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Safe Home Practical tips for
fall-proofing.
REIN TIDEIKSAAR s many as one-third of the elderly population fall at least once each year at home(l). Many of those falls result in serious injury or death. In fact, it has been found that falls are the leading cause of accidental death among persons over age 65(2). Elders who fall suffer hip fractures, wrist fractures, head trauma, and hot water burns (from falling into the bathtub), as well as immobility-induced hypothermia, pressure ulcers, and urinary tract infections. Psychologically, falls diminish self-esteem and create a fear of falling again. As a result, elderly persons who have fallen may gradually become less and less mobile. About 85 percent of elders' falls occur at home, usually in bedrooms, bathrooms, and kitchens(3). Elders fall most often while transferring
A
Rein Tideiksaar, PhD, is the director of the
Falls and Immobility Clinic at the Department of Geriatrics, Mount Sinai Medical Center, NewYork. NY and assistant professor of geriatrics, Jewish Home and Hospital for Aged, New York, NY.
from beds, chairs, and toilets; getting into or out of bathtubs; tripping over carpet edges or doorway thresholds; slipping on wet surfaces, and descending stairs(4,5).
reach or bend to get objects from shelves. Ifa home visit is unrealistic, you can teach the person how to evaluate his home himself and then propose the necessary changes. The guiding principle for making a home safer for an eider is that function takes priority over aesthetics. Walk with us through the following situations to see exactly how to find and fix environmental hazards in seniors' homes.
Harry Rose, 82, had fallen repeatedly in his bathroom. During the environmental evaluation, Mr. Rose, who uses a walker because of poor balance; left his walker in the hallway and entered the bathroom, remarking that the bathroom wasn't roomy enough for the walker. I watched as Mr. Rose leaned on the towel bar, sink edge, and toilet rank for support. Bingo. I'd found the cause of his falls. Those structures weren't designed to provide support. A sink edge or tank top is slippery, especially when it's wet. And a towel bar separates from the wall as soon as any weight is applied to it.
Evaluate the Environment Before designing a program for preventing falls at home, we need to know whyanelder falls so we can correct the factors that contribute to the falling. Usually, falls stem from an interplay of intrinsic (illness, drug therapy, alcohol use) and extrinsic (environmental hazards) factors. Of course, an obstacle in the environment may also be the sole cause of a fall. Although we cannot necessarily remove the intrinsic factors, we can modify a senior's home to help compensate for any limitations imposed by functional changes and/or any disease state. Begin by just observing the elder as he maneuvers and functions in his usual living environment. Watch him walk from room to room over different floor surfaces, climb and descend stairs,-transfer to and from beds, chairs, and toilets; get in and out of the bathtub or shower, and
280 Geriatric Nursing November/December 1989
Since Mr. Rose needs to use the bathroom fixtures for support, we had to modify them. The towel bar was replaced with a nonslip grab bar, se-
curdy fixed into the wall studs so it won't pull out. A grab bar in a color that contrasts with the wall behind it is best. If a grab bar is already in place, or if the color choices of a new bar are limited, applying nonslip colored adhesive tape to the bar can help make it more visible.
Eighty-year-old Anna Brady's vision is poor as a result ofmacular degeneration and parkinsonism. She'd fallen several times in her home. During the evaluation, I saw that her stepping height was inadequate: She shuffled when she walked, so any irregular or slippery ground surfaces were hazardous for her. As if to prove the point, she tripped on the bathroom door threshold while I watched and then lost her balance when she stepped on a scatter rug. To help Ms. Brady see the glass-top coffee table she'd also tripped over, I suggested placing nonslip strips along the table's edges.
Nonslip adhesive strips can also be placed along the sink and tank top. This provides Mr. Rose with a nonslip surface for grasping. Matching colors is a better idea for these surfaces, because older people who have problems with depth perception may see contrasting strips as a hazard to be avoided. (We used contrasting strips here only so they'd show up for the photographs.)
tm Since Ms. Brady couldn't afford to replace all of her rugs, we decided to make them slip-proof by putting double-sided nonslip adhesive tape on the back.
