Problems With Dressing in the Frail Elderly

William C. Mann, Christine Kimble, Michael D. Justiss,

Elena Casson, Machiko Tonnita, Samuel S. Wu

OBJECTIVE. Dressing is an important activity of daiiy liying, yet many oider adults haye difficuity due to
impairments. The purpose of this study was to expiore the use of assistive devices for dressing by oider persons with impairments, and to iook at ditterences among fraii eiders with no dressing difficuity, upperextremity-oniy dressing difficulty, lower-extremity-oniy dressing difficuity, and both upper- and iower-extremity dressing difficuity.
M E T H O D . We conducted in-home interviews and functionai assessments with 1,101 eideriy persons with
actiyities of daiiy iiving and/or instrumentai actiyities of daiiy iivihg limitations in Western New Yori< and
Northern Fiorida, Participants were assigned to one of four groups based on Functionai Independence
Measure item scores for upper-extremity dressing and iower-extremity dressing. Descriptive statistics were
used to report resuits,
RESULTS. Compared to women, there were reiativeiy more men with iower-extremity dressing difficuity than
with upper-extremity dressing ditficuity. The group with both upper- and iower-extremity dressing ditficulty
reported the highest ievei ot pain and scored iowest on aii measures ot tunctionai status and mental status. The
most commoniy used dressing devices were associated with iower-exiremity dressing.
CONCLUSION. There are ditterences in gender, heaith status, functionai status, and mental status among
eideriy persons grouped by upper- or lower-extremity dressing difficuity. Resuits suggest that therapists should
consider such differences as gender and type of difficuity (upper- or lower-extremity dressing) in both therapeutic approaches and recommendations tor assistive devices. Pain is another important consideration, but it
can often be reduced during dressing by using assistive devices.
Mann, W. C, Kimble, C, Justiss, M. D., Casson, E., Tomita, M., & Wu, S. S. (2005). Problems with dressing in the trail
elderly. American Journal of Occupational Therapy. 59, 398-408.

William C. Mann, PtiD, TR, is Ctiair and Protessor,

Department ot Occupational Therapy, University ot Florida,
PO Box 100164, Gainesville, Florida 32610-0164;
wmann@hp.utl.edu
Christine Kimble, OT is Master's Student, Department ot
Occupational Therapy, University ot Florida, Gainesville,
Florida.
Michael D. Justiss, MOT OTR/L, Research Assistant,
RERC-Tech-Aging, Retiabilitation Science Doctoral
Program, University ot Florida, Gainesville, Florida.
Flena Oasson is Publications Director, Department ot
Occupational Therapy, University ot Florida, Gainesville,
Florida.
Mactiiko Tomita, PhD, is Clinicai Associate Protessor,
Department of Rehabilitation Sciences, University at
Buttalo, The State University ot New York, Buttalo,
New York.
Samuel S. Wu, PhD, is Assistant Protessor, Department
ot Statistics, Coiiege of Medicine, University ot Florida,
Gainesville, Florida.

398

n 1996, tbere were 33.9 million people in tbe United States more tban 65 years
of age (Administration on Aging, 1996), and by 2020, tbis group will increase to
53.2 million (Sigel, 1996). Tbe "oldest-old" elderly persons, tbose more tban 85
years of age, are tbe fastest growing segment of tbe population, and tbis will accelerate witb tbe baby boom generation now reacbing 65 years of age (Sigel, 1996).
In 2000, 35% of elderly persons reported limitations in activity (Centers for
Disease Control and Prevention, 2003). Sixteen percent of persons more tban 85
years of age bave difficulty witb dressing and 11% require belp (Hobbs & Damon,
1996). Assistive devices are available tbat can be used for dressing; bowever, we
know relatively little about tbe use of assistive devices for dressing by elderly persons witb functional limitations. We do know tbat overall, assistive device use bas
been increasing wbereas use of personal assistance is declining (Mantn, Corder,
& Stallard, 1993). We also know tbat people who use assistive devices report less
unmet need relative to tbeir personal care (Agree & Freedman, 2003). Tbe purpose of tbis study was to explore tbe use of assistive devices for dressing by homebased elderly persons with functional limitations.

Literature Review

Ability to complete activities of daily living (ADL) independently can affect one's
sense of well-being. Krach, DeVaney, DeTurk, and Zink (1996) examined six
Number 4

