Unfortunately, many older adults view hearing loss as a normal part of aging and

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do nothing about it. Hearing loss can impact on communication, which in turn can result in isolation and depression (Capella-McDonnall, 2005). Hearing loss affects health and safety in other ways, such as not being able to understand instructions for taking medications or not being able to hear re alarms. Causes and types of hearing loss are discussed in Chapter 5. The rst step in addressing hearing impairment is to seek medical advice. Surgery is employed for some types of hearing loss; age should not be the determinant in considering a surgical approach (Capella-McDonnall, 2005). A relatively new surgical procedure, developed for profoundly deaf persons, involves implanting electrodes that bypass damaged hair cells surrounding the cochlea. Although a cochlear implant can enable a person to hear sounds, the procedure has not yet been developed to the point that a person is able to discriminate speech. Cochlear implants are a promising new technology, but most older adults do not have the type of profound hearing loss that would require this procedure. Approximately 174 in 1000 people over 64 experience tinnitus (U.S. Public Health Service, 1995). There is no cure for tinnitus, but maskers are sometimes used to provide a

more acceptable sound than that produced by the tinnitus. Hearing aids are often used to offset the effect of the hearing loss that can accompany tinnitus. Surgery is sometimes employed to reduce tinnitus, as are drugs, relaxation techniques, and biofeedback (Desai et al., 2001).

Hearing Aids
There are many assistive devices for people with hearing impairments, the most common of which is the hearing aid, typically prescribed by an audiologist. Therapists encounter many older adults who use hearing aids but because of ne motor or vision impairment, have difculty replacing batteries, positioning the device, or adjusting the controls. Working with older adults, the therapist often establishes a goal of improved ne motor performance that can lead to independence in use of the hearing aid. The therapist might also assist a person in nding tools for working the controls or replacing the batteries more easily.

Assistive Listening Devices

When hearing aids do not provide adequate sound amplication, assistive listening devices (ALDs) may be used. ALDs include microphones for the person speaking, ampliers to capture the

FIGURE 24-7 Assistive listening device.

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sounds, and, for the person with the hearing loss, a headset or ear receiver. ALD systems are hardwired or use either FM radio waves or infrared signals. Many churches, schools, and theaters have ALD systems, usually FM and infrared systems. The hard-wired system is more often used in a home. Figure 24-7 illustrates an assistive listening device.

Telecommunication Devices
Telecommunication devices for the deaf (TDDs) 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 nal receiver with the spoken message. TDDs are now available in public places such as airports. Figure 24-8 provides a picture of a TDD.

amplification. Closed-captioned television provides text at the bottom of the screen on televisions equipped with a special decoding device. All new televisions with a screen greater than 13 inches now have this feature installed in the factory. Other devices include smoke detectors that provide a visual alert such as a flashing light or vibration. 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

Personal Digital Assistants (PDAs)
Memory loss can occur with a number of diseases associated with aging. One low-tech solution to memory impairment is to write notes on paper and post them in appropriate places. An alternative, high-tech solution is to use a PDA. A number of these are available for under $500. The alarm can be used to provide a reminder for taking medications. Many digital wristwatches now offer similar features. One recent study reported the effectiveness of use of an electronic memory

Amplication Devices
Electronics and phone stores carry phones that offer amplified sound and devices that can be added to an existing phone to provide

FIGURE 24-8 Telecommunication device for the deaf (TDD).

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device by persons with Alzheimers disease. In this study, participants made signicantly more statements of fact and fewer ambiguous utterances. In addition, participants showed more initiative in conversations (Bourgeoris, 1990). However, caution must be exercised in recommending these devices, as some may be too complex for someone to operate even in the early stages of Alzheimers disease.

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 can sound an alarm when someone attempts to open a secured door.

Determining Assistive Technology Needs Using the ICF and Practice Framework
The World Health Organizations International Classication of Functioning (ICF) (2001) and the Occupational Therapy Practice Framework (AOTA, 2002) can guide the practitioner throughout the assistive technology process from assessment to follow-up. Specically, the ICF model provides the underlying foundation of the process by giving the practitioner a picture of the client in a healthy and an unhealthy state at various levels of functioning and contextual factors. The Practice Framework delineates the procedures to follow during each step of the process. A practitioner uses the ICF model to gain an understanding of a persons typical functional performance and contextual factors without a disease, disorder, or condition, and, in turn, uses this information to determine the clients functional needs, abilities, limitations, and impact of various contextual factors. The rst level of the ICF modelthe body structure/function levelis where the practitioner assesses the clients previous physiological and anatomical integrity and the changes that occurred at this level due to a disease, condition, or disorder. The second and third levels of the ICF modelthe activity and participation levels consist of obtaining the clients prior level of functioning at these levels, and then evaluating the clients activity limitations and participation

