In most homes we can identify hazards that may present as a risk for falling, specifically for older adults. However, rarely do we identify them unless we are looking for them – or a fall has taken place.
The following is the checklist included in the Safe City Windsor – Fall Prevention Brochure:
Using this checklist – conduct an assessment your own dwelling environment. You can choose just one room, or multiple rooms. There should be at least one room for each group member. Providing photographs in an appendix is encouraged. Together, write a two page report about the:
The evidence on modifications or assessments made to the environment and the
relation to fall prevention is still emerging [Iwarsson et al., 2009]. Although empirical
evidence on reducing home hazards is weak, there are various checklists that have
been developed [Pynoos et al., 2005; Iwarsson et al., 2009]. Checklists are often
preferable because they are low- to no-cost. Unfortunately, checklists – whether
they are used as a self-assessment, or conducted by another individual such as an
Occupational Therapist or Kinesiologist – they rarely afford the opportunity to watch
an individual, or individuals, engage with their environment while performing various
tasks [Pynoos et al., 2005]. Thus, it may be advantageous to pair an environmental
assessment with a functional performance test.
Again, a common question ends up being – who is responsible for performing the
assessments and making recommendations? There are a lot of programs that
afford an Occupational Therapist to do a home visit and assess the dwelling
environment of an individual. However, that does not necessarily mean that the
entire house will be assessed – rather it may be that only a certain room or rooms
are looked at. Commonly, the bathroom is assessed for the need of grab bars.
On a personal note, when my sister Laura (born with Down Syndrome) was alive,
we were recognizing that her living at home was becoming too challenging for
many reasons. Part of the assessment process was having an Occupational
Therapist perform an environmental assessment. However, it was during COVID19, thus the assessment needed to be done via the telephone (in other words, the
Occupational Therapist never stepped foot in the house where my sister lived, he
did not even see a picture). Due to my knowledge and expertise, my mother had
me take the phone call. This was helpful to the Occupational Therapist, as he noted
on several occassions, to have this discussion with someone who understood what
he was asking was refreshing. Nonetheless, he provided a report with almost 80
recommendations. 80!!!! Perhaps a bit overwhelming? Perhaps. It would have also
been cheaper to, as my mother said: “level the house and build a new one”.
Meaning, the recommendations were not remotely feasible. Yet, the Occupational
Therapist was proud of his work, thought he was thorough, and was truly helping
my family. In reality, he was not helpful. He actually created more anxiety, increased
frustration, and a general sense of being overwhelmed. My sister would pass away
less than two weeks of this assessment – could you imagine if a family began to
spend the money to make the changes, and then their loved one passes away?
True – if it was following universal design principles, these changes would – shouldbe beneficial for everyone. The majority of the suggestions made in this scenario
would not have aligned with the principles. I am not sure if the Occupational
Therapist was even aware of universal design. He was doing his job – but it
definitely illustrated that just because one modification may be ideal for one person,
does not always mean it is advantageous for another. How do we ensure concepts
like universal design are embedded in assessments? That the individual performing
the assessments and providing recommendations is aware of these concepts?
There are many studies that include follow-ups 3 months, 6 months, 12 months, or
even 24 months after a fall prevention intervention has taken place. However,
because their main concern was the occurrence of a fall, that is typically the
outcome measure being evaluated. Therefore, any improvements in fall prevention
are implied to be caused by the recommendations provided through the
environment modifications. This can only be an assumption, however. It is
imperative that follow-ups are done to see how many recommendations were
actually implemented. You may be surprised how often the answer will be that littleto-none are implemented. Why?
They were deemed not necessary.
They were too expensive.
They weren’t going to help.
I meant too, but I forgot.
My son or daughter was against the idea.
Perhaps 80 recommendations were given and they were just
overwhelmed.
The list could go on. Even when grab bars are installed in the bathroom, and follow
universal design principles – that does not mean they are used.
Thus, if you are conducting research or implementing changes in your own field of
work, consider the fidelity – the extent to which older adults adhere to the provided
recommendations.
The intent of environment modifications is to reduce the potential threat to falling,
but to also support independent living by making tasks easier to perform. After
scoping the literature, Pynoos et al., (2005) provided eight main environmental
factors one should consider modifying as they may affect the risk of falling:
1. Poor or inadequate lighting
2. Changes in floor surface or slippery surfaces (e.g., wet or polished
floors, and non-slip-resistant bathtub surfaces)
3. High-gloss floors and/or walking surfaces
4. Problems associated with stairs (e.g., lack of handrails)
5. Inappropriate chair or cabinet heights
6. Clutter, storage problems, and tripping hazards such as furniture or
throw rugs
7. Poor sidewalk and pavement conditions
8. Pets and pet-related objects
Pynoos et al., (2005) also reported on the main areas that pose the biggest
threats:
1. Outside steps to the entrance à perhaps modify with a ramp
2. Inside stairs to a second floor à there may be the need for railings
3. Unsafe bathrooms à alter for easier access and support (e.g., grab
bars)
Some of the easiest and low-cost modifications can include [Pynoos et al., 2005]:
Removing hazards (e.g., clutter, throw rugs)
Adding assistive devices (e.g., grab bars, ramps)
Moving furnishings
Changing where activities occur (e.g., sleeping on the first instead of
second floor)
Renovations (e.g., installing a roll-in shower)
Although this publication is from the year 2005 – the same issues and the same
low-cost modifications remain relatively the same.