domains of functioning (physical, mental, social, spiritual,

economic, and ADL) in 50 cognitively intact subjects more
than 85 years of age (mean age 89 years) living in a home
setting. Measurement tools for this study included the
Older American Resources and Services instrument
(OARS), Mini-Mental Status Examination (MMSE),
Geriatric Depression Scale (GDS), and Spiritual WeilBeing Scale (SWBS). The majority of subjects required
assistance with at least four ADL. The areas with the highest proportion of problems were witb ADL (72%) and
physical functioning (55%) (Krach et al.). Using correlation
analysis, significant relationships were found among physical, mental, social, and economic variables, and ADL. The
study illustrates the profound and broad implications of
dressing problems for older adults.
Frailty among older adults has been shown to relate to
ADL performance, including dressing tasks. Ho, Williams,
and Hardwick (2002) studied 78 community-dwelling
individuals with a mean age of 74.1 years (5D 6.1). Thirtyseven of these individuals were characterized as being at
high risk for frailty, and 42 were at low risk for frailty.
Logistic-regression analysis indicated there were significant
differences between tbe two risk groups in areas of balance,
mobility, range of motion, uppet-extremity control, and
ADL. Tbe ADL tasks included zipping a zippet, tying a
shoe, huttoning three large buttons, buttoning three small
buttons, picking up and fastening three safety pins, and
donning and taking off a shirt. High-risk individuals were
2.9 times mote likely to score below the mean on the seven
ADL tasks {p = .0274) (Ho et al., 2002). Difficulties with
tasks involved with dressing are predictive of frailty.
Adaptive equipment is often used to offset difficulties
experienced with dressing tasks. Gitlin, Levine, and Geiger
(1993) studied adaptive equipment use from the perspectives of both older adults with mixed disabilities and home
health therapists. Thirteen subjects (mean age 73 years, 10
women, 3 men) from a bospital rehabilitation unit were
interviewed once before discbarge concerning prescription
of assistive devices. Eight of those dischatged participated in
one 20-minute interview by telephone each month ovet 3
months. They were asked to rank theit most valued piece of
adaptive equipment, how often they used adaptive equipment they had been issued wbile in rehabilitation, and any
reasons for non-use of adaptive equipment. Dressing equipment was the most frequently issued device, with all 13 of
the subjects receiving a dressing aid. Six devices were already
in subjects' homes before hospital admission. The average
number of devices in each home was 3.15 (1.46). Of the 23
dressing aids, subjects reported using 11 (47%) frequently
or consistently during tbe first montb at home. The four
major reasons for non-use of devices were: (1) task per-

formed by others, (2) perception of lack of need, (3) equipment failure or loss, and (4) equipment too "cumbersome"
(Gitlin et al., 1993). In a related study, Githn, Scbemmm,
and Landsberg (1996) found tbat o 642 devices provided
to 86 rebabilitation in-patients, 50 percent were used frequently to always in the fitst 3 months following discharge.
These studies illustrate the importance of assistive devices
for dressing, but do not specifically examine differences in
upper- and lower-extremity dressing difficulties, as in the
present study.
Other studies have also addressed use of assistive
devices for dressing, de Klerk, Huijsman, and McDonnell
(1997) identified variables related to the use of assistive
devices in a study of 498 single, independent-living elderly
persons (mean age 81 years). Aids for ADL (such as buttonbooks, raised beds) were used by 73.5% of tbe sample.
Tbe most frequently used dressing aid was the long-handled shoehorn with 10% of subjects using this device.
Women and those living in small or sheltered housing used
more assistive devices. Elderly persons who received home
care used more devices than those not receiving home care.
The investigators postulated that caregivers provide informal training and stimulate their care recipients to use more
assistive devices. No significant relationship was found
between educational level and the use of assistive devices.
Subjects witb bigber income used fewer devices than those
with lower incomes. Use and number of assistive devices
used for basic ADL activities wete positively correlated with
having chronic illness (de Klerk et al.).
The importance of dressing devices was also identified
in a study of hospital patients' concetns, petceptions, and
beliefs regarding assistive devices (Gitlin, Luborsky, &
Schemm, 1998), with a sample of 103 stroke patients who
wete receiving rehabilitation. Devices were categorized as
addressing mobility, dressing, feeding, seating, and bathing.
Mobility devices generated the most comments, followed
by dressing devices. Dressing devices received a proportionately larger number of positive comments compared to tbe
other device types. User satisfaction and dissatisfaction were
studied in more detail in the present study.
The use of "technical aids," including assistive devices
for dressing, was studied in a sample of 57 subjects more
than 74 years of age who reportedly had difficulties performing ADL (Parker o Thorslund, 1991). Four hundred
twenty-two technical aids (7.4 per person) were found in
the subjects' homes, of which 75% were being used. Aids
for personal hygiene (raised toilet seats, bathtub bencbes,
and dtessing aids) composed 20% of the aids. Subjects wbo
reported diBculties in dressing, eating, and transfers were
the least likely to have aids for these limitations. When
dressing, subjects relied on personal assistance, adapted the
399

task, or avoided the activity altogether. Personal assistance

was required for 12 subjects in donning coats. Thirty-six
subjects reported difficulty dressing, with 28 (78%) using
aids. The most frequently reported difficulties in ADL were
in the areas of personal hygiene and mobility (Parker &
Thorslund). This study provides further evidence that
dressing difficulties are common among older persons, and
a significant number of them do use assistive devices to
address these difficulties.
Schemm and Citlin (1998) studied methods that occupational therapists use in rehabilitation clinics to teach use of
dressing and bathing devices. They studied 86 patients and
19 occupational therapists during training sessions and found
to teach dressing device use, therapists averaged 2.5 sessions
of 10-minute average session duration. Teaching was primarily demonstration and oral instruction. Patients receiving
training in device use reported it to be "satisfactory." The
importance of training in the use of assistive devices, including dressing devices, was clearly identified in this study.
Loss of independence in ADL, including dressing, has
a relationship to quality of life (Krach, DeVaney, DeTurk, &
Zink, 1996) and frailty (Ho et al., 2002). The importance
of assistive devices for dressing has been identified in several studies (de Klerk et al., 1997; Cithn, Levine, & Ceiger,
1993; Citlin et al., 1998; Cidin, Schemmm, Landsberg, &
Burgh, 1996; Parker & Thorsiund, 1991). Perhaps because
these studies had relatively small sample sizes, they did not
explore differences in upper- and lower-extremity dressing
difficulties. Yet, different movements are required for upperand lower-extremity dressing, and different assistive devices
are available to address these difficulties.
This study included a larger number of participants
than in previous studies of use of dressing devices by older
persons, and it explored differences among participants
grouped by upper- and lower-extremity dressing difficulties.
The following questions were addressed: (1) What are the
differences in demographic health, functional and psychosocial status, and quality of life for frail older persons
grouped as follows: (a) no dressing difficulty, (b) upperextremity-only dressing difficulty, (c) lower-extremity-only
dressing difficulty, (d) both lower- and upper-extremity
dressing difficulty; (2) What types of dressing devices are
most commonly used; and (3) What are the reasons for dissatisfaction with dressing devices? Having a better understanding of the underlying factors that relate to upper- and
to lower-extremity dressing could help therapists in identifying older persons potentially in need of assistive dressing
devices. Knowing what dressing devices are most commonly used, and reasons for dissatisfaction with devices, could
potentially guide therapists in providing assistive dressing
devices rhat will be successfully used.
400

