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Original Investigation
Health Care Reform
March 22, 2021

Unmet Need for Equipment to Help With Bathing and Toileting Among Older US Adults

Author Affiliations
  • 1Division of Geriatrics, Department of Medicine, University of California, San Francisco
  • 2Division of Epidemiology and Biostatistics, Department of Medicine, University of California, San Francisco
  • 3Associate Editor, JAMA Internal Medicine
JAMA Intern Med. 2021;181(5):662-670. doi:10.1001/jamainternmed.2021.0204
Key Points

Question  How many older adults who need equipment to help with bathing and toileting do not have it?

Findings  In this nationally representative cohort study of 2614 adults 65 years or older, an estimated 42% of individuals who expressed or demonstrated diminished capability to bathe or toilet independently lacked grab bars or seats to help. This percentage represents 5 million individuals in the US with unmet need for equipment.

Meaning  These findings suggest that low-cost and beneficial assistive devices to support injury prevention, independence, and quality of life for older adults are being underused, and better clinical assessment for and better provision of these aids are needed.


Importance  Home modification through seemingly mundane equipment, such as grab bars and shower seats, mitigates injury, dependence, and reduced quality of life in older adults coping with increasing disability. However, whether these interventions are underused in the US is unclear.

Objective  To estimate how many older adults who need equipment to help with bathing and toileting do not have it, describe factors associated with not having equipment, and describe how many who did not initially have equipment acquired equipment over time.

Design  This observational cohort study of participants 65 years or older used secondary data from the 2015 to 2019 waves of the US National Health and Aging Trends Study. Participants included community-dwelling older adults who would unequivocally benefit from equipment, defined as those with poor physical performance or substantial difficulty bathing, toileting, transferring, or walking. Respondents were representative of the US population 65 years and older. Data were collected from May 2015 to October 2019 and analyzed from August 1, 2019, to February 24, 2021.

Exposures  Population characteristics (eg, age, sex, income, health conditions, and physical performance), environmental factors (eg, home ownership and living arrangement), and health behaviors (eg, prior knee and/or hip surgery).

Main Outcomes and Measures  Prevalence of any unmet need for equipment, defined as either needing bathing equipment (bath grab bars and shower seat) but having none or needing toileting equipment (toilet grab bars and raised toilet seat) but having none and the cumulative incidence of equipment acquisition during 4 years of follow-up.

Results  A total of 2614 participants representing 12 million US individuals would benefit from equipment. The mean (SD) age was 80.5 (8.2) years, and 1619 individuals (62%) were women. Of these, an estimated 5 million individuals (42%; 95% CI, 39%-44%) had an unmet need. After adjustment for age, sex, and race/ethnicity, unmet need was associated with younger age (49% if aged 65-74 years, 37% if aged 75-84 years, and 29% if aged ≥85 years; P < .001), having fewer health conditions (55% if none vs 39% if ≥3; P = .002), non-White race/ethnicity (40% if White vs 51% if Black, 54% if Hispanic, and 55% if other; P < .001), no recent hospitalization (46% vs 37% if hospitalized; P = .001), and no prior knee and/or hip fracture or surgery (46% vs 35% if prior fracture or surgery; P < .001). After 4 years of follow-up, 35% of those with bathing equipment needs and 52% of those with toileting equipment needs never received equipment.

Conclusions and Relevance  This cohort study suggests that in the US, 42% of older adults with impairments that would make bathing or toileting difficult lack equipment to assist. This situation is a missed opportunity to help 5 million individuals live independently and safely.

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    2 Comments for this article
    Need for bathing equipment under Medicare
    Claude Gerstle, MD | retired ophthalmologist
    Medicare was not developed to be a welfare program but rather medical insurance. Some Medicare beneficiaries also eligible for Medicaid. In most states, Medicaid does pay for some or all bathing equipment. It’s important not to expand the scope of Medicare, especially as demand builds for “Medicare for all”.

    I’m quadriplegic and when I left the rehabilitation hospital Medicare paid for a wheeled shower chair for me. Something to the tune of $1300. There are some people who need a chair like this and one of the problems is that the  hospital had to order the chair months
    earlier based on my needs when I was admitted. After discharge I used the chair once and donated it, opting to pay out-of-pocket for a much smaller and easier to use chair that met my needs.

    Medicare DME (durable medical equipment)  is still a broken and flawed system. Medicare pays top dollar for items such as catheters, urinary drainage bags and diabetes supplies. Again, I know these things firsthand. For example, leg bags for my catheter are $13 each for the ones that come through Medicare DME, while I buy them for $0.79 each.

    A sturdy wheeled shower and commode chair like the one I use costs under $200. A better solution is for states to require landlords to provide grab bars at toilets and in showers when prescribed by a doctor.
    Proxy for ALL Kinds of Assistive Toileting Devices
    Peg Graham, MPH | Small Business Startup
    From my own family caregiving experience helping a parent age with post-polio syndrome, the unique demands of toileting assistance often gets "lost in the sauce." Hope readers of this article realize that most adults with mobility disability put together combinations of personal assistance, all kinds of equipment - to make it through 24 hours/day, 7 days/week need - relying on family members when home health workers are not available. We welcome the attention that NHATS and the authors bring to this issue - and we hope there is more to come!
    CONFLICT OF INTEREST: I own the patent for an innovative bedside commode, seeking to commercialize that patent