CC0 Public Domain via Max Pixel
Universal Design often implies accessibility. However, just because something is sold
with the idea that it has a universal design, does not mean that is true in practice
[Mustaquim, 2015]. I know personally there are many products that claim they are
“ergonomic” – when that is not even close to the case. Sometimes certain words
become the “hot descriptor” or “halo words” that sells. The term universal design has
definitely fallen victim.
The next video I invite you to watch is among my favourite. It is important to note
from the beginning that this building has won awards for its design – do you think it
was award worthy? The title of the video may give the answer away. Watch this
video that was published on YouTube in 2017 by the Toronto Star entitled: Ryerson’s
new Student Learning Centre fails accessibility test (despite winning awards!):
Ryerson’s new Student Learning Centre fails accessibility te…
te…
Was that building, even just the entry way, really designed for any person, regardless
of age and ability, to use without additional adaptations or modifications?
Universal design is ensuring that a product, or an environment, can be used
universally by all, or most, people. Universal design should help ensure the removal
of environmental barriers to promote inclusion rather than exclusion of certain
populations. Integration should also help to minimize the many stigmas that exist
when populations are excluded. This can be particularly important for individuals
who may be trying to reintegrate within their society [de Souza et al., 2016].
For more information on universal design aginginplace.com provides the following:
Aging In Place – Universal Design
or see the link: https://aginginplace.com/universal-design/
Picture Source: Pixabay
Pynoos et al., (2005) has referred to housing as “Peter Pan” housing – designed for
people who never grow old.
The environment is one of the modifiable external risk factors associated with
falling [Stevens, 2005]. Some fall prevention strategies are multifaceted and claim
to be a superior approach. Whereas, some single-intervention programs, such as
just exercise, or just environmental modifications, have seen mixed results.
Regardless, every fall somehow involves both a person and their environment.
Most people want to stay in their own homes. This often means they are living in an
environment that puts them at an increased risk of falling. As someone becomes
weaker, confused, and/or tired, the number of hazards their home environment may
pose can increase. Not every hazard is the same for each person. We all learn
different coping and navigation strategies. Hence, why it is always important to
assess what an individual CAN do. Thus, the intrinsic aspects of a person can play
a role in whether or not the extrinsic factors presented by the environment act as a
hazard [Pynoss et al., 2005]. After all – consider the time old question à if a tree
falls in a forest but there is no one there, does it still make sound? à if there is a
hazard in a house but there is no one there for it to be an obstacle, is it still a fall
risk factor? As Lord et al., (2006) point out it is the interaction between a person
and their abilities with the exposure to environmental demands that may result in a
fall – and not the mere existence of a home hazard alone. We will talk more about
this relationship next, but first, what are the potential hazards?
Throw rugs
Obstructed hallways
Room clutter
Lack of stair railings
Lack of grab bars
Slippery surfaces
Unstable furniture
Poor lighting
Pets
Grandchildren … or maybe just the grandchildren toys
Reports have indicated the majority of falls among older adults occur indoors or
inside the home [Pynoos et al., 2005; Moreland et al., 2015]. Does this surprise
you? Perhaps as we age we tend to spend more time inside our home – and thus,
more falls occur there based on the numbers/exposure. Perhaps COVID-19
increased these stats as well! Regardless, environmental hazards have been
associated as being a major contributor to falls among older adults [Pighills et al.,
2016]. It has also been reported that one half of the remaining falls that do not
occur inside the house take place in close vicinity to the house [Pynoos et al.,
2005].
So where are the falls within the home taking place?
Tripping or slipping while walking forward (e.g., walking into the dishwasher)
During a transfer (e.g., getting up from a chair/toilet)
Stairs/Steps!!
Loose mats/rugs/flooring
Electrical cords
More specifically, what rooms are problematic? Typically, in increasing order of
concern:
Hallways
Bathrooms
Kitchens
Bedrooms
Living rooms
Wait! Bathrooms are not number one? A lot of research indicates the issue of falling
in the bathroom! Falling in the bathroom is definitely a high priority concern –
mainly because of the injuries associated with said falls.
As most people spend a lot of time in either the bedrooms or living rooms, it is not
surprising that those are the two highest on the list. Furthermore, in bedrooms
specifically, people often have beds that are too high to easily get up on to. Thus,
this may introduce the need for a step ladder or some form of a step. There is often
a lot of clutter in both the bedrooms and the living rooms. Also of concern is poor
lighting, pets, and loose rugs.
Kitchens are a lot more of a concern than we sometimes realize. Lifting and
lowering dishes or various ingredients (e.g., bags of flour) can become problematic.
Sometimes, it is easier to have smaller amounts of flour and sugar in a container on
the counter than the heavier and larger bag in a higher cabinet. Also, you would be
surprised how often the dishwasher is problematic! Having to lean over quite far to
grab a clean plate to return to the cupboard could cause someone to become dizzy
or lose their balance. Also, sometimes the dishwasher door is left open – which
causes a tripping hazard as people may forget or not be aware that it is open and
bump into it!
Picture Source: Picryl
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