Methods
Sample
This report is based on the Rehabilitation Engineering
Research Center (RERC) on Aging Consumer Assessments
Study (CAS), a longitudinal study of the coping strategies
of elderly persons with disabilities. From 1991 to 2001, 26
senior service agencies and hospital rehabilitation programs
referred individuals they currently served, or in the case of
hospital rehabilitation programs, individuals discharged
home, to the CAS. A comparison of the sample with the
Federal Interagency Forum on Aging-Related Statistics
(2000) demonstrated that the resemblance of the subjects
to the national population of elderly persons was very close
for race and living status. However, compared to the statistics of the U.S. Census Bureau (2000), the subjects were
older and a larger proportion of them were women. This
sample further closely resembled the approximately 20 percent of the elderly population who has difficulty with at
least one ADL or instrumental activities of daily living
(IADL) (Administration on Aging, 2004).
The CAS was initiated in Western New York (WNY)
where 790 elderly persons were interviewed. In the final
two years, the CAS was replicated with 311 study subjects
in Northern Florida (NFl). For the present report, we combined initial interviews of the NFl and WNY samples and
grouped study participants based on Functional
Independence Measure(tm) (FIM(tm)) dressing scores.
We grouped study participants based on the two FIM
dressing item scores (upper-extremity dressing and lowerextremity dressing items). FIM item scores range from 1
through 7 and each score is defined; for example 7 =
"Complete Independence," 3 = "Moderate Assistance," and
1 = "Complete Dependence." Croups were defined as follows: (1) NDDNo Dressing DifficulryFIM lower- and
upper-dressing item scores equal to 7 ( = 295); (2)
UEODDUpper-Extremity-Only Dressing Difficulty
lower-extremity FIM item score equals 7 but upper-extremity FIM item score less than 7 {n = 23); (3) LEODD
Lower-Extremity-Only Dressing
Difficultyupperextremity FIM item score equals 7 but lower-extremity
FIM item score less than 7 ( = 118); (4) BLUEDDBoth
Lower- and Upper-Extremity Dressing Difficultyboth
upper-extremity and lower-extremity FIM item scores
below 7 {n = 665).
Demographic information for study participants is presented in Table 1, broken down by group assignment. The
following information is for the entire sample {N = 1 JOl).
Participants ranged from 60 to 106 years of age, with a
mean age of 75.3 years (8.3). Eight hundred one of these
study parricipants (72.8%) were female, and 80.2% were
tulv/Atiai/Kt

", Number 4

Table 1. Demographic Information for Elderly Persons With Problems DressingNew York and Florida Population Year 1
NDD

UEODD

(n = 295)
% or x(SD)

(/7=23)
% or x(SD)

Age (/V= 1,097)

75.8

77.4

Gender *(/V= 1,099)

Female
Male

229 (77.9%)
65 (22.1%)

20 (87.0%)
3 (13.0%)

85 (72.0%)
33 (28.0%)

467 (70.2%)
197 (29.7%)

801 (72.8%)
298 (27.2%)

Race (A/=1,096)
Black
White
Hispanic
Asian
Other

41
249
2
1
1

6 (26.1%)
17 (73.9%)

23 (19.5%)
94 (79.7%)

132 (20.0%)
523 (79.1%)
3 (0.5%)
(0.5%)

202 (18.4%)
883 (80.6%)
5 (0.5%)
2 (0.2%)
4 (0.4%)

Education (/V= 1,099)

Less than high school
High school
Some college
College
MA/MS
Doctorate

60 (20.5%)
110 (37.5%)
65 (22.2%)
29 (9.9%)
21 (7.2%)
8 (2.7%)

7
6
6
4

(30.4%)
(26.1%)
(26.1%)
(17.4%)

34
36
28
12
8

(28.8%)
(30.5%)
(23.7%)
(10.2%)
(6.8%)

169 (25.5%)
253 (38.0%)
143 (21.5%)
54 (8.1%)
24 (3.6%)
13 (2.0%)

270 (24.6%)
405 (36.9%)
242 (22.0%)
99 (9.0%)
53 (4.8%)
21 (1.9%)

Marital Status (/V= 1,099)

Married
Widowed
Divorced
Single
Other

90 (30.6%)
150 (51.0%)
32 (10.9%)
19 (6.5%)
3 (1.0%)

5
12
4
2

(21.7%)
(52.2%)
(17.4%)
( 8.7%)

34 (28.8%)
58 (49.2%)
12 (10.2%)
10 (8.5%)
3 (2.5%)

216 (32.5%)
315 (47.4%)
66 (9.9%)
57 (8.6%)
11 (1.7%)

