Am Fam Physician. 2009;80(9):963-968
Patient information: See related handout on home adaptations, written by the authors of this article.
Author disclosure: Nothing to disclose.
Family physicians commonly care for older patients with disabilities. Many of these patients need help maintaining a therapeutic home environment to preserve their comfort and independence. Patients often have little time to decide how to address the limitations of newly-acquired disabilities. Physicians can provide patients with general recommendations in home modification after careful history and assessment. Universal design features, such as one-story living, no-step entries, and wide hallways and doors, are key adaptations for patients with physical disabilities. Home adaptations for patients with dementia include general safety measures such as grab bars and door alarms, and securing potentially hazardous items, such as cleaning supplies and medications. Improved lighting and color contrast, enlarged print materials, and vision aids can assist patients with limited vision. Patients with hearing impairments may benefit from interventions that provide supplemental visual and vibratory cues and alarms. Although funding sources are available, home modification is often a nonreimbursed expense. However, sufficient home modifications may allow the patient and caregivers to safely remain in the home without transitioning to a long-term care facility.
Family physicians commonly care for patients with disabilities. An estimated 36 million persons, or 14.5 percent of the U.S. population, are affected by a disability. Patients with disabilities may have difficulty performing activities of daily living (ADL), maintaining a safe home environment, and keeping their home accessible for egress. These challenges can lead to a loss of independence. Family physicians play a critical role in helping patients and their families plan for safety and functional convenience.1
More than 80 percent of Americans older than 50 years wish to remain in their homes indefinitely, rather than moving to an assisted living or nursing care facility, even in the event of disabling illness.2 Being at home usually denotes comfort, quality of life, and independence, regardless of age and disability. Home environmental modifications may be needed to mitigate new disability arising from disease or aging. Home modification especially helps the 25 to 50 percent of older persons who experience loss of functional independence after an acute hospital stay, because only two thirds of these patients return to prehospital function within three months of returning home.3 Family physicians can supervise home health care services that meet patients' needs and preferences.
More than 75 percent of adults 55 years and older moved into their current residence before 2000.4 Older buildings seldom include features that assist persons with disabilities in performing ADL.5 Research shows that environmental and technologic interventions in the homes of frail older persons slow functional decline compared with home care without these interventions, and reduce personal care expenditures that would be used for institutional care (e.g., nursing, case worker visits).6 However, evidence regarding the economic benefits of care in the home environment is still mixed.7-10
A Cochrane review found little evidence that changing the home environment prevents injuries; however, it did not show that home modifications were ineffective.11 The authors note that the studies in the review did not contain enough participants for adequate statistical power. Despite the limited evidence for injury prevention, home modifications appear to decrease dependency on caregivers for instrumental activities of daily living (IADL) and reduce caregiver upset.12 In general, environmental assessment and home modification appear to be most successful in preventing falls in older adults when conducted as part of multidimensional risk assessment (for factors such as medications, vision, environmental hazards, and orthostatic blood pressure) with an individualized action plan.13 This article describes general home modification and safety strategies that family physicians can promote to maximize function, preserve independence, and potentially prevent injuries.
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Home modifications can slow the rate of functional decline in older persons. | B | 6 |
| Home modifications can decrease dependency on caregivers for instrumental activities of daily living, reduce caregiver upset, and increase caregiver effectiveness in patients with dementia. | B | 12 |
| A multidimensional risk assessment and management program is the most effective intervention to prevent falls in older adults. | B | 13 |
The Physician's Role
The medical interview allows the physician to identify specific needs and consider possible solutions. Based on these needs, the physician and patient can propose and prioritize potential home adaptations. The physician can then recommend appropriate resources directly or through a referral. The physician is also responsible for supervising home-based therapies.
