Home Modifications and Safety
Mary is a 78 year woman who has been living alone for three years since her husband’s death. Like many persons her age, Mary’s vision is not nearly as good as it was before, and she must wear a hearing aid. At times, when her arthritis flares up, she uses a cane to get around. Mary is generally in good health and she still lives in the farm house that her husband’s father built many years ago. Until now. . .
Mary fell last week at home and is in the hospital, recuperating from surgery to repair her broken hip. She is devastated with the realization that, due to physical limitations, she must consider moving from her home into an environment that is more supportive. She believes that the only way she can be safe is to move into an assisted living center or a nursing home.
Unfortunately, Mary is not unlike many older persons who suddenly come to the same conclusion she did. However, older persons in many cases could stay at home with a few simple modifications. Not surprisingly, over 85% of older Americans say they desire to stay in their own homestead through out their entire life until death. This section of this class is designed to help you understand some of the physical changes that occur during human development that create unsafe environments, relate how these physical changes influence everyday independence and function, and learn what modifications can be done to the environment that will allow the older person to remain in their home.
Aging’s impact on safety:
As we age, our bodies experience natural changes that can dramatically influence the safety of our own home. Often these changes occur gradually, almost undetectably, until suddenly there is a fall or a deterioration of independence. Eventually, each of us will experience these developmental changes to one degree or another. And although the medical and cosmetic world have tried for years, there is very little we can do to prevent these changes from occurring.
SENSORY SYSTEM CHANGES
Vision:
Blindness occurs more frequently in the older population than any other age group. One in 20 persons over 85 is legally blind. However, changes in our eyes affecting our vision begin as early as age 50. As we age, our pupils naturally get smaller resulting in less light entering the eye. For the older person, this creates difficulty seeing detail or objects in dim light, much like when a younger individual is attempting to see in the dark. In addition, the eyes adjust much slower to the dark. What used to take the eye only two to three minutes to accommodate when you are 30 may take up to ten minutes at 80. It also takes longer for an older person’s eyes to change from focusing on objects that are close to ones further away. The cornea of the eye may yellow, creating a decrease in depth perception and difficulty tolerating glare. Peripheral vision is also greatly reduced. Finally, there are often degenerative changes in the retina, the part of the eye that contains the rods and cones that receive the images we see.
Implications to home activities and safety:
There are numerous activities that are affected when one’s vision is impaired, which intern affects safety. Every year hundreds of injuries occur from people accidentally walking into sliding glass doors, thinking they are open (The Complete Guide of Alzheimer’s Proofing Your Home, p 371). Also, he or she may not be able to see steps or judge the height or depth of stair treads which may precipitate a fall. Floor level changes may not be easily observed. The person may not be able to distinguish where one wall meets another or where a wall meets the floor. Vision problems may make it difficult for people to pick out details in their environment. Small items on the floor can become an unseen tripping hazard. They may have difficulty reading clocks, labels on medicines, food containers or household cleaning products. This could potentially result in accidental poisoning or missed medication dosages. Thermostat dials, controls on appliances such as the stove or the washing machine, and telephone touch pads may also be difficult or impossible to read, creating additional safety hazards.
Modification suggestions:
Perhaps the most common home modification to accommodate a person with low vision is to enhance the lighting. Task lighting should be added to selected spaces, such as under the kitchen cabinets, in stair wells, or in the bathroom. Task lighting may include things like adding plug- in ceiling swag lights, floor halogen or fluorescent lamps, or stick on touch lights in closets. Incandescent light bulbs can be replaced with fluorescent or halogen lights which have a brighter, non-glaring illumination. Natural lighting can be added as well by adding sky lights. In addition, it is important to ensure lighting is even through out the environment to avoid “shadowed” areas . The changes that occur in the eye make it difficult for the eye to see shadows and to adjust to light intensity changes. Night lights should also be used, especially along the path to the bathroom and in rooms where windows are not present to add natural light. Caution should be used, however, as some night light bulbs tend to get very hot to the touch.