345 (31.4%)
535 (48.7%)
114 (10.4%)
88 (8.0%)
17 (1.5%)

Living Status (A/=1,097)

Live aione
Live with someone

170 (57.8%)
124 (42.2%)

15 (65.2%)
8 (34.8%)

66 (55.9%)
52 (44.1%)

338 (50.8%)
324 (48.7%)

589 (53.7%)
508 (46.3%)

Housing Status (A/= 1,100)

Own
Rent
Other

155 (52.7%)
124 (42.2%)
15 (5.1%)

15 (65.2%)
8 (34.8%)

65 (55.1%)
48 (40.7%)
5 (4.2%)

359 (54.0%)
247 (37.1%)
59 (8.9%)

594 (54.1%)
427 (38.8%)
79 (7.2%)

Economic Status (A/=981)

Less than $10,000
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000 or more

111 (42.5%)
80 (30.7%)
30 (11.5%)
24 (9.2%)
16 (6.1%)

10 (50.0%)
8 (40.0%)

48 (46.2%)
36 (34.6%)
10 (9.6%)
4 (3.8%)
6 (5.8%)

287 (48.2%)
176 (29.5%)
65 (10.9%)
32 (5.4%)
36 (6.0%)

456 (46.5%)
300 (30.6%)
105 (10.7%)
61 (6.2%)
59 (6.0%)

(8.3)

(13.9%)
(84.7%)
(0.7%)
(0.3%)
(0.3%)

(7.2)

LEODD

BLUEDD

Ail Participants

% or x(SD)

(n=665)
%orx(SD)

/V=1,101
% or x(SD)

75.3

75.2

74.4

(8.2)

(8.5)

1 (0.8%)
3

1 (5.0%)
1 (5.0%)

(8.3)

Wofe. BLEDD = hoth iower- and upper-extremity dressing difficuity; LEODD = lower-extremity-only dressing difficuity; NDD = no dressing ditticuity; UEODD =
upper-extremity-only dressing difficuity.

*p<.05

white. Thirty-seven percent had completed high school.

Three hundred and forty five study participants (31.3%)
were married, 589 (53.5%) lived alone, and 594 (54%)
owned their own home. Forty-seven percent of the sample
had incomes under $10,000 per year. Table 2 presents
information on measures of health, functional, and psychosocial status organized by study groups. Study patticipants averaged 5.7 (5.9) physician visits during the 6
months prior to the study interview. They reported taking
an average of 5.4 (3.8) medications, and had a mean of 6.2
(3.1) chronic diseases or conditions. Poor vision or blindness was reported in 16.7% of participants, and 40.3%
reported less than "good" hearing. On average, study participants were 26.9% (15.4%) physically disabled (Sickness
The Amer"-

Impact Ptofile [SIP] score, which represents the percent of

disability). Study participants scored a mean of 9.1 (3.9)
out of 14 for IADL, and 75 (14.8) out of 91 on FIM Motor
section. Participants' mean MMSE score was 26.4 (5.7); 24
is typically the cutoff point for separating samples into cognitively/noncognitively impaired (Braekus, Laake, &
Engedal, 1992). Table 3 lists the frequencies of the chronic
diseases and conditions reported by the study participants.

Instruments
The CAS uses a battery of instruments to measure multiple
dimensions including instruments developed by other
investigators, and instruments developed to meet the
unique requirements of this study. The Consumer
401

Table

2.

Health Status, Functional Status, Psychosocial,

and Mental

Health
Number of MD visits past 6 montiis
Number of sick days pasf 6 monfhs* (N = 1,081 )
None
Less than a week
1 week-1 month
1 month-3 monfhs
4 months-6 months

StatusNew York and Florida Population Y e a r 1

MDD

UEODD

LEODD

BLUEDD

(/7 = 295)
% or x(SD)

(n = 23)
% orx(SD)

(n=118)
% or x(SD)

(/7 = 665)
% or x(SD)

5.3

5.0

(6.1)

5.8

70
14
17
15
2

(59.3%)
(11.9%)
(14.4%)
(12.7%)
(1.7%)

333
109
84
71
57

(50.9%)
(16.7%)
(12.8%)
(10.9%)
(8.7%)

2.6
4.2
5.8

(6.8)
(2.8)
(2.8)

2.7
5.5
6.3

(9.1)
(3.9)
(3.0)

5.7

(5.5)

170
36
35
36
9

(59.4%)
(12.6%)
(12.2%)
(12.6%)
(3.1%)

(3.6)

10 (43.5%)
7 (30.4%)
1 (4.3%)
5 (21.7%)

1.4
5.0
7.2

(3.5)
(3.2)
(3.3)

(6.0)

Number of days in a hospitai

Number of medications***
Numher ot chronic illnesses
Eyesight (A/=1,099)
Exceiient
Good
Fair
Poor
Blind

2.4
5.7
6.2

(7.1)
(3.7)
(3.5)

44
130
67
47
6

(15.0%)
(44.2%)
(22.8%)
(16.0%)
(2.0%)

5 (21.7%)
10 (43.5%)
8 (34.8%)

20
56
29
13

(16.9%)
(47.5%)
(24.6%)
(11.0%)

77
297
172
105
13

(11.6%)
(44.7%)
(25.9%)
(15.8%)
(2.0%)

Hearing Abiiity(/V= 1,096)

Exceiient
Good
Fair
Poor
Tofaiiy Deaf

59
107
72
44
9

(20.3%)
(36.8%)
(24.7%)
(15.1%)
(3.1%)

