Equipment Update: The Challenge of Getting Older Adults to Use DME
Although many are reluctant to use durable medical equipment in home care, it’s vitally important.
A frustrating scenario for a geriatrician is that many older adults are reluctant to use necessary durable medical equipment (DME) in their home care.
Excuses range from “the equipment is too bulky and causes mobility problems,” to “it’s too difficult to operate when using it,” or they simply have difficulty in understanding the result reports.
Jennifer Kim, DNP, GNP-BC, GS-C, FNAP, FAANP, president-elect of the Gerontological Advanced Practice Nurses Association, notes some older adults dislike how medical equipment disrupts the aesthetics of the residence, while others have a hard time conceding that they truly need the DME to safely live at home.
“DME is often a visual reminder of functional loss; it is normal for an older adult to grieve this loss,” she says. “DME is also expensive, and some older adults do not realize that Medicare covers the cost if the DME is prescribed by a primary care provider and deemed to be medically necessary.”
Geriatricians and gerontological advanced practice providers (eg, advanced practice nurses, physician assistants) often encourage older adults to use DME, emphasizing its importance in mitigating the risk of falling, injury, and subsequent decline.
“Many of us have had longstanding relationships with our patients and their families, which is important for patient buy-in for some more difficult issues and challenging conversations,” Kim says. “We also normalize the use of this equipment, reminding patients that its use isn’t a sign of weakness.”
Mariah Robertson, MD, MPH, associate program director of the Geriatric Medicine Fellowship Program and an assistant professor of medicine, geriatric medicine, and gerontology at Johns Hopkins School of Medicine, spends a lot of time in people’s homes thinking about the barriers to mobility.
“We tend to think that just giving someone the equipment is enough to make them more mobile, and it’s not necessarily true,” Robertson says. “For an older adult, giving them an assistive device or other home medical equipment can sometimes come with that fear of it being a hindrance to their ability to do things. That’s a big reason why people are reluctant.”
More Reasons Patients Object
Christina Steinorth-Powell, a licensed psychotherapist who specializes in geriatrics and aging issues, explains that one of the main reasons some older adults are reluctant to use DME in home care is because they are in denial of the help they really need.
“In their mind, it signals a loss of independence, and this can be difficult to accept,” Steinorth-Powell says. “Sometimes aging adults can't see themselves objectively. In addition, when their adult children try to assist, the aging parent can’t get past the fact that, regardless of the age of their children, they still see them as kids, and with that they see them as inferior on some level. This is why it’s helpful for geriatricians to assist.”
Kenneth Lam, MD, MAS, a geriatrician in San Francisco and an assistant professor of medicine at the University of California, San Francisco, notes many older adults don’t have DME in their home for a variety of reasons, of which reluctance is only one.
“There’s a reasonable amount of research out there describing how: a) you don’t know when you need it, b) you don’t know how to get it or where to install it or what pieces you need, and c) even if you think you need it, it can be stigmatizing,” Lam says.
For that reason, he suggests that geriatricians shouldn’t assume outright that people do not want this, as it could just be a case of not knowing what’s available, what’s possible, or what to get.
Still, Lam has seen enough examples of older adults who are unwilling to use this equipment.
“It’s not my job to force people to get equipment; it is my job to make sure they understand and see what could be possible rather than feel resigned that this is as good as it gets or a nursing home is the only available alternative,” he says.
“Many older adults use ambulatory assistive devices such as canes or walkers because mobility may become more challenging with advanced age,” Kim says. “Many falls occur in the bathroom, given the mobility and balance challenges with undressing and changing positions from sitting to standing.”
While bathroom falls come to mind to a lot of doctors, Lam has seen some data suggesting falls in the hallway are also common, and equipment for both are important.
He looks at DME equipment in broad categories: shower equipment would include a non-slip mat, handheld shower, grab bars, shower bench, and perhaps a walk-in shower that can let wheelchairs in; toilet equipment includes a raised toilet seat and toilet grab bars; other modifications include cupboards in the home, arm rests for chairs to help with getting up, equipment that raises sofa heights, and adaptable rail systems.
“Another common thing we do is we order a hospital bed for a patient’s home,” Robertson says, who stresses it’s important to know the size constraints and space that’s available.
Getting Them On Board
For example, her 88-year-old father, a successful banker, had been fiercely independent—it was either his way or the highway. Having to admit any type of weakness was something he didn’t do, so it was extremely difficult to get him to use any type of assistive device.
“I bought him a top-of-the line walker that literally sat in his dining room for over four years until his gait became so bad that he had no choice other than to use it,” she says. “Of course I would try to get him to use it on every visit, touting how much better and safer for him it would be. I never grew impatient with him because I knew that wouldn’t help.”
That’s important advice for anyone working with an older adult—don’t try to force someone to do what they don’t want.
“Keep in mind, you can’t force someone to do something they’re not ready to do, but if you gently remind them how much easier things would be if they used the equipment provided, eventually some may come around,” Steinorth-Powell says.
While it might seem that men would be more resistant to getting help, Robertson says that most everyone feels that loss of independence and that denying their need for DME equipment is not uncommon in women as well.
The vital step, she explains, is for the provider to communicate the importance of the equipment and properly assess the suitability of the equipment in the home. For instance, one individual may be reluctant to use a walker because it may not work in a narrow hall, while another may not have been educated about how to use the walker while cooking.
“The home environment therefore plays a huge role, as they may not see the equipment they’ve been prescribed as practical to use in their homes and that gives them an excuse not to use it,” Robertson says. “I would recommend having a home safety assessment done, and most geriatricians can order this as part of home care. This lets them see how they exist in their home and can pick the tools that work best in the home.”
From Kim’s experience, there’s really nothing geriatrics health care professionals can do to convince a patient to use DME. However, she’s found that many older adults just want to be heard.
“When actively listening to older adults, we find out why they are hesitant and with that greater understanding, we can then address their concerns,” she says. “I like to frame the discussion around a patient’s functional goals; patients may be more amenable to using DME when they understand that it will help them achieve their goals.”
When appropriate, it’s also important to reiterate that use of DME may be temporary, as is often the case when an older adult is rehabilitating from an illness or hospitalization.
A great tip is to get the older adult’s family involved in helping to convince them to use what they need. Robertson calls that a critical part of them buying into utilizing safety measures in the home and DME.
“I think having a family member be present for the therapy also helps that family member understand how to help the loved one get around more safely using the equipment that they have,” she says.
Physical and occupational therapists have advanced education and training in assessing and evaluating older adults for the use of assistive equipment, and these services are typically covered by Medicare, including a home evaluation.
“It’s important for older adults to be evaluated and to use equipment that has been recommended by physical and occupational therapists because, oftentimes, these devices need to be fitted to a particular individual,” Kim says. “An ambulation assistive device that is not specified and tailored for a patient can actually contribute to fall risk and injury.”
— Keith Loria is a D.C.-based award-winning journalist who has been writing for major publications for nearly 20 years on topics as diverse as real estate, travel, Broadway, and health care.