Color can be used strategically to minimize the functional deficits of vision problems. Yellow-oranges and reds are more easily distinguished by older adults and can be used to alert the homeowner to level changes, furniture or doorways. Enhancing color contrast is another simple strategy that can increase the safety of a home. Persons with poor vision may not be able to define where a tan chair on brown carpet sits and may trip over it or misjudge it’s location when attempting to sit. However a navy blue chair can more easily be distinguished against tan carpet. Using bright, contrasting colors can also be used to differentiate walls from floors or counters. Stair risers and treads can similarly be marked with different colored or patterned tape to provide better visual contrast for safety. The first and the last step can be marked specially to provide an alerting cue. White or reflecting tape can clearly mark hazardous changes in floor levels. Decals applied to sliding glass doors can make them more visible.
Replacing visual cues with other sensory cues is another approach to modifying the environment to accommodate visual deficits. Using different types of floor covering in each room provides tactile cues for navigation. For example, foyers by exits can be tile while the flooring in front of other non-exiting doors can be carpet or vinyl. Adding sticky backed felt or velcro patches on the smooth surface of switches or frequently used push pads on the microwave can also provide tactile cues. Place some adhesive backed felt on the stair rail at both the top and the bottom to alert the user that they are on the last step. Often the next to the last step is mistaken for the last, or the traveler expects one more step resulting in a fall.
Reducing glare is another important home modification that can greatly improve safety and independence in the home. Highly polished floors or white gloss painted walls have high glare ratings. The Illuminating Engineering Society (IES) provides glare ratings for several different types of materials. Direct lighting and lighting from windows may also create a blinding glare. Therefore, the use of wall sconces or lamps with shades directing illumination up and the use of sheer curtains may be required.
Touch and Dexterity:
The sensation of touch allows us to discriminate between textures and shapes, distinguish hot and cold, and sense pressure changes against our skin. Touch sensation also tells us where parts of our body are in space in relation to the rest of our body and to the environment. For example, our sensory system allows us to know if our arm is straight or bent, or if we are sitting or standing even when our eyes are closed. Our touch sensory system also is responsible for our perception of pain. As we age, our tactile sensory system becomes less acute. Medical conditions such as diabetes, hardening of the arteries, spinal cord injury or stroke also cause sensory impairments that may leave numbness, tingling, or even complete loss of sensation to portions of the body.
Dexterity is the ability to execute fine finger movements such as pinching, gripping, turning, twisting, buttoning, and so forth. Dexterity is closely related to the sensation of touch. Often a person will lose dexterity because of numbness or other sensory deprivation of the hands and fingers. Dexterity can also be lost due to a coordination, strength or range of motion deficit. Arthritis is a common disability that can significantly hinder an older person’s ability to effectively use their hands.
Implications to home activities and safety:
Loss of touch and dexterity often result in difficulty adjusting small controls such as the thermostat or those on appliances. Gripping, turning and twisting doorknobs or faucet handles may also become difficult. Handling a key to unlock a door may be impossible. Problems with dexterity and hand strength also makes opening jar and bottle lids difficult. Additional problems that may occur around the home include plugging or unplugging electrical cords, opening packaged goods such as cereal or chips, writing checks, or opening the mail. To determine if objects would be difficult for a person with dexterity deficits to operate, an able - bodied person should attempt to operate them himself with a closed fist. Any object that can be operated effectively in this manner can be operated by almost anyone, regardless of the hand disability.
Perhaps the largest safety risks resulting from disturbances in touch are undetected burns from scalding water in the tub or sink or from the burner or heating element on a stove. There is also increased risk of sustaining cuts from a knife or other sharp implement in the kitchen. If the numbness is in a persons feet, he or she may also be at a greater risk for stepping on sharp objects, tripping, or possibly even falling. This is because a person’s sense of balance when walking is due in part to the ability of the feet to feel the surface below them. Muscles in the toes and feet make small adjustments continually that maintain balance. For example, the foot can detect the slipperiness or stability of a surface.
