The National Center for Injury Prevention and Control states that falls are the number one cause of home injury, and studies suggest that a significant proportion of all falls are due to environmental factors (Connell, 1996). The second most common home injury is burns, primarily from fires, and older adults are killed in home fires at twice the rate of society as a whole (National Association of Home Builders (NAHB), 1990). Poisoning is third on the list, mainly occurring through medicine non-compliance: older adults are six times more likely than other age groups to suffer adverse medical reactions (Alliance for Aging Research, 1998).
In addition to modifying the home to prevent injuries, the environment should be set up to compensate for declining abilities. Many environmental recommendations for safety concerns also improve function. For example, grab bars in the bathtub both prevent falls, and also make getting in and out of the tub easier. In considering those changes in the home that should be undertaken we need to take into account that older adults: (1) exhibit a wider range of physical and psychological differences than any other age group; (2) have changing needs that require on-going assessment of the environment; (3) live in different housing structures with their own unique characteristics and (4) engage in learned behavior that affects the ways they relate to their environments. Consequently, in seeking solutions to environmental barriers and safety hazards, there is no one answer to all problems. Finding the right solution may require trial and error.
One of the challenges of working with older adults is developing the ability to identify what is a safety hazard for a particular individual; for a person with severe arthritis, a chair that is too deep and too low would carry a "higher score" than for an adult with full independent movement. Moreover, if a person is dependent upon another individual for an Activity of Daily Living (ADL), an environmental solution should be explored that will increase that person's autonomy and reduce caregiving. In either case, it's best to begin the analysis of home modifications by considering environmental, rather than personal deficits. Too often, older adults blame themselves for their inability to engage in activities they once took for granted, and consequently, do not seek solutions. Positive outcomes of increased comfort, safety, and independence should be emphasized. Below is a partial list of environmental and health issues along with a variety of possible interventions.
Floor surfaces. The severity of a fall depends on the height of the fall, fall direction, impact location on the body, density of the bones and the hardness of the surface (Hayes, 1994). In most cases, the floor surface is the risk factor easiest to control. An "energy absorbing" flooring such as a low pile carpet may reduce the severity of injury (Healey, 1994). For many, wall to wall carpeting is a good flooring choice, especially in the bathroom, where falls usually occur on hard, wet surfaces. Collins and Aikman manufactures carpeting for wet areas that is both anti-microbial and waterproof. Carpeting, however, may cause too much friction and make walking more difficult for those with a severe shuffling gait who walk by sliding their feet against the floor surface. An alternative to carpeting is slipretardant vinyl sheet flooring: minute granules embedded in the surface reduce the tendency of the foot to slip on the flooring surface, even when wet. Armstrong and Mannnington both manufacture slip-retardant flooring in attractive residential colors.
Area carpets, such as throw rugs, can pose safety risks, especially if a person has low vision or a mobility impairment, and should be removed. Many people, however, are reluctant to part with cherished belongings, so the next best solution is to adhere the carpet to the floor with double-sided tape, taking care to place the tape all the way to the edge, where the toe easily gets caught. Door sills may also need to be removed for those patients using walkers, wheelchairs or who shuffle.
Trochanter hip pads. For those who are frequent fallers, new "hip-protective" undergarments, with shock absorbing pads sewn inside, may help reduce the incidence of hip fracture. Older people tend to fall sideways or backwards, which increases the chance of a hip fracture. Protective hip padding redirects the impact force from the trochanter to the surrounding tissues (Hayes, 1994). Unfortunately, current products on the market add significant bulk to the hip area and may be avoided on aesthetic grounds; new streamlined models are currently in production.
Hand supports and stair safety. A handrail (or long grab bar) installed horizontally along a wall in the bedroom or a long hallway encourages safer walking for adults with mobility and gait impairments. Install the handrail at a comfortable height and choose a shape appropriate for the individual. IPC Systems manufactures a flat handrail with a rounded edge that can be used by either grasping the rail or, for those with arthritis, by simply placing the palm of the hand on the rail for support. Handrails need to be installed directly into the wall studs to support a person's weight; a stud locator, a small hand held device, is available in home supply centers. Grab bars at the toilet and in the bathtub and shower area help a person move from one position to another and offer a support to "grab" onto if a person is unsteady. Horizontal grab bars can be attached directly onto the toilet to facilitate pushing off or, for adults who use walkers, a hinged wall-hung grab bar is also available that can be swung up out of the way. Grab bars are available in brilliant blues, reds, greens, and yellows.
Stair climbing can be a good form of daily exercise if safety measures are in place. Handrails on both sides of the stairs can enable a person to compensate for reduced lower body strength by using the arms to pull up the stairs. As most falls occur during the descent, especially on the bottom step, (Miller, 1997) it is important to bring attention to this area by highlighting the bottom step with glow-in-the-dark tape. Another solution is to adhere a small piece of ribbed vinyl on the banister to alert the stair user of the approaching bottom step. If climbing the stairs is no longer a safe option, chair lifts are available for purchase or rental. For a smooth quiet operation, look for a lift with a rack and pinon drive.
Lighting. Due to age-related changes in the cells of the lens and retina, most older adults require up to three times as much light as a 25 year old (Faye & Stuen, 1995). Without adequate lighting it may be difficult for an older adult to see a doorsill in dim light or read the fine print on a medicine bottle. Unfortunately, many older adults, accustomed to conserving energy in the depression years, still live in minimally lit surroundings. Adding the correct type of lighting is one of the easiest and yet most powerful home changes we can make. Most of the products suggested below are available through local hardware, home remodeling centers or specialty stores.
