The Importance of Including the Home Environment in Assessment of Frail Older Persons

Environmental hazards have long been implicated in falls and other accidents so common in, and often deadly to, older persons. In most studies, between 35 and 45% of falls are attributed to home hazards such as poor lighting, inadequate bathroom grab rails and stairway banisters, exposed electrical cords, clutter on floors, and the ubiquitous throw rug.12 These hazards are found often in homes in America and in most other developed countries despite widespread advice to eliminate them. Most of us live in equilibrium with our environmental hazards and are often willing to take chances with what we view as minor safety trade-offs. It is often easier and cheaper to live with precarious extension cords and fraying area rugs then to pay for custom wiring or carpet repairs. However, with frail older people, these trade-offs might not be so minor because of their increased susceptibility to hazards stemming from impaired vision, unsteady gait, and slowed righting reflexes. Perhaps because their importance seems so obvious, relatively few studies have been published on the role of environmental hazards and the effectiveness of interventions to reduce them. In fact, until now we did not even know the answer to the question of whether such hazards were more common or less common in homes of older people with frailties and disabilities compared with homes of older people without such increased vulnerability. In the current issue of the Journal of the American Geriatrics Society, Gill and colleagues3 document the disturbing finding that not only are potentially serious environmental hazards widespread in the homes of the older persons they studied, but, ironically, many of these hazards seem to be even more common in the homes of frail older people with disabilities — defined here as persons with self-reported deficits in activities of daily living (ADLs) or specific observed deficits on Tinetti's Performance Oriented Mobility Assessment (POMA). Almost three-fourths of homes studied had loose throw rugs, almost half had obstructed floor pathways, about a quarter had curling carpet edges, and almost 20% had low lying chairs. Except for loose throw rugs, which were equally prevalent in the homes of persons with and without disabilities, these hazards were significantly more common in homes of persons with disabilities. On the positive side, persons with disability were more likely to have grab bars installed in their bathrooms, but even here only about one-third of the disabled people had such grab bars. (In purpose-built senior housing apartments, about 90% of subjects did have bathroom grab bars installed, a testimony to some of the benefits of age-specific housing.) Of course even the best of studies have a few limitations, and this one is no exception. Definitions of hazard are always a matter of judgment and may not be reproducible. What an inspector sees as an “obstructed floor pathway” may actually be a carefully laid-out series of chairs giving support to the person on the way to the bathroom. Nor has the relative importance of these frequently cited hazards been well quantified. Is the lowly throw rug really as bad as we all say it is? How much protection is really conferred by the raised toilet seat or non-skid strips in the shower? Until we have better data, we can only speculate. Could the nurse inspectors in the study have been more sensitive to identification of hazards in the homes of persons whom they knew had mobility deficits, thus introducing a subtle bias when collecting these data? The authors do not address this, but even if the hazards were not significantly more common in the homes of the more disabled older people, their prevalence rates there were still unacceptably high, and this paper sounds an important alarm. How can we better address these environmental risks? I think one answer is clear: health professionals need to perform more visits to the homes of frail older persons. Studies of organized home visit programs involving nurses and other health visitors have already shown many benefits, including reduced mortality, reduced functional deterioration, reduced nursing home admissions, and better overall adherence to prevention guidelines.4 Although accident prevention from these interventions has not yet been well documented, it may be because the studies were not sensitive to this outcome variable. Instruments to quantify the home environment and its hazards are only beginning to get established and receive validation.5 See also p 88 Many other benefits result from home inspections. The home visit allows much better inspection of how well the person is managing illness and disability. A kitchen inspection reveals valuable information about the individual's nutritional adequacy and sanitary conditions. A look in the medicine cabinet and other medication caches and storage places around the house gives unique insights into medication-taking behavior and has actually been shown to improve prescribing knowledge and appropriateness.67 Social supports can be observed and interviewed first hand, and signs of elder abuse and neglect can be noted. Although office-based patient and family education about home safety may be helpful, and pamphlets and checklists can be sent home to help,89 these techniques have not yet been proved to be particularly effective. Moreover there is a natural resistance to changing one's home environment on the basis of some off-the-cuff advice or a “patient awareness” pamphlet, which may explain the lack of proven effectiveness of these low-cost attempts at environmental improvement. The findings from this and previous studies on home visits give further support to the notion that frail older persons should have a periodic home visit, preferably tied to a comprehensive geriatric assessment and follow-up system. Not only will this probably make their environment a safer place, but many other benefits can result, ranging from better disease management and increased survival to improved quality of life. It is possible that even falls and accidents can be reduced by such home visits if we are able to study these outcomes carefully.