Modification suggestions:
To accommodate for a diminished sense of touch, tactile sensation should be heightened by changing the surfaces of walls, counters, and floors. Brick, wood and certain types of vinyl or carpet are some useful surfaces for this purpose. Emphasis can also be placed on using other sensory components to enhance the sense of touch. Visual cues are the most common way to accomplish this. Visual markers on faucets can be used to indicate the desired safe temperature, preventing unintentional scalding. There are also specialized bath mats that change color when the bath water is too hot, to provide a visual cue. Most stovetop ranges include an indicator light to signal when a burner is turned on. However, several also include an indicator light that remains on for a reasonable time after the burner is shut off, but it may still be hot. An additional manufacturer’s feature is the heating element becoming brighter and redder as it gets hotter. When purchasing new appliances, potential buyers should inquire about such safety features. “Stop-Hot!” labels can be placed on any item that may get hot and cause a burn such as the stove, radiator, or fireplace. These small signs may help call attention to an item that may be hot and divert a possible accident (The Complete Guide of Alzheimer’s Proofing Your Home, p 361).
Another approach to enhancing safety is to lower the temperature on the hot water heater to less than 120 degrees. A new mandatory code in many states requires showers and tubs to include a temperature limiting mixer valve. When the water gets too hot their internal parts expand and turn off the flow of water. Pressure balance valves may also be recommended. They compensate for changes in pressure from the flush of a toilet or other circumstances that may cause a sudden, dramatic temperature change as well. Exposed pipes under sinks should be insulated to protect knees from getting burned.
For those with dexterity deficits, levered handles or C- or D- shaped loop handles on doors, cabinets and drawers may be beneficial. Levered handles can also be used on kitchen and bathroom sinks, to provide ease in operating. Instead of buying all new controls, rubber furniture leg tips can be placed over existing knob controls and a small wooden dowel can be inserted through it to create a lever arm. Light switches can be replaced with toggle or rocker panels, touch pads or motion sensors. Door locks requiring keys can be replaced with push button combination locks or attachments can be added to keys that increase the size of the key.
Hearing and Smell:
One special consideration is safety for those who are hearing impaired or have decreased olfactory perception. Hearing loss is the most common disability among older persons. Hearing commonly worsens as a natural process of aging, becoming of particular impairment in a person’s seventies and eighties. Nearly 75% of individuals between 75 and 79 experience significant hearing loss, with an estimated 15% legally deaf over the age of 65 (Santrock, p. 492). Older persons may have difficulty hearing soft or high pitched tones. They may have difficulty filtering background noise or distinguishing specific sounds when background noise is present. Locating the source of sounds can also be difficult. Similarly, olfactory receptors in the nose begin to lose efficiency and sensitivity through the years. A diminished sense of smell makes it difficult to detect odors that are present, or may make it difficult to discriminate the differences between multiple odors that are present.
Implications to home activities and safety:
When hearing is impaired, a person may not be able to hear timers signal on the oven or washer and dryer. In addition, smoke detectors may not be heard. Other sounds within the home that may not be detected are doorbells, telephones or alarm clocks, and it may difficult to understand what someone is saying on the television or radio.
Deficiency in the olfactory system may prevent that person from smelling warnings such as smoke from a fire. Odors such as natural gas, spoiled food, or other airborne pollutants or irritants may also go undetected.
Modification suggestions:
Some hearing problems can simply be corrected by the use of hearing aids. Wearing two hearing aids that are balanced correctly for each ear can often make a drastic change. Hearing aids are not always effective, however. By making auditory signals louder, the hearing impaired individual may be able to respond to the telephone, doorbell, or other tones. Amplifiers can be placed on existing telephones, and a doorbell can be replaced with one that chimes more loudly. When amplification is not sufficient or not possible, auditory signals should be replaced or enhanced with other sensory stimuli. Smoke detectors can be purchased that cause a bright light to flash as well as sound a tone. Flashing lights can also be added to the doorbell or telephone. Tactile cues can also be used. For example, a sound detector can cause the bed to vibrate, arousing a sleeping individual. Finally, reducing background noise is a simple strategy for making a safer environment for those with hearing impairments. Noisy appliances or a ceiling fan can be replaced with quieter ones or can have insulation installed around them. Fluorescent lights that hum can be replaced with halogen or incandescent bulbs. Carpet on the floors and curtains in the windows can be installed throughout the home to reduce distracting echoes.