5 (21.7%)
11 (47.8%)
4 (17.4%)
2 (8.7%)
1 (4.3%)

22 (18.6%)
57 (48.3%)
28 (23.7%)
11 (9.3%)

129
263
172
105
13

(19.4%)
(39.6%)
(25.9%)
(13.7%)
(1.4%)

Pain (Jette) (range10-40)***

12.2 ( 4 . 9 )

15.5

(7.8)

Functional Status
FIMTotai (18-126)***
FIM Motor***
FiiVl Cognition***
IADL-OARS(0-14)***
SiP (0-100)***

118 (5.4)
84.6 (4.4)
33.4 (2.7)
11.1 (2.7)
16.5 (11.4)

Psyctiosocial and Mental Status

Mentai StatusMMSE (0-30)***
Self-Esteem Rosenberg (10-40)***
DepressionCESD (0-60)**
Quaiify ot Lite**
Life Satisfaction***

27.4
33.1
11.1
2.2
3.2

(3.4)
(4.7)
(9.1)
(0.9)
(0.9)

15.1

(6.7)

13.8

(4.9)

114.4 (6.7)
81.0 (5.4)
33.4 (2.0)
10.7 (2.6)
24.1 (10.9)

115.4 (4.7)
81.8 (4.4)
33.9 (1.5)
11.1 (2.6)
22.5 (12.2)

99.0 (21.5)
69.0 (16.5)
30.2 (7.5)
7.8 (4.1)
32.4 (14.9)

27.9 (2.3)
32.8 (4.9)
14.1 (12.0)
2.3 (1.0)
3.2 (1.1)

28.3 (2.5)
33.2 (4.9)
11.4 (10.3)
2.3 (1.0)
3.0 (0.9)

25.5 (6.8)
31.6 (5.2)
13.6 (10.8)
2.4 (0.9)
2.8 (1.0)

Note. BLUEDD = both lower- and upper-extremify dressing ditticuity; LEODD = lower-exfremity-only dressing difficuify; NDD = no dressing difficulty; UEODD =
upper-extremify-oniy dressing difficuity.
*Significance < .05, **Significance < .01, ***Signiticance < .001

Table 3. Most Common Illnesses

iiiness

NDD
(n = 295)

UEODD
(/7=23)

LEODD
(n=^^8)

BLUEDD
(/i = 665)

Cardiovascular Disease

203 (68.8%)

21 (91.3%)

93 (78.8%)

515 (77.4%)

Arthritis

193 (65.4%)

19 (82.6%)

91 (77.1%)

477 (71.7%)

91 (30.8%)

10 (43.5%)

42 (35.6%)

201 (30.2%)

Vision impairment (inciuding cataracts, macular degeneration, and glaucoma)

145 (49.1%)

12 (52.2%)

56 (47.5%)

310 (46.6%)

Hearing impairment

252 (85.4%)

7 (30.4%)

31 (26.3%)

169 (25.4%)

Urinary Tract Disorders (inciuding prostate troubie)

77 (28.0%)

5 (21.7%)

29 (24.6%)

196 (29.5%)

Respiratory Disorders

68 (23.1%)

4 (17.4%)

24 (20.3%)

141 (21.2%)

Other Muscuioskeietal Disorders

61 (20.7%)

8 (34.8%)

26 (22.0%)

129 (19.4%)

Diabetes

52 (17.6%)

8 (34.8%)

24 (20.3%)

153 (23.0%)

Cerebrovascuiar accident

29

4 (17.4%)

12 (10.2%)

149 (22^4%)

Stomach and intestinal Disorder

(9.8%)

Note. BLUEDD = both iower- and upper-extremity dressing difficulty; LEODD = iower-extremity-only dressing difficulty; NDD = no dressing difficuify; UEODD =
upper-extremity-oniy dressing difficulty.

402

Number 4

Assessments Study Interview Battery contains several parts

from tbe OARS including: Physical Health Scales and
Instrumental Activities of Daily Living Scale (Mann,
Karuza, Hurren, & Tomita, 1993). A summary of the
instruments included in tbe CAS Interview Battery is
described below and presented in Table 4.
Heaitii Status instruments. The Physical Health Scales
on the OARS include self-report regarding number of
physician visits in tbe past 6 montbs; number of inpatient
hospital days; number of medications taken; and number
and types of chronic illnesses. For this instrument study,
participants are asked which of 38 predetermined illnesses
they have, and the extent to which each illness interferes
with activities. The Functional Status Index consists of 10
items within three sections (gross mobility, hand activities,
and personal care) scored on a 4-point scale from 1 = no
pain to 4 = severe pain. The item scores are summed for a
total score. The minimum possible score is 10; the maximum score (severe pain on every item) is 40. Tbe reliability and validity of the Functionai Status Index have been
examined and found to be adequate (Fillenbaum, 1988).
Functionai Status instruments. Three instruments are
used to measure functional status: the IADL section of the
OARS, the SIP, and the FIM. These instruments are moderately correlated with each other and tbere is some overlap
in content sucb as mobility. However, there are substantial
differences in these measures, conceptual and structural, as
described below. Tbe total IADL score is calculated by sum-