Table 1 describes the domains the physician can explore with a patient or caregiver coping with chronic illness or disability.14 These include assessment of current and possible future impairments, the patient's values and priorities, ADL, IADL, current adaptive measures, potential medication side effects, home services, and social support. Physical therapists, occupational therapists, social workers, and visiting home nurses can also help advise the patient about specific home intervention measures. Performing a home visit will help the physician acquire more first-hand information about the home care environment.15
| Priorities | ||
| What are your biggest concerns right now? | ||
| What is most important to you? | ||
| What are your thoughts about going home, having this procedure, your diagnosis? | ||
| What might it look like if this situation turned out the best you can imagine? | ||
| What could we do to help you and your family with this change in your circumstances? | ||
| Areas to assess | ||
| Activities of daily living | ||
How are you doing with:
| ||
| Instrumental activities of daily living | ||
| What is a typical day like for you? | ||
| How does your condition affect the activities you enjoy each day? | ||
How are you doing with (or how will you manage):
| ||
| Social and family context | ||
| Where do you live? | ||
| Who lives with you? | ||
| What is your family situation? | ||
| Who is a friend or source of support? | ||
| How have your finances been affected by your medical needs? | ||
| What activities do you enjoy doing with other people? | ||
| Support and coping | ||
| How are you doing with this? | ||
| How is your family (e.g., spouse, partner, son, daughter) coping? | ||
| Who helps you deal with this? | ||
| Who can you call if you need some help? | ||
| Who can you call if you want to talk with someone? | ||
| Coordination and payment | ||
| Who helps you coordinate your (health care, help on a day-to-day basis, etc.)? | ||
| What resources do you have to pay for the services you need? | ||
| What resources do you have to pay for modifications to your home? | ||
| Communication that builds partnership (PEARLS) | ||
| Partnership: “Let’s tackle this together.” “We can work together to figure this out.” | ||
| Empathy: “You look pretty upset.” “I can see that this is a difficult time for you.” | ||
| Apology: “I’m sorry this happened.” | ||
| Respect: “I appreciate your (courage, decision, action).” | ||
| Legitimization: “Anyone would be (confused, challenged, bothered, upset) by this situation.” | ||
| Support: “I’ll stick with you as long as necessary.” | ||
| Resources | ||
| Child and family | ||
| Child Find | ||
| Childcare | ||
| Education and development intervention services | ||
| Exceptional Family Member Program | ||
| Family-to-family support | ||
| Parent training and information center | ||
| Respite program | ||
| Logistic supports | ||
| Disabled American Veterans | ||
| Durable medical goods | ||
| Meals on Wheels | ||
| Nutrition services | ||
| Transportation | ||
| Nursing services | ||
| Community health nursing | ||
| Home health nursing | ||
| Hospice | ||
| Visiting Nurse Association | ||
| Physical care/rehabilitation | ||
| Head injury program | ||
| Occupational therapy | ||
| Physical therapy | ||
| Rehabilitation program | ||
| Respiratory therapy | ||
| Skilled nursing facility | ||
| Speech/language therapy | ||
| Spinal cord therapy | ||
| Vocational rehabilitation | ||
| Psychosocial services | ||
| Adult day care | ||
| Alcohol/substance abuse services | ||
| Day treatment program | ||
| Patient representative | ||
| Psychiatric nurse liaison | ||
| Psychiatry | ||
| Psychology | ||
| Respite program | ||
| Senior citizen program | ||
| Social work | ||
| Support groups | ||
| Coordination | ||
| Care coordinator | ||
| Case manager | ||
| Discharge planner | ||
| Hospital administrator | ||
| Military disability counselor | ||
| Primary care physician/medical home | ||
| Social worker | ||
| Payment/health benefits | ||
| Debt assistance officer | ||
| Health benefits advisor | ||
| Medicaid | ||
| Medicare | ||
| Supplemental Security income/Social Security | ||
| Disability income | ||
| TRICARE | ||
| Veterans Administration |
Home Modifications
Planning ahead for hospital discharge after an acute disabling condition can prepare the patient's home for rehabilitation or continuing care. Often, a patient in the hospital cannot return home unless it is deemed adequate for egress and safety. Many transportation and home health services have “zero lift” policies requiring ramps or mechanical lifts if the home does not have an entry without steps.
The modification priorities for individual homes depend on the patient's current and anticipated future medical conditions, environmental restrictions, and resources (see Online Table A for a checklist of home renovation priorities). Since the mid-1990s, homes are often built to universal design standards,16 which attempt to maximize accessibility and function while preserving aesthetics and minimizing the need for future modifications. Key features of universal design include one-story living, no-step entries, wide doorways and hallways, and extra floor space. These features allow easier use of a wheelchair or other assistive devices. They also help the caregiver by providing extra room for assisting the patient throughout the house, especially in the bathroom and bedroom.