Like the other sensory impairments, the loss of smell can be compensated for by implementing alternative sensory cues. Detectors for smoke, carbon monoxide, radon, and other pollutants can be used that will signal visually or auditorily if such things are found. To avoid food poisoning from spoiled food, dates should always be written on food containers in the refrigerator or freezer and items should be thrown out if not used with in a reasonable time frame, regardless of how they might smell.
NEUROMUSCULAR SYSTEM CHANGES
Mobility:
Every year approximately 200,000 adults over the age of 65 fall and fracture a hip. Alarmingly, over half of these older adults will die within one year, usually from complications from pneumonia. Your family member may occasionally stumble, and eventually they may fall once or twice. What is happening within the human body as it ages that makes falling at home so commonplace for older adults?
Declining balance is one way in which mobility is impaired. It is not uncommon for one who has difficulty hearing to also have poor equilibrium. Equilibrium gives the sense of where the head is positioned in space in relation to the body. In the ears are semicircular canals which are filled with fluid and tiny little stones. As the head is moved, the stones in fluid also move and stimulate receptors that send messages to the brain. This process tells the brain if the head is moving and in what direction without the eyes open. As a person ages, the fluid in the semicircular canals can begin to dry up, reducing the effectiveness of the equilibrium process.
In response to a decline in coordination and balance, those feeling a sense of instability may begin to shuffle their feet when they walk. Concurrently, the unstable person may reach for furniture or other objects along the navigated pathway that may not be stable. The intention is to reduce the risk of falling; however, these futile attempts actually increase this risk.
Altered vision can also create a dysfunction in mobility. Objects in the path, uneven surfaces, or throw rugs may not be seen and cause an older person to trip. In addition, the aged body’s reaction time is much slower, causing a simple stumble to become a serious fall. Decreased body and bone mass and fragile skin provide a significantly greater risk for a fall to result in an injury such as broken bones or the need for stitches.
Finally, mobility can become impaired simply from the process of normal human development, which results in a gradual decline in strength and range of motion of the limbs. Medical conditions such as arthritis, surgical orthopedic procedures (such as hip replacement), stroke, or heart attack can exponentially compound these limitations. Especially in women, osteoporosis can cause severe posture changes, which can make it difficult for them to look ahead to where they are going and potentially trip. For many, diabetes impairs sensation in the feet, making it difficult to feel the stability of the surface being walked on. In some cases, assistive devices may be required for safe ambulation, such as a cane, walker, or even a wheelchair. Each of these mobility devices causes additional barriers with in the users home.
Implications to home activities and safety:
Each of these causes for mobility impairments can by themselves significantly limit one’s independence. Typically, however, two or more of these issues are present, simultaneously creating an extremely dangerous situation. For example, Mildred, who is 79, has cataracts, wears a hearing aid in her left ear, and uses a walker to assist her due to the pain she has in her hip from arthritis. In the hallway between her bedroom and the bathroom is a throw rug, which has been there for decades. Yesterday was another one of those rainy days that made her hip and other joints ache, severely, causing her to drag her feet as she walked. Although she knew the rug was there, on her way to the bathroom her foot caught on the corner of the rug. She only stumbled a little but her quick movements to catch herself caused her to become dizzy, and she fell. Fortunately, she only bruised and tore the skin on her elbow. Mildred’s family has been suggesting for months that she remove the throw rugs from throughout her home, knowing that they were a potential tripping hazard. The combination of her decreased vision, strength, balance and reaction time with the increased pain she experienced that day provided Mildred with the perfect set up for a disastrous fall.