restrictions caused by a condition, disease, or disorder. Environmental factors are deemed as facilitators if they positively impact ones functional performance, or hindrances and limitations if they negatively affect a persons functional performance (Arthanat, Nochajski, & Stone, 2004). Personal factors, such as age, gender, tness, coping abilities, and social background, are also important in determining how the person will react to intervention. Thus, the ICF model provides the practitioner with a framework for gathering necessary information about the clientneeds, abilities, and limitationsbefore and after the onset of a disease, condition, or disorder. According to the Practice Framework (AOTA, 2002), any occupational therapy evaluation, including the assistive technology assessment, begins with constructing an occupational prole of the client. After an occupational prole is gathered, the practitioner analyzes the clients occupation performance. This includes evaluating the persons performance skills (e.g., motor and process skills), performance patterns (e.g., habits and roles), and performance in areas of occupation (i.e., ADLs and instrumental activities of daily living [IADLs]). Impairments, limitations, restrictions, and barriers in any of these areas are explored to determine which therapeutic strategy or combination of strategiestherapeutic intervention, compensatory techniques, assistive technology, or environmental modications would give the client the most independent level of functional performance. Assistive technology should be selected when the other strategies are not adequate or sufcient in helping the client achieve his or her full functional potential, and for energy conservation, joint protection, or to reduce repetitive motion. An outcome assessment is performed after assistive technology provision and training to determine whether or not the technology was successful in helping the client reach the desired goals. The following section will explore the appropriate application of technology for people given the number and type of classication levels affected by that persons disease, condition, or disorder. Person 1 is a community-dwelling older male who enjoys golng, meeting with his friends to play cards, reading the newspaper, and doing crossword puzzles. He has recently developed an age-related eye condition called presbyopia that affects the accommodative power of his

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intraocular lens causing decreased visual acuity at near distances. He has noticed increased difculty reading the newspaper, lling out crossword puzzles, and reading road signs when driving. He does not have any difculty performing any other ADLs or IADLs. According to the ICF model, the condition, presbyopia, directly affects the body structure/function level, and indirectly affects the other levels as noted by only minor activity limitations and participation restrictions mentioned above. Although this is not a typical client seen for occupational therapy services, this client does represent a person on the high functioning end of the continuum; that is, the client has a condition that affects one level on the ICF model with minimal effects to the other, and only requires low-tech assistive technology (i.e., eyeglasses) to remediate these limitations and restrictions. Person 2 is an older female with mild dementia who resides with her daughters family. Prior to developing dementia she lived independently and had no difculty performing her ADLs and IADLs. Currently, she is beginning to have difculty remembering to take her medications and to turn off the stove after cooking. Occasionally, she also gets confused when performing certain self-care and home management tasks, as well as getting disoriented when walking in the neighborhood. Her family is concerned for her safety because she is home alone while they are working or going to school. In this case, the condition affects the body/structure level of the ICF model, as well as the activity and participation levels. The client appears to have many positive environmental factors (e.g., good social support network), but also several negative environmental factors that endanger her safety (e.g., stove burners without automatic shutoff). Interventions cannot be implemented at the body structure/ function level to alleviate problems in the other two levels. Because the evaluation results show no other impairments except for memory and cognitive-processing skills, intervention focuses on environmental modications, compensatory strategies, and family education. An outcome assessment performed by the therapist concludes that the goals relating to the patients safety and medication management have not been fully met. Thus, the occupational therapist begins to explore assistive technology options with the client and her family, taking into account her strengths, limitations, and acceptability of the device. The client, her family, and the therapist decide on the

following devices: burners with automatic shutoffs, electronic pill organizer and reminder, an electronic notebook that provides audible reminders, and a bracelet locator for when she gets disoriented (www.abledata.com/abledata. cfm?pageid=19327&ksectionid=19327). A followup evaluation found that with the intervention and assistive technology, the client successfully met her goals and will be able to continue to live with her family members.

Issues Relating to Use of Assistive Technology with Older Adults

Repair and maintenance of assistive devices are important concerns. What are the costs, will it be available when needed, and how long will it take? Lack of repair and maintenance can be dangerous and fail to provide the optimal amount of assistance. A study of 227 adults with various disabilities found that 29.3% of all devices were abandoned (Phillips & Zhao, 1993). Furthermore, this study found that device abandonment was signicantly related to one of four factors: 1. Lack of consideration of user opinion in selection 2. Easy device procurement 3. Poor device performance 4. Change in user needs or priorities In recommending assistive devices, rst it is important to give the client options of different assistive technology devices and work with vendors to allow the client to try equipment out before making the purchase, especially with more expensive devices. After determining which device the client prefers, the therapist should help the client in identifying funding for the device. Last, the therapist should provide training in the use of the device, and leave instructions regarding repair and maintenance, either with the device user or with a caregiver. Locating service providers capable of offering quality assistive technology services is often difcult not only for the older consumer but for other service providers who make referrals. There is also some fragmentation of services as a result of specialization. Experts in vision, hearing, and cognitive disabilities may not be capable of working with the complex