ming together the scores on the 7 items from the IADL section of the OARS (Fillenbaum, 1988). The 7 items ask
whether or not the study participant can use the telephone,
get to places out of walking distance, go shopping, prepare
meals, do housework, take medicine, and handle money.
Responses are scored: 2 = without help, 1 = some help, 0 =
completely unable or no answer. The IADL score can range
from 14, totally independent, to 0, totally dependent.
Reliability on the IADL section of the OARS was found to
be high (Fillenbaum & Smyer, 1981).
The SIPPhysical Dysfunction Section, was used to
determine percent of physical disability for study participants (Gilson, Gilson, & Bergner, 1975). Three sections of
the SIP (Body Care and Movement, Mobility, and
Ambulation) bave a total of 45 separate items tbat are used
to calculate the percent of physical disability score.
Testretest reliability of tbe SIP is reported as high (Bergner,
Bobbitt, & Carter, 1981).
The FIM was developed as an instrument to determine
the severity of disability (Center for Functional Assessment
Research, 1990). The FIM consists of 18 items, each with a
maximum score of 7, and a minimum score of 1. Thus, tbe
highest possible total score is 126, and the lowest, 18. Each
level of scoring (1 through 7) is defined; for example, 7 =
"Complete Independence," 3 = "Moderate Assistance." Tbe
FIM measures the following areas: Self-Care, Sphincter
Control, Transfers, Locomotion, Communication, and
Social Cognition. The FIM has been found to be reliable

Table 4. Instruments in the Consumer Assessments Study Interview Battery

iNSTRUMENT(S)

DliVlENSiON

DEVELOPED BY

1.0ARS
2. RERO-Aging Demographic Survey

1. *Duke university
2. **RERC-Aging

Health Status
Physical Heaith
Pain

OARS
Functionai Status index-iVlodified

Duke University
A. Jette

impairment Status
Vision and Hearing
Cognition
iVlotor

OARS
Mini-Mentai Status Examination
Sickness impact Protiie

Duke university
iVi. Foistein, S. Folstein, R iVIcHugh
B. Giison et ai.

Functional Status
instrumentai Activities of Daiiy Living
Functionai independence

OARS
FiM

Duke University
C. Granger

Psychosociai Status
Depression
Seit-Esteem

OESD (Center for Epidemioiogicai St

Rosenberg Seit-Esteem Scaie

L. Radioft
R. Rosenberg

Assistive Technoiogy

Assistive Technoiogy Lised

RERC-Aging

Home Environment

Home Environment Survev

RERO-Aging

Demographic intormation

Note. OARS = Older Americans Research and Services instrument.

*Duke University Center for the Study of Aging and Human Development.
**Rehabiiitation Engineering Center on Aging.

The Ame"/-

'The

403

and valid, even with study participants more than 80 years

of age (PoUak, Rheult, & Stoecker, 1996).
Psychosocial Status Instruments. Instruments to measure this domain include the MMSE, the Rosenberg SelfEsteem Scale, and the Center for Epidemiolgica! Studies
Depression Scale (CESD). The MMSE consists of 11 items
that are summed to create a mental status score (Folstein,
Folstein, & McHugh, 1988). The MMSE score ranges
from a maximum score of 30 to a minimum score of 0.
Scores less than 24 are considered indicative of cognitive
impairment. The test-retest reliability of the MMSE has
been reviewed across several studies and found to be consistently over .89.
Rosenberg Self-Esteem Scale: This scale consists of 10
items. Responses for each item are measured on a 4-point
Likert scale (1 = strongly disagree through 4 = strongly
agree). The self-esteem score ranges from 40 (high selfesteem) to 10 (low self-esteem) (Rosenberg, 1965). In a
study of over 1,700 employees of a state agency, reliability
was reported to be .8 (Shahani, Dipboye, & Phillips, 1990).
CESD: The CESD consists of 20 items asking study
participants to describe how they felt during the past week,
and is an indicator of depressive symptoms. For example,
one item states: "I had trouble keeping my mind on what I
was doing." Responses are measured on a 4-point scale (0 =
less than once a day: 1 = some of the time: 12 days a week;
2 = moderately: 3-4 days a week; 3 = mostly: 5-7 days a
week). Scores range from 0 to 60 with the higher score indicating a greater number of depression symptoms. Typically,
a score of 16 or higher is considered indicative of depression
(Radloff, 1977). Studies report test-retest reliabiliry
between .4 to .7, ranging from 2 weeks to 1 year (Devins et
al., 1988, Radloff & Locke, 1986).
Assistive Technology Instruments. An assistive technology data collection instrument called the AT Survey was
developed for the CAS. The AT Survey provides a count of
the number of devices and the number of people using specific categories of devices grouped into the general categories of devices for persons with: (1) physical (motor) disabilities, (2) hearing impairments, (3) visual impairments,
(4) tactile impairments, and (5) cognitive impairments.
Study participants are asked, in an open-ended formar,
what devices they have. They are also asked if they use the
device and if they are satisfied with the device (yes or no
response). If they have a device and it is not used and/or
they are not satisfied with it, they are asked, in open-ended
format, to explain why not. In addition to asking the participant what assistive devices they have, the interviewer
"tours" the home, and asks about devices they might have
and use in each of the rooms. Reliability of this approach
has not been established.
404

Data Collection
For the CAS, nurse or occupational therapist interviewers
collected all data in face-to-face interviews in study participants' homes. Interview time averaged about 2.5 hours.
Appointments were scheduled at times convenient for study
participants to ensure that they would be rested, comfortable, and not feel rushed.
Statistical Analysis
We compared the four dressing groups on demographic
variables, health status, functional status, psychosocial status, and mental status using the Kruskal-Wallis tests
(Hollander &C Wolfe, 1999). To correct for multiple comparisons, we calculated permutation-adjusted p values for
each hypothesis. With this approach we measured the significance of each difference by comparing the observed
study restilt with those results derived from randomly
assigning 1,101 study participants to the four dressing
groups, taking the correlation structure between the
hypotheses into account (Westfall & Young, 1993).' We
chose the Fisher's combining function because it is the most
sensitive among different types of combinations oip values
according to Birnbaum (1954).
We adopted nonparametric methods with permutation-based/> values because they are more robust, adjust for
testing multiple outcomes, and have valid type-I error control even for unequal group sizes. However, for each dependent variable, we did not perform multiple pair-wise comparisons among the 4 dressing groups as one group was
significantly smaller than the other 3 groups {n = 23), and
thus limit our conclusions to differences among the 4
groups, rather than specific differences between any one
group and otbers. We report the descriptive findings for
each of the 4 groups to guide others in future research.

