Aids for the frail, elderly person living at home can be quite expensive. There are two sorts -- items like canes, walkers and answering machines, and structural changes in the home itself, such as adding ramps, lowering cabinets and replacing throw rugs with safer floor covering. An interesting study has been reported which shows the concrete benefits of putting such aids in place.¹ They were shown to improve independence and postpone the need for nursing home admission, as well as reduce overall health costs.

The study was done in New York State, USA. Over 100 frail elderly persons living at home were randomly assigned to receive either the "usual care" services or intensive aid services. The "usual care" participants made use of any aid they had purchased or obtained on their own (or via their caregiver's initiative) from local agencies, volunteer services, etc. The intensive aid participants were visited at home by an occupational therapist who made recommendations for the necessary changes, and, together with a nurse and a technician, acquired or installed the aid, and provided instruction for use, with good follow-up.

The study went on for 18 months. At the end of this time participants were assessed by a special scale that measured their mental and bodily abilities (the Functional Impairment Measure, or FIM), as well as two other scales that measured physical handicap and physical independence. The degree of chronic pain experienced was assessed at the start and the end of the study. All health-care costs were estimated, including those associated with the additional aids provided in the intensive group.

The 50-odd participants in each group were similar with respect to their age (average 73 years), sex (73% women), race (74% white), level of education, income, marital status and general health. Most importantly, their functional independence was similar at the start of the study. Ten participants died or dropped out of the "usual care" group, and 4 died in the intensive aid group. On average, each participant in the intensive aid group received over 15 tools or apparatus, and 1-2 different structural alterations in the home. In the "usual care" participants, such changes were minimal.

After 18 months there was a decline in functional independence (FIM scores) in both groups, but the changes were significantly smaller in the intensive aid group. Similar benefits were recorded in the handicap and physical disability scales. With regard to pain, the "usual care" participants had, on average, an increase in pain after 18 months, while pain levels were unchanged in the intensive aid group.

In comparing total health costs, the "usual care" group had significantly greater costs for in-home help and institutional care (i.e. they required more hospital or nursing home care, on average). These more than offset the costs of the provision of aid in the intensive group. The average total cost for someone in the "usual care" group for 18 months was over US $31,000, and for someone in the intensive aid group less than US $15,000.

The findings in this study suggest that cost-conscious health providers should supply people who are frail and living at home with appropriate aids - both equipment and structural changes in the home. The cost effectiveness is quite clear. However, until such measures are standard practice, old persons living at home must accept that spending money on practical aids to make their life easier and safer can have a pay-off, such as a delay in the need for nursing home care, or a lessened likelihood of development of chronic pain.