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interweave of factors that often are present in an older person. Occupational therapists are often the most knowledgeable about assistive technology services and either make an intervention or refer the client to another provider. One source of information on service providers is the lead agency in each state under the Technology Related Assistance for Individuals with Disabilities Act. The Society for the Advancement of Rehabilitative and Assistive Technology (RESNA) in Washington, DC, provides technical assistance to the states and could be contacted for information on your states lead agency. Funding is another problem with assistive devices and the services required for successful use. Even though many devices are low in cost and can be covered by the user, many other devices are expensive and not affordable to all who need them. The national trend is for less public funding for health care and for greater outof-pocket funding: The ndings demonstrate the startling and accelerating growth in the elderlys out-of-pocket costs for health care. In fact, the elderlys out-of-pocket health expenditures have grown much faster than Medicare and Medicaid program costs (Crystal, Johnson, Harman, Sambamoorthi, & Kumar, 2000). Assistive devices help people maintain or regain independence and, thus, can reduce overall health

care costs. However, access to assistive devices is often blocked, restricted, or limited because thirdparty payers do not cover them. Acceptability of the device to the individual is a crucial factor. The persons needs and wishes must be considered. Some people may nd the devices unacceptable cosmetically, and some may resist being dependent on these devices. Further, high tech is intimidating to some older adults. It may be possible to address this factor in a training program for the use of a certain device, but it is also possible that the device will still be left in a closet to collect dust or, worse, that it will get in the way and make function more difcult. Although there are problems related to assistive technology and environmental interventions, these tools offer great potential for helping older adults maintain independence and lead satisfying lives. Occupational and physical therapists as well as other service providers often play an important role in identifying the appropriate technology, in training older persons in how to use it, and in providing follow-up support. Audiologists deal with devices related to hearing, and physical therapists, mobility devices. Opticians or optometrists may be knowledgeable about vision aides. Social workers are vital in identifying sources of nancing for all these devices and services.

C a s e

S t u d y
Questions
1. What is the rst step for an occupational therapist? 2. Based on this assessment, how would you evaluate her difculties at each level of the ICF? What environmental factors might affect her performance? 3. What kinds of occupational therapy intervention might be most helpful?

Mrs. Jones is a 78-year-old female who had a right cerebrovascular accident (CVA) and left hemiplegia several years ago and uses a manual wheelchair for all of her mobility needs. She lives alone in the community but has family members who live next door and come and check on her at least once a day. She also has home health nurses come by once a week to check on her and nursing assistants that come by three times a week to assist her with bathing, dressing, and light house chores. Recently, the client has reported increased difculty moving around her house and operating appliances.

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R e v i e w

Q u e s t i o n s

1. What is the difference between high-tech and low-tech assistive devices? What makes universal design important to all older adultsthat is, including those who have only minimal functional limitations? Mrs. A is a 67-year-old widow with mild arthritis and mild presbycusis. How might environmental control devices assist her in maintaining independence in her apartment? 2. Mr. Y is in the early stages of macular degeneration. What assistive devices might a therapist consider to help him as his vision declines? 3. A therapist has provided an environmental control device for Ms. D. On a home visit, she notes that the device is sitting on the table, collecting dust. What are the possible reasons that Ms. D might not use the device, and what could the therapist do?

We b - B a s e d

R e s o u r c e s

For helpful information about the experience of products and technology, visit:
Product Reports (20032005). www.aarp.org, American Association of Retired Persons (AARP), date connected July 16, 2007. Developed for AARP members, each of these reports provides overviews of the device type and comparative information. Several reports are planned, but those currently available include Wheelchairs, Hearing Aids, and Personal Alerting Devices. www.phhp.u.edu/centers/rerc.htm, Rehabilitation Engineering Research Center on Aging, date connected July 16, 2007. A series of training material for professionals and information on products for consumers, including videos, slides, booklets, training guides, and case studies. www.RESNA.org, Assistive Technology (journal), published by RESNA Press, date connected July 16, 2007. This quarterly journal is the ofcial publication of RESNA, The Society for the Advancement of Rehabilitative and Assistive Technology. www.abledata.com, Abledata, date connected July 16, 2007. This site includes a large number of products that can be helpful to individuals with physical disabilities and for older adults. Resources

Smart technology for aging, disability, and independence: The state of the science (2005). published by Wiley Interscience, Hoboken, NJ. This 379-page text covers assistive technology devices for various disabilities and contains a unit on assistive technology information. Technology and Disability, IOS Press, 5795-G Burke Centre Parkway, VA 22015. This journal communicates knowledge about the eld of assistive technology devices and services, within the context of the lives of end userspersons with disabilities and their family members. Although the topics are technical in nature, the articles are written for a broad comprehension despite the readers education or training. Its contents cover research and development efforts, education and training programs, service and policy activities, and consumer experiences. The journal publishes original research papers, review articles, case studies, program descriptions, Letters to the editors, and commentaries. Suggestions for thematic issues and proposed manuscripts are welcomed.

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