Results
Research Question 1
What are the differences among the four dressing difficulty groups in demographic characteristics, health status.
'Algorithm 4.1 in Westfall and Young was modified using Fishet's combining fijnction for^ values. Fitst, the individual unadjusted/) values/>,
- Pi- - PK ^re evaluated for the 7i'hypotheses based on the nonparametric tests. Then we randomly permuted the patients for B times
and calculated the corresponding/; values/)*,/)';, . . . , / ) * , for the b"'' permutation. Using the Fisher's combining fianction h(x^, x,, . . . , x ) =
- 2 2 - ^ 1 log(x ), the /) value for the combining statistic is estimated as

A,, = Yf^.JWp'',,

/ > * . , , . . . ,/)!.) > % , / ) , . , , . . . ,/)^.)]/.S, where 7(-)

is the indicator function. Finally, the adjusted/) value fot the ;''' hypothesis is given \yy pf = n^ax p^^. The Westfall and Young's original algorithm corresponds to the Tippett combining function for tests, h{x , x,,
. . . , X, ) = min(.V|, X,, . . . , x^).

luly/Aueust 2005. Volume

Number 4

Functionai Status. Significant differences were found

among the dressing groups on the FIM (including the total
FIM score, FIM Motor score, and FIM Cognition score),
the OARS-IADL scale, and the SIP. For our study participants, the N D D group consistently scored higher (scores
reversed for SIP) in functional status than the other groups,
and the BLUEDD group participants were consistently the
most functionally impaired. The other two groups were relatively similar.
Psychosocial and Mentai Status. There were differences
among groups on the MMSE, the Rosenberg Self-Esteem
Scale, and the CESD. For the present study participants,
the BLUEDD group scored lower on the MMSE than the
other three groups, and the UEODD showed the highest
number of depression symptoms. Although there were significant differences among the groups on both Quality of
Life and Life Satisfaction, the actual size of the differences
was quite smallwithin .4 points on a 5-point scale.

Table 5. Distribution of Dressing Devices (/; = 234)

Shoe horn: iong, medium, & regular
Sock aide
Dressing stick*
Button aide
Velero shoes
Adapted ciothing
Eiastic shoe iaces
Reacher
Stocking aid*
Sfool
Zipper pull*
Coding of ciofhing for visual impairment
Grab bars/rails
Jeweiry device
Storage device for ciofhing
Cane
Commode chair
Raised toiiet
OtherPliers to fasten Velero

# Ovi/ned

#Used

# Satisfied

127
83
58
24
18
15
15
14
14
10
6
3
2
2
2
1
1
1
1

97
42
45
15
18
13
13
13
7
10

115
68
55
20
17
14
13
13
12
9
6
3
2
2
1
1
1
1
1

CJl

functional status, mental status, psychosocial status, and

quality of life?
Demographics. The only significant difference among
the four groups on demographic variables was for gender.
Within this sample, men were relatively more highly represented in the groups with lower-extremity difficulties.
Heaitii Status. There was a significant diffetence among
groups fot pain. Within our sample, the BLUEDD group
reported the highest level, on average, for pain, whereas the
NDD reported the least. There were also significant differences among groups for "number of sick days in past 6
months," and for number of medications. Study participants in the N D D and UEODD groups had relatively
fewer sick days than the other two groups, and the LEODD
gtoup used the fewest number of medications (mean =
4.2 [2.8]), wheteas the N D D gtoup used the most (mean =
5.7 [3.7]).

3
1
2
2
1
1
1
1

*Sfudy participant modifications of household items used for dressing inciuded a broom handie with a nail as a dressing stick, a bent coat hanger for a
sfocking aid, and piiers used as a zipper puli.

Table 6 summarizes the results for reasons for dissatisfaction

with dressing devices.

Discussion
This is the largest in-depth study of home-based elderly persons with dressing difficulties. We looked closely at three
groups of elderly persons with either or both lower- or
upper-extremity dressing difficulty, and a fourth group of
elderly persons who had difficulty with at least one other
ADL, but who had no difficult)? with dressing. We discuss
the results relative to demographic variables, health status,
fianctional status, psychosocial and mental status, and
device use and satisfaction.
Demograpiiics