| Area | Priority | Universal design features | |
|---|---|---|---|
| Entrances | 1 | One entrance (usually 34- to 36-inch clear opening) without steps or with a very low threshold | |
| 1 | Minimum 5- × 5-foot level space for maneuvering at a step-less entrance with awning or porch covering | ||
| General | 1 | Passage doors with 32-inch-wide clearance (usually at 36-inch interior door) | |
| 1 | Smooth, durable fooring for wheelchair use | ||
| 2 | Hall width of 42 inches | ||
| 2 | Maneuvering space at doors; if door obstructs access, modify doors with offset hinges, pocket doors, reverse door swing; use opposite jamb or widen doorway | ||
| 2 | Increase number of electrical outlets for lighting, equipment, and alarm indicators | ||
| Kitchens | 1 | Clear foor space for maneuvering (at least 5 × 8 feet) | |
| 2 | Stove with controls at the front; elevated dishwasher; front-loading washer and dryer | ||
| 2 | Adaptable cabinets with under-sink knee space | ||
| Bathrooms | 1 | Clear foor space for maneuvering (at least 5 × 8 feet) | |
| 2 | Adaptable cabinets with under-sink knee space | ||
| 2 | Reinforcement inside walls around toilets and bathing fxtures for installation of grab bars | ||
| 2 | Toilet in a 48- × 56-inch space with 18 inches of space to sidewalls from centerline of toilet | ||
| 2 | Curbless showers, at least 36 × 60 inches with shower bench or seat | ||
| 3 | Offset controls (easier to reach handles) in bathtub or shower to minimize bending and reaching | ||
Some older persons may decide to move to homes built to universal design standards within communities that are developed specifically to meet the needs of this population. Home modification may allow these patients to stay within their homes and neighborhoods, and remain engaged in their existing social networks and activities.2
Home modification can prevent or delay transition from community living to assisted living or nursing home care. The cost of home modification (e.g., $3,000 to $7,000 for an access ramp; $5,000 to $15,000 for bathroom modification) may be modest compared with the costs of moving into assisted living or a nursing home (e.g., $32,000 per year for a one-bedroom unit in an assisted living facility; $70,000 per year for a private room in a nursing home).17
PATIENTS WITH DEMENTIA
Home modifications for patients with dementia should promote safety for the patient and peace-of-mind for the caregiver. The modifications listed in Table 2 allow patients with dementia to receive ongoing care in the least restrictive environment possible, and may be implemented as the need arises.18 Home modifications for patients with dementia are associated with improved caregiver effectiveness and less caregiver upset.12
| Bathroom |
| Install grab rails in tub, shower, and near toilet |
| Install handheld shower |
| Install nonskid surfaces on tub or shower |
| Install tub chair or bench to sit while showering or bathing |
| Place sign on bathroom door, keep door open |
| Raise toilet seat or commode to higher level |
| Remove or reverse inner door locks or keep keys accessible |
| Remove rugs and electrical appliances |
| Replace glass shower doors with plastic doors or curtains |
| Bedroom |
| Add night-lights |
| Consider bedside commode |
| Consider hospital bed |
| Install room-darkening shades or curtains |
| Lower bed to floor level if patient is falling out of bed |
| Remove carpeting if patient has trouble with incontinence |
| Use baby monitor to monitor activities |
| Car |
| Install driver-controlled door locks and window |
| Notify police of patient's disability |
| Secure garage door opener out of patient's reach |
| Take away patient's car keys or disable car |
| Fire prevention |
| Add firefighter sticker at bedroom window |
| Conduct fire drills |
| Install smoke alarms |
| Notify fire department of patient's disability and home measures |
| Remove lighters and matches |
| Restrict smoking |
| Use flame-retardant bedding materials |
| Kitchen |
| Consider electric stove or install hidden shut-off valves or auto-pilots |
| Consider locks on cabinets, refrigerators, and freezers |
| Cover stove burners |
| Disable garbage disposal |
| Install locks on oven doors |
| Lock up sharp objects and glassware |
| Remove small, nonfood items that could be consumed |
| Remove stove knobs |
| Secure garbage out of patient's sight and reach |
| Unplug or store electrical appliances out of patient's reach |
| Outdoors |
| Be aware of danger areas, such as embankments, streams, lakes, and busy streets |
| Consider fences or hedges around yard |
| Remove poisonous plants |
| Secure outdoor equipment |
| Stairs |
| Add contrasting color on edge of treads |
| Consider barriers or gates at top and bottom |
| Install banisters on both sides |
| Replace stairs with ramp |
| General precautions |
| Childproof electrical outlets |
| Cover radiators |
| Cover shiny or reflective surfaces |
| Install door alarms |
| Install double key locks |
| Install scald-proof faucets or reduce water temperature |
| Install spring-loaded door closers |
| Keep first-aid kit accessible |
| Keep legal documents accessible |
| Lock up cleaning supplies, chemicals, poisons, and medications |
| Make a list of patient's medications and health conditions |
| Notify police and emergency medical services of patient's disability |
| Program emergency phone numbers on speed dial |
| Provide neighbors with set of house keys |
| Provide patient with identification card and bracelet |
| Reduce clutter |
| Remove free-standing floor and table fans |
| Remove hazardous furniture (e.g., high-back chairs, pedestal tables, easily moved furniture) |
| Remove mirrors if they cause delusions or hallucinations |
| Remove or lock up sharp or breakable objects |
| Remove or reverse inner door locks or keep keys accessible |
| Remove small rugs without nonskid backing |
PATIENTS WITH LIMITED VISION
Approximately one in three patients has some form of vision reduction by 65 years of age.19 Loss of vision from common conditions such as cataracts, age-related macular degeneration, glaucoma, and diabetic retinopathy is associated with depression and loss of function. Home modifications for patients with low vision emphasize the promotion of adequate lighting and contrasting colors to identify hazards (Table 3).20 These modifications are particularly important because patients who experience vision loss late in life may have difficulty coping with this change.
