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Elderdesign: Home modifications for enhanced safety and self-care

Therapeutic Bedroom

During recuperation from illness or surgery, or in the last stage of life, many of the activities that once took place in other rooms may be centered in the bedroom, so special consideration must be given to the room's design. In setting up a "therapeutic" bedroom, both safety and comfort need to be addressed. According to one home study on hip fractures in older adults, the bedroom had the highest fall rate (Jinnah, Michelson, & Myers, 1993). This comes as no surprise when various factors are examined: old, sagging mattresses, uncomfortable to sleep on, buckle under a person's weight when sat upon; beds, without any hand supports are difficult to get in and out of; pitch black bedrooms and hallways make night time trips to the bathroom dangerous; and boxes of medical supplies and extension cords strewn across the floor become potential tripping hazards. In addition to making environmental changes, older adults may need to alter their behavior: 25% of all falls are due to "drop attacks", stemming from a drop in blood pressure upon standing (John Hopkins Medical Letter, 1997). Since many occur within one minute from standing, an older person should be encouraged to sit on the edge of the bed for a couple of minutes before arising.

Spring and coil mattress. Many adults sleep on mattresses that have not been replaced for years, over time both the foundation and the mattress lose the capacity to provide adequate support, exacerbating problems such as lower back or hip pain. In addition, the edge of a soft mattress is considered a risk factor for falls as it does not properly support body weight during a transfer. A new bed may be required for the patient's comfort and safety. For certain individuals, a washable sheepskin pad placed over an existing mattress, can both help absorb moisture and reduce skin breakdown from friction (Abrams, Beers, & Berkow, 1995).

Pressure-relieving surfaces. Due to technological changes and consumer demand, there now exist a variety of sleeping surfaces, beyond the standard spring and coil mattress, designed to provide a pressure-relieving surface for those with chronic pain or who are at risk for, or receiving treatment of, a pressure sore.

  • The "open cell" foam mattress by Tempur-pedic, has been successfully tested by the Veterans' Administration for its ability to distribute body weight, reduce localized pressure, and aid in the healing of pressure sores (Palmer, 1994). Many patients prefer this mattress over a vinyl air mattress for its comfort factor. The overlay pad is a cost-effective alternative for individuals who weigh less than 200 pounds.
  • A large-celled alternating pressure mattress is a vinyl air-filled mattress that inflates and deflates small air cells at regular intervals via an electric pump (the noise can be disturbing to some patients). Its therapeutic value lies in the mattress's ability to move the patient imperceptibly and re-distribute body weight, and is indicated for individuals at high risk for skin breakdown and those with Stage 1 or 2 pressure sores (Abrams et. al., 1995).
  • A low air-loss mattress is comprised of air-filled cushions designed to exert the lowest possible pressure, with separate zones for the head, shoulder, seat, leg and heel areas. It can be placed on top of a standard twin bed. Low air-loss mattresses are indicated for patients with Stage 3 and 4 pressure sores (Maklebust & Sieggreen, 1996).

Height of bed. When seated on the bed, a person's feet should rest firmly on the floor and their legs should be at a 90 degree angle (Miller, 1997). To lower the height of the bed, either remove the castors, cut down the wooden legs, or replace the standard 7" high metal frame with a 3" frame. To raise the height, either replace the metal frame with a higher frame, or place blocks, available from rehab catalogs, underneath the legs.

Incontinence. Caring for a patient with urinary incontinence can be made easier with the right equipment. In addition to using disposable pads, rubberized sheets with soft backing on the surface protect the mattress while offering comfort to the patient. For women who are bedbound or in a wheelchair, the use of an external urinary collection system can enhance patient care. A small tube is attached to an absorbent feminine hygiene type pad and, through the use of a microprocessor, a small pump draws the fluids away from the pad into a small sanitized box for disposal when convenient. The box can be placed on a bedside table or hung on the back of a wheelchair.

Commode. A bedside commode is helpful for those who are bedridden or have difficulty reaching the bathroom without an accident. For those who have balance problems, or are extremely weak, choose a commode that does not tip over easily. One model, manufactured by BSC Enterprise, is bolted to a slip-resistant platform. The person's weight on the platform keeps it securely in the move between the bed and the commode. For added safety, the commode has built-in handrails to provide support.

Bathing. If a patient cannot access the existing shower or bathtub, even with the aid of a transfer bench or bath lift, and a bathroom renovation is not advised, a portable shower system may be a viable alternative to a sponge bath. These shower stalls are temporarily set up in the bedroom or in an adjacent room near the hot and cold water supply. A hose to the bathtub supplies water and takes care of drainage. For individuals with limited range of reach, use a terry cloth bathrobe to help both dry and keep them warm.

Bed handrail. An attachable handrail addresses an elder's need for a support to facilitate safe entry and exit from the bed. Moreover, for some patients it can substitute for a personal assistant allowing a person the freedom and dignity of getting out of bed without help. Choose a model that is height-adjustable, swivels and locks in place, and attaches securely to the bedframe.

