Therapeutic Home Adaptations for Older Adults with Disabilities



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Am Fam Physician. 2009 Nov 1;80(9):963-968.

  Patient information: See related handout on home adaptations, written by the authors of this article.

This version of the article includes supplemental content.

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.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

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


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

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


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

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

Table 1.

Priorities, Activities, Social Context, and Support/Coping Coordination for Patients and Families

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:

Bathing

Communicating

Dressing

Eating

Toileting

Walking, getting around

Writing

How does this (injury, illness, diagnosis, etc.) affect the things you do to care for yourself every day?

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):

Everyday responsibilities

Getting together with people

Managing finances

Transportation

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


note: This is an expanded version of the table that appeared in the print version of this article.

Adapted with permission from Hanson J. PASS-C Form (Priorities, Activities, Social context, Support/Coping—Coordination). Advocating for Patients and Families. Bethesda, Md.: Uniformed Services University; 2008:ii.

Table 1.   Priorities, Activities, Social Context, and Support/Coping Coordination for Patients and Families

View Table

Table 1.

Priorities, Activities, Social Context, and Support/Coping Coordination for Patients and Families

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:

Bathing

Communicating

Dressing

Eating

Toileting

Walking, getting around

Writing

How does this (injury, illness, diagnosis, etc.) affect the things you do to care for yourself every day?

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):

Everyday responsibilities

Getting together with people

Managing finances

Transportation

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


note: This is an expanded version of the table that appeared in the print version of this article.

Adapted with permission from Hanson J. PASS-C Form (Priorities, Activities, Social context, Support/Coping—Coordination). Advocating for Patients and Families. Bethesda, Md.: Uniformed Services University; 2008:ii.

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.

Online Table A.

Renovation Priorities Checklist

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


1 = high priority for person with a wheelchair to independently enter, exit, and move about dwelling; 2 = offers patients with disabilities the possibility of being safe and independent as long as possible; 3 = offset controls offer increased safety for all users.

Adapted with permission from North Carolina State University. College of Design. Center for Universal Design. Residen­tial rehabilitation, remodeling and universal design. http://design.ncsu.edu/cud/pubs_p/docs/residential_remodelinl. pdf. Accessed May 13, 2009.

Online Table A.   Renovation Priorities Checklist

View Table

Online Table A.

Renovation Priorities Checklist

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


1 = high priority for person with a wheelchair to independently enter, exit, and move about dwelling; 2 = offers patients with disabilities the possibility of being safe and independent as long as possible; 3 = offset controls offer increased safety for all users.

Adapted with permission from North Carolina State University. College of Design. Center for Universal Design. Residen­tial rehabilitation, remodeling and universal design. http://design.ncsu.edu/cud/pubs_p/docs/residential_remodelinl. pdf. Accessed May 13, 2009.

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

Table 2.

Home Modifications for Patients with Dementia

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


Information from reference 18.

Table 2.   Home Modifications for Patients with Dementia

View Table

Table 2.

Home Modifications for Patients with Dementia

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


Information from reference 18.

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.

Table 3.

Home Modifications for Patients with Vision Loss

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


Information from reference 20.

Table 3.   Home Modifications for Patients with Vision Loss

View Table

Table 3.

Home Modifications for Patients with Vision Loss

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


Information from reference 20.

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

Table 4.

Home Modifications for Patients with Hearing Loss

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


Information from reference 24.

Table 4.   Home Modifications for Patients with Hearing Loss

View Table

Table 4.

Home Modifications for Patients with Hearing Loss

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


Information from reference 24.

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.

The Authors

BRIAN K. UNWIN, COL, MC, USA, FAAFP, is assistant professor of family medicine and geriatrics at the Uniformed Services University of the Health Sciences (USUHS), Bethesda, Md.

CHRISTOPHER M. ANDREWS, LCDR, MC, USN, is a physician intern at the National Naval Medical Center in Bethesda.

PATRICK M. ANDREWS, BA, is a Certified Graduate Remodeler and a Certified Aging-in-Place Specialist in Perrysburg, Ohio. He works with persons with physical disabilities as an expert in barrier-free building design, including health care facilities.

JANICE L. HANSON, PhD, is an associate professor of medicine, family medicine, and pediatrics at USUHS.

Address correspondence to Brian K. Unwin, MD, FAAFP, Uniformed Services University, 10405 Stallworth Ct., Fairfax, VA 22032 (e-mail: bunwin@usuhs.mil). Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army or U.S. Navy Medical Departments, the Uniformed Services University of the Health Sciences, or the U.S. Department of Defense.

Author disclosure: Nothing to disclose.

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