Not only can the physical changes that occur with aging cause changes in gait, they can make going upstairs difficult, and even make getting up or down from chairs, the toilet or the bed challenging. Older adults may not be able to balance while standing at the sink to brush their teeth, or while pulling up their pants in the morning. Getting into the tub for a shower can become a mountainous task. Navigating long, uneven, or inclined paths can become dangerous. For many, carrying heavy items like grocery bags from one place to another cannot be accomplished. Nor can they reach into floor level or the upper shelves of tall cabinet to retrieve items without losing their balance. For those who use a mobility aid, such as a walker or wheelchair, daily life may become full of impossibilities.
Perhaps most alarming, it is nearly impossible for a person with these defecits of mobility and agility to get up from the floor once they have fallen. This means following a fall such as Mildred’s, she may have had to lay on the floor for hours or possibly days before someone attempted to phone her or came over. A seemingly minor fall could turn potentially deadly.
Modification suggestions:
Perhaps the simplest modifications to increase the safety around the home for those who have mobility challenges is to pick up any throw rugs, low level types of furniture such as coffee tables or planters, and clutter that may create a tripping hazard. The furniture along the pathways should be sturdy and reliable for holding the person’s weight without moving, rocking, tipping or sliding. Also, strategically place sturdy furniture along the path close enough that each piece can easily be reached when a little extra support is needed without traveling long distances between them. If a mobility device is used, or the older adult requires another person to walk beside them, ensure that the pathway is wide enough to accommodate the extra size. A good rule of thumb is to create a four-foot pathway without obstacles.
When negotiating stairs is difficult, relocate bedrooms and bathrooms to the main floor where possible. Perhaps a den can be transformed into a bedroom and a half bath can be expanded into a full bath. A gate may be needed at the top and bottom of the steps to provide an additional cue not to attempt to use the stairs. In many instances, it is not feasible to relocate living spaces to the main floor. Perhaps adding handrails and visual cues will sufficiently enable the independent use of the stairs. Stair-Glides may also be installed, although they may not fit into the budget of many older adults.
Strength and Range of Motion: After older adults notice a decrease in endurance, they may feel as though they are becoming weaker. Endurance of muscles refers to the length of time a contraction of the muscle can be sustained. A muscle may be able to meet the demand of lifting a 25 pound box. However, if endurance is impaired, the muscle will not sufficiently maintain the required level of strength to be able to hold the box to carry it from the car to the front door. Endurance can also be affected by one’s respiratory status. Pneumonia, asthma, emphysema, and chronic obstructive pulmonary disease (COPD) are all respiratory conditions that can severely limit the capacity of the lungs to efficiently breathe in air, remove the oxygen for use by the body and exhale carbon dioxide and other impurities. A lack of endurance in this way can render a person extremely short of breath, gasping for air, after very minimal activity. For some, even holding a conversation may be difficult to do when facing poor endurance. One may feel very fatigued and weak as the muscles require vast amounts of oxygen to create and maintain muscle power.
Range of motion refers to the extent a joint allows freedom of movement of the body or its specific parts. Joints are the parts of the body where two bones meet, and are responsible for protection of the bones as well as providing a certain extent of movement. Each joint has only a certain range of motion possible and may be limited by which direction it can move. For example, the knee can bend, or flex, to bring the heel up towards the buttocks, but it cannot extend past the point of straight to bring the toes up toward the stomach. The amount of range of motion possible is limited by factors such as the bulk or size of the body near the joint, inflammation of the joint itself, the amount of synovial fluid present in the joint providing lubrication, and the severity of pain present with movement of the joint and strength. Age affects range of motion as the joints begin to produce less synovial fluid. Arthritis may set in and muscle strength is no longer sufficient to power full movement around the joint.