Transfer sheet. Transfer of a person in and out of bed without causing injury to either the patient or the caregiver is a major concern. The U.S. Department of Labor (1997) informs us that home health aides have one of the highest industry rates for low back injuries caused by lifting patients during transfers. In addition, many older adults are at risk for skin breakdown when dragged against a standard bedding surface. New technological advances in fabric transfer systems can reduce both occurrences. One example is the Phil-E-Slide system, developed in England by a nurse educator; this low friction sheet enables many patients to transfer with minimal assistance by sliding across the sheet.

Telephone. Every bedroom should have a large-numbered telephone, equipped with a highfrequency volume control or flashing lights for those with hearing impairments. To reduce caregiver and patient stress for adults using extremely complicated machinery, some home health agencies use picture phones: viewing medical personnel by remote television while discussing medical care can help ease the feelings of isolation that many caregivers experience (Kaye, 1995).

Chair. Evaluate the chair for correct depth and height, and make sure that it is not too low, too deep or too soft. The chair arms should be extended to the edge of the seat to facilitate pushing off, and the bottom of the chair should be open so the feet can be tucked underneath as the weight is shifted forward to stand. Chairs should be sturdy, especially if a person holds onto them for support during walking. For persons with Parkinson's disease who rock back and forth to exit a chair, a high back chair will reduce the chances of falling backward (Tideiksaar, 1986).

Personal emergency response system. Having a personal emergency response system (PERS)) enables people to call for help even if they can't reach a phone. A PERS consists of a phone unit that also functions as a regular phone, and a small transmitter, placed within either a waterproof pendant or bracelet. Unfortunately, getting adults to wear the transmitter is a major problem. One manufacturer, LifeLine, has designed a transmitter in a pendant form that resembles a piece of jewelry, complete with its own attractive "jewelry box". This attractive design may encourage greater use. Average monthly fees for a PERS range between $40 and $50, but for those with limited financial resources, many companies offer reduced monthly fees. A new PERS model is also available with no monthly fee as there is no monitoring center. The emergency call is routed instead to four or five preprogrammed numbers until a relative, neighbor, or 911 answers the call. However, there is always the chance that no one will be available during an emergency, except of course, for emergency personnel at 911.

Remote doorbell. Quite often, a patient cannot hear the front doorbell ring from a remote part of the house. A simple solution is to add a wireless doorbell, consisting of a pushbutton and chime, in a back bedroom or wherever needed. A signal is sent from the pushbutton to the remote chime, usually within a 50 - 150 foot range, depending on the model. For persons with hearing impairments, a remote doorbell is also available with a flashing light ringer.

Remote control. These systems enable a patient in bed to manipulate the room's light levels, open draperies, and turn on and off sound systems. As consumer demands increase and technology costs decrease, these systems are becoming more affordable; a simple handheld remote control unit costs approximately $30.00. For patients who do not have use of their arms, recommend the use of a "sip and puff" control system that operates by blowing into a straw. When choosing a remote control system, keep in mind "the simpler the better."

Door answering system. At times it is difficult for an aide to gain access to the home, especially if the patient has difficulty getting to the front door. Currently, there are affordable remote controls, similar to those on car doors, that unlock a front door deadbolt, but the range is very limited, approximately 20 feet. It is possible to purchase a video phone that, when connected to an electronic locking system, allows an occupant both to see and buzz the guest in without going to the door. These systems are more expensive, but the cost of video door units have dramatically fallen in price in the last decade, from approximately $2200 to $400, not including the electronic lock and installation. Future technological developments will probably make these systems even less expensive.

Sensory stimulation. Music can have calming, sedative effects for a person who is in pain or experiencing sleep disturbances. Studies have shown that while listening to appropriate music patients required less pain medication and sleeping pills (Steckler, 1998). In addition, for persons with dementia, the work of music therapist Connie Tomaino suggests that seemingly lost memories can be retrieved by hearing familiar melodies. Her studies also show that persons with Parkinson's Disease can regain some ability to perform movements by listening to familiar and stimulating music with rhythm. To help individuals who do not own a sound system enjoy the potential benefits of music, an inexpensive cassette player should be obtained.

Talking books, or large print books with a nearby lamp shining directly on the pages, may increase a person's ability to enjoy a good story. Those with severely limited upper body strength but still mentally alert can benefit from a page turning device that enables them to read independently by turning the pages of a book or magazine by puffing on a straw.

The presence of birds, a gold fish tank, or a windowbox full of flowers can both increase patient stimulation and add enjoyment to a guest's visit, especially children who might be frightened by the declining health of a grandparent.

Electric needs. Many dwellings have overloaded sockets that are potential fire hazards. In addition, certain types of high-tech equipment, such as a mechanical ventilator or an infusion pump, will need to be attached to a "grounded" outlet which has 3 wires, unlike the two wire system found in old homes or apartments. To upgrade the home's electric system without the expense and disturbance of tearing through walls, an electrician can add cable-mounted wiring and additional outlets along the baseboard in the appropriate rooms.

 
 
 
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New York-Presbyterian. The University Hospitals of Columbia and Cornell