- The simple addition of extra light fixtures, or higher wattage bulbs, can make all the difference in a person's visual acuity. A 100 or 150 watt incandescent light, shining directly on the task at hand, may be appropriate for a reading lamp, whereas a 300-watt bulb may be needed for a floor lamp (Faye & Stuen, 1995). However, if the maximum wattage is not listed on the lamp fixture, it is necessary not to exceed 60-watts (U.S. Safety Product Commission, 1992).
- To increase the amount of overall lighting, a torchere, an uplight which bounces light off the ceiling to other parts of the room, is an excellent solution. Until recently, torchere lamps were only manufactured with halogen bulbs which, due to the bulb's high temperature, posed serious fire risks. Today, torchere lamps are available with colorcorrected fluorescent bulbs, a safer alternative to halogen.
- Reduce fumbling around in the dark during a power outage by installing a plug-in emergency light; the battery back-up unit turns on automatically during a blackout.
- If there is no light switch at the entrance to a room, add a wireless wall switch at the doorway. This inexpensive glue-on wall switch can make walking into a dark room obsolete. It operates by sending a remote radio signal that turns on a designated table lamp. Small remote control units, which cost approximately $25, give mobility-impaired individuals increased control of their environments, turning on/off lights and small appliances, even through walls.
- Use nightlights to light the pathway from the bedroom to the bathroom, where many falls occur. As nightlights are less popular in the bedroom, since they can interfere with sleeping, a "sensor" nightlight may be preferable. It turns on only when motion is detected, and off again when activity ceases.
Color contrasting. Color, used as a visual identification system, can be a valuable tool in helping adults who have either low vision or difficulties with depth perception (Bailey, 1995). Use strong color contrasts to highlight where one surface begins and another ends: a dark wooden toilet seat against a white floor or a red plate against a white tablecloth are examples. Contrasting colors can be used for a wide range of household items and architectural features including doors, doorknobs, counters and tabletops, chair fabrics and bedspreads. Low-cost solutions include highlighting on/off controls with red nail polish and using glow-in-the-dark tape around the edge of tables and light switches.
Hot water scalding. As elders have reduced skin sensitivity and a slowed reaction time to stimuli, taking precautions to reduce burns is important. Many apartment buildings have the hot water temperature set at 150 degrees, at which a first degree burn can be sustained in one second (Nichols, 1996). Even when a home health aide has mixed the hot and cold water to an acceptable temperature, it can turn scalding when another occupant or building resident nearby also uses the water supply. An anti-scald device can be inserted into the existing shower head, but you will need to replace the existing bathtub spout with a special anti-scald spout. Both will automatically reduce the water to a trickle when it reaches 120 degrees. A homeowner also has the option of reducing the temperature of the hot water to 120 degrees.
Cooking fires. The kitchen is the room where most fires occur and the main reason is food left unattended on the stove (NAHB, 1994). The use of timers should be encouraged, along with smoke alarms, which double a persons' chance of surviving a fire (National Fire Protection Association (NFPA), 1995). As it is difficult for elders manually to replace the battery on a yearly basis, one solution is to use a lithium battery smoke alarm. It has a lifespan of ten years. Adults should also be instructed on how to extinguish a small grease fire in a pan. Fire marshals recommend placing a large lid over the flaming pan (NFPA, 1995). Water should never be used, because it only spreads this kind of fire. In addition, the use of sensor appliances should be encouraged: in addition to automatic shut-off functions on teapots and irons, microwaves are now available that both automatically calculate the cooking time of a food item and shut off the power when cooking is completed. However, persons with dementia may not be able to learn how to operate a microwave if they have only have experience with a gas or electric stove. Alternatives measures to reduce the risk of a cooking fire are: (1) turn off the gas supply on a temporary or permanent basis; (2) install a separate on-off switch in a locked cabinet for the caregiver's use; (3) set up a microprocessor-driven fire extinguisher in the range hood that automatically puts out fires; and (4) connect an automatic turn-off unit to an electric stove that shuts off the power after a set time.
Cigarette fires. The main cause of fire injury and death for those 65 years or older is smoking; Sixty percent of all smoking-related deaths are caused by abandoned smoking materials (NAHB, 1995). Smokers should be encouraged to smoke in one chair only, preferably one without fabric, such as a wooden or metal chair. A small metal box with a lid should be used for an ashtray. Smoking in bed should be discouraged, but many will continue to do so, especially persons with mobility problems who find transferring difficult. These individuals may require new bedding. All mattresses manufactured after 1973 are flame retardant (U.S. Consumer Product Safety Commission, 1992).
Medicines. A 1998 research study sponsored by the Alliance for Aging Research stated that older adults on average take four and a half prescription drugs and two-over-the counter medicines every day. This study also suggests that difficulty with keeping track of so many medications is one of the main reasons older adults have a disproportionately high percentage of adverse outcomes when compared to other age groups. A weekly pillbox, with individual sections for morning, noon, and evening pills, is an inexpensive solution to increase medical compliance. Several other medication reminder products are under development for those with more severe memory loss. The HealthWatch, is a digital wristwatch, which besides telling the time, beeps up to eight times a day, with instructions on which medication to take at that particular time. It will soon be available through CVS Pharmacies. For patients whose health is seriously jeopardized by missing a single dose of medication, a computerized pill dispenser can be programmed automatically to contact an emergency response monitoring service when the dispenser does not register that the pills have been taken.