Researcii Question 2
What types of dressing devices are most commonly used?
Table 5 lists the number of devices owned and used,
and the number with which study participants were satisfied. Shoe horns were the most common device, followed
by sock aides, dressing sticks, button aides. Velero shoes,
and adapted clothing.
Researcii Question 3
What are the reasons for dissatisfaction or non-use of dressing devices?
The largest percentage of responses for not satisfied ot
non-use related to a perception that the device was not
needed (65.1% of all responses). This was followed by "does
not work well" (16.3%) and "too difficult to use" (12.8%).
The AmericaiLJui

nl n-f

Orrutt/ltinn/iJ

In looking at demographic differences among these groups,

gender was the only significant variable. Within out sample,
men were disproportionately represented in the groups with
lower-extremity dressing difficulty. It is difficult to explain
why relatively more men than women had lower-extremit/
dressing difficulty; this is an important area to explore in
iture research. Recognizing that proportionately, more
Table 6. Reasons for Dissatisfaction With Dressing Devices
Reason Not Satisfied/Used
Don't Need/Use
Does Not Work Weli
Too Difficult To Use
Broken
Losf
Other

Frequency

Percent of Responses

56
14
11
2
2
1

65.1%
16.3%
12.8%
2.3%
2.3%

1.2% ^m

older men may have difficulty with lower-extremity dressing, therapists should make certain to address lowerextremity dressing in their assessments of older men.
Heaitti Status
We found an overall high number of medications taken,
which is a reflection of the participants in the sample: older
persons with ADL and IADL difficulties. Even those study
participants who were not having difficulty with dressing
(and were taking a somewhat higher number of medications) were baving difficulty with at least one other ADL or
IADL. The results for health status differences among the
four study groups were somewhat surprising. We did not
expect participants in the NDD group to use more medications than the other groups. All groups were taking more
than four medications, but tbe NDD group participants
were taking one and one-half more medications, on average, than the LEODD group participants. However, the
NDD group participants did have fewer sick days in the
past 6 months, and reported the lowest level of pain. The
group participants with BLUEDD reported the highest
level of pain, which could be a major factor in the difficulties they were having with dressing tasks. Review of medications to determine use of pain relievers, and referral to the
family physician to address the pain issue could be an
important role for a therapist working with patients with
dressing difficulty and pain.

ing home patients with dementia, simple prompting led to

more independence and participation in dressing (Rogers et
al., 1999). The use of assistive prompting devices for assisting elderly persons with cognitive impairment in dressing is
currently being studied by the Universit}^ of Florida
Rehabilitation Engineering Research Center on Technology
for Successful Aging (www.rerc.ufl.edu), and such "smart
assistive devices" may be available in the next few years.
Device Use and Satisfaction
In looking at the most common assistive devices used for
dressing, those associated with putting on socks and shoes
were the most owned and used devices, which parallels the
findings of de Klerk et al. (1997). The large number (783)
of participants with lower-extremity dressing difficulties
could explain why these devices were more common than
upper-extremity dressing devices. Dressing sticks and button aides and adapted clothing are also owned and used by
many study participants with dressing difficulties. All these
devices are low-tech, low-cost. Some devices represent adaptations of standard household items, such as the use of a
broom handle with a nail as a dressing stick. Well over half
of the stated reasons for not using a dressing device that
they owned, related to a perceived lack of need, similar to
the findings of Gitlin, Levine, and Geiger (1993). Perceived
lack of need could be related to improvement, decline in
condition (with more personal assistance), or an inappropriate purchase or prescription.

Functionai Status
As expected, study group participants with BLUEDD also
scored lowest on other measures of functional status,
including the IADL scale and the SIP Difficulty with completing dressing tasks is highly correlated with other ADL
and IADL. Measurement of dressing represents 2 of 18
items on the FIM. Therefore, it is not surprising that dressing difficulty status for our study participants should be
correlated with the total FIM score. For therapists, these
results suggest that if someone is having difficulty with
dressing, they are likely to be having difficulty with one or
more other ADL or IADL.
Psyciiosociai and Mentai Status
Study participants in the group with BLUEDD scored
lower than participants in the other groups on the MMSE.
Study participants with significant cognitive impairment
typically require assistance with dressing. We know from a
previous CAS analysis of study participants with cognitive
impairment but no other impairments, that the amount of
human assistance required with dressing is related to
MMSE score (Mann, 2001). In a study of the use of bebavioral approacbes to improve ADL performance witb nurs406

Limitations
Although the total sample size was large (A'^= 1,101), one
group, the UEODD group, was disproportionately small,
with only 23 subjects. Although we can generalize regarding differences on study variables among all four groups, we
have been careful to state tbat the differences among specific groups are limited to our study participants, and these
differences can not be generalized.
Reievance to Occupationai Therapy
Dressing is an important activity of daily living. In assessing
older adults' ADL performance, occupational therapists
should consider all aspects of both upper- and lowerextremity dressing. Many older persons adopt alternative
approaches to dressing, such as wearing slippers instead of
shoes, because they cannot don socks and shoes. This can in
turn lead to a decrease in their mobility, sucb as not leaving
the house. Yet, there are assistive devices and special clothing, including shoes and socks, that can make dressing easier. Therapists can recommend approaches, such as sitting
down while dressing, and assistive devices to make virtually
all dressing tasks easier. Therapists can review the range of

July/August 2005, Volume 59. Number 4

assistive devices, including those for dressing, at www.

abledata.com. At the writing of this paper, searching the
keyword "dressing" under AbleData provided links to 359
dressing-related products. The importance of training in the
use of assistive devices, including dressing devices, has been
documented in an earlier study (Schemm & Gitlin, 1998),
and occupational therapists can provide that training. Therapists can also work with elderly persons with cognitive
impairment by training through prompting, as reported by
Rogers et al. (1999). The impact of pain on dressing difficulty is also important for therapists to carefully consider in
assessing ADL performance of older persons. Gender differences in dressing difficulty and device use with dressing,
as well as with other ADL, deserve further study. A

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