| Avoid protruding cabinetry hardware |
| Consider incandescent lighting over fluorescent lighting |
| Consider yellow or amber lenses to help patients with sensitivity to glare; hats with brims or visors may also be helpful |
| Ensure that printed materials are high-contrast, low-glare, 16- to 18-point simple (nondecorative) font, with wide letter and line spacing |
| Install bright lights at exterior doors with motion or sound activation |
| Install contrasting material on leading edge of stair |
| Install flush door thresholds to reduce tripping hazards |
| Install lighted keyholes and doorbells |
| Install mirror that can be positioned close to patient for grooming |
| Install single-handle scald-proof faucet |
| Install strip lighting under cabinets |
| Install switches with distinctive “on” and “off” positions |
| Install task lighting in areas such as the bathroom, dressing room, kitchen, and laundry room |
| Install telephones, thermostats, thermometers, and appliances with large numerals to maximize residual sight |
| Provide bold-lined paper and bold felt-tip markers to communicate messages and reminders |
| Use blinds or shades to control light entering room to limit glare |
| Use contrasting colors to help with object recognition |
PATIENTS WITH HEARING IMPAIRMENT
Hearing loss affects more than 2 million Americans older than 70 years,21 and routine screening for hearing loss is recommended by the U.S. Preventive Services Task Force.22 Hearing loss in older persons is usually progressive and can significantly impair communication, potentially contributing to social isolation and lower quality of life.23 In addition to hearing aids, home modifications can apply technology to create alarms and notification messages using visual and vibratory alerts (Table 4).24
| Activate closed captioning on televisions |
| Install appropriate furnishings to improve room acoustics (e.g., acoustic tiles, carpeting, furniture, tapestries, wall hangings) |
| Install doorbells or intercom systems that activate flashing lights or vibrating pager; or wireless doorbells with volume control and multiple receivers (some have flashing lights) |
| Install doors with vibration sensors that activate when visitors knock |
| Install security system: hardwiring or plug-in systems for strobes, bed-shakers, etc. |
| Install smoke detectors and carbon monoxide detectors with flashing strobe light, extra-loud alarm, pillow vibrator, or paging system |
| Install spring-loaded handles or motion detectors for faucets |
| Provide assistive devices for television, radio, or stereo (e.g., personal amplifiers, FM and infrared systems) |
| Provide wristwatches and timers with vibration |
| Use personal pager system for communication |
| Use telephones and cell phones with special equipment |
| Use weather warnings with pager systems or weather radios with sound/strobe/vibration systems |
Resources for Home Modifications
Local organizations of the National Association of Area Agencies on Aging (http://www.n4a.org/) and the National Association of Home Builders (NAHB; http://www.nahb.org) provide lists of reputable home remodeling contractors. The National Association of the Remodeling Industry (http://www.nari.org), the AARP, and the NAHB have developed a program for Certified Aging-in-Place Specialists (CAPS). Although most CAPS professionals are remodelers, an increasing number are general contractors, designers, architects, and health care consultants.25 Additional certification is offered by Certified Environmental Access Consultants.26
The resident of the home is responsible for paying for most home modifications. Other options include funding via reverse mortgages or insurance policies (e.g., automobile insurance in cases of auto-related injuries, disability, workers compensation, long-term care, Veterans Affairs benefits). Social workers may help patients research funding options. Patients with Medicare Part B (out-patient) coverage may be eligible for home occupational therapy assessment, treatment, and training in the use of home modifications. Medicare will also pay for some indicated durable medical equipment used in the home, but not the cost of home modification. Medicaid services vary by state, but some patients may qualify for Home and Community Based Services or other waiver programs.