Implications to home activities and safety:
Decreased strength and endurance can make activities of daily living very difficult. An older person may not be able to perform an entire morning self care routine all at once (dressing, grooming, eating breakfast, making bed, etc). It may take half of the day before they are able to complete the sequence of self care between frequent, lengthy rest breaks. Activities like carrying the groceries, vacuuming, and laundry may become impossible. Limitations in strength may making getting up and down from the couch or favorite easy chair impossible. Many older adults also find it difficult to stand for long periods of time due to decreased strength and endurance which makes tasks such as washing dishes, meal preparation, and showering an extreme challenge. Range of motion deficits may create difficulty reaching into low or high cupboards. Retrieving items from the top shelf or the clothes rod in a closet may also be inhibited. Once simple tasks like closing the window shades or dusting can now be impossibilities. Similar activities that require reaching, bending and lifting can also become affected.
Modification suggestions:
Shortness of breath and decreased endurance that interfere with the efficient completion of daily tasks can be very crippling to an older person. Participation in a physical or occupational therapy regime may be needed to improve lung capacity and strength. Around the home, simple changes can be made that will compensate for the loss. Place sturdy chairs in the bedroom or bathroom where the person gets dressed. Sitting down to dress takes less energy than standing. Organize clothes and grooming supplies so they are easily accessible with one trip. Store grooming supplies on the vanity or an easy to reach shelf.
For those who have decreased strength and are unable to stand for long periods of time, a stool may be placed at the kitchen counter to be used when washing dishes or preparing meals. A safety harness could also be installed to decrease the strength and endurance requirement for standing. Lower workspaces could be provided at the table or a lowered section of the counter allowing a seated person to complete tasks. A tub bench with a hand held shower can be used to reduce the length of time standing while showering. Perhaps a tub can be replaced with a walk in shower to eliminate having to step over the tub side. Also, grab bars can be installed, not only in the bathroom but throughout the house, to assist with balance and with standing up.
Other helpful strategies around the house may include adjusting the tension on storm doors or maybe even closet doors or some cabinets possibly. Spray attachments at the sink, C- or D- shaped handles on cabinets, and easy glide rollers on drawers may also be helpful and can easily be installed by a handy member of the household. A piece of plywood can be placed under soft cushions of the couch or easy chair or under the mattress, to make it easier to stand. In severe cases, those finding it hard to stand from the chair can purchase a catapult seat cushion device or an automatic recliner lifter.
The primary approach to compensate for limited range of motion is to move the objects of daily life skills into an easily accessible range. For most people, this is roughly 27 to 48 inches from the floor and no deeper than 20 inches. For example, difficulty reaching kitchen items due to a decrease in range of motion may require the kitchen to be reorganized. Frequently used items should be placed on the counter top or the top shelf of lower cabinets and the bottom shelf of upper cabinets. Heavy pots and pans could be stored on the stove. Another solution is to invest in adjustable height cabinets. With the push of a button, upper cabinets can be lowered to within reach, then raised back up again. Faucet levers and appliance controls should be positioned toward the front to allow easier access to those with limited reach. Other useful products include a front loading dishwasher or washer and dryer, a side-by-side refrigerator/freezer, and lazy susans in the cabinets and even the refrigerator. Pull out rolling carts are also a good idea for under the counter storage.
COGNITIVE CHANGES:
Memory, problem solving, judgement, safety awareness, and orientation are among several areas related to mental capacity or cognition that begin to deteriorate naturally as we age. In addition, a stroke or Alzheimer’s disease can exponentially worsen the problems. Much research and consideration has been taken in regards to Alzheimer’s disease and other forms of dementia. No cures have been found; however, there are many things that can be done in the home that can drastically help. This course provides an entire section devoted to just that issue.
CONCLUSION:
Aging is a natural process that each of us will experience. Our bodies change and develop through out the entire life span, and our ability to naturally adapt is part of what makes us human. Often, we are unable to adapt adequately, or the physical changes come on so fast that we cannot prepare. By altering the environment in which we live to accommodate for these changes, our independence and dignity can be preserved. The majority of older persons state that they want most of all to be able to stay in their home throughout their entire life. In fact, most people, when asked, would even rather die in their home than anywhere else. Our home should support us; it should foster growth and independence; it should allow us to age in place.
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