P
Mr. Rose's fear that he'd fall and be unable to get up made him agreeable to modifying his home.
/
To help Ms. Brady see tripping hazards and step over them, I suggested placing color-contrasted, nonskid strips along the length of all thresholds. If necessary,-you can plane thresholds down to a height of V4inch or remove them entirely.
Whenever Ms. Brady lost her balance, she'd try to grasp something nearby for support---frequently leaning on her pedestal-type table. My only alternative in this case was to teach Ms. Brady to avoid using such a table for support because it can tip over so easily. When testing a table for stability, look for straight legs that don't extend beyond the table edges, have no casters or wheels, and have nonslip grips fastened to the bottom surfaces. Push and lean on the table to see if it gives way. A table top and legs that contrast in color with floors and walls improve the table's visibility.
Geriatric Nursing November/December 1989 281
k
........
........ Y
Rosa Sanchez, 76, has bilateral cataracts and an old right-sided CVA that left her with a slight foot drop. She has difficulty negotiating the stairs to her basement, and she'd fallen twice while climbing them. When I evaluated the staircase area in her home, I found that the handrails, steps, and surrounding walls were all similar in color. To make matters even worse, the illumination in the stairwell was poor and the steps were slippery. No wonder Ms. Sanchez had trouble locating the handrails and finding the first step with her foot. To highlight the handrails and steps visdally, I suggested painting them to contrast with the walls, bearing in mind that light-colored walls reflect available light best. We also decided to add fluorescent lighting to the stairwellma better choice than incandescent bulbs because fluorescence provides more light for less electricity. To cue Ms. Sanchez visually to the step edges, we decided to place nonskid rubber strips parallel to each step.
est when they are round, positioned about 30 inches above the stairs, and set out far enough from the wall to be grasped firmly. Worn step runners or carpet should be replaced. Nonslip strips or rubber runners on steps are safest when they contrast in color with the steps. Keep in mind that the older eye can see warm colors (red, yellow, and orange) better than cool (blue and green).
[ t3K ,OF LEVEGE......) Winifred King, 83, has a long-standing history ofosteoarthritis, primarily affecting her knees, and proximal muscle weakness from prolonged immobility. She has difficulty transferring from chairs, her bed, and the toilet. Typically, people with arthritic knees and weak muscles lack quadricep strength and cannot flex their knees enough to position their legs under the buttocks for leverage. When I evaluated Ms. King, I saw that she would rock back and forth until she built enough momentum to get up from her low-seated chairs and toilet. Occasionally, the rocking thrust her too far forward and she lost her balance and fell. When getting out of bed, her feet slid away on the floor.
Although these changes were all Ms. Sanchez needed, other elders may require positioning lights to avoid glare or shadows, installing light switches at the top and bottom of the stairs to avoid having to travel in either direction in the dark, and placing night-lights by the first and last steps. Installing handrails on both sides is also a good idea. Handrails are saf-
282 Geriatric Nursing November/I)ecember 1989
The first thing I did was instruct Ms. King to use only chairs equipped with armrests to increase her leverage. An average-sized person can achieve maximum leverage in a chair that has the armrests positioned about seven inches above the seat. The seat's height is appropriate when the person can sit in it with feet planted firmly on the floor and knees flexed 90 degrees and can rise without difficulty. Avoid chairs with crossbars spanning the legs, as they can impede sliding the legs underneath the seat for leverage.
I suggest pneumatic-spring catap a r chairs for those who have extreme difficulty rising from a chair.
Contrasting the chair's color with its surroundings makes it more visible. Ifthe person uses a chair back for support while walking, you should test the chair to see if it gives way and make sure the legs do not rest on casters or metal tips.
tumm•ttD
m
_
_
Eighty-year-old Bill Fox has problems with balance. He'd fallen seweral times when he used the shower rod to balance himself while getting in and out of the tub. He had also slipped on the wet bathroom floor and had lost his balance when sitting down on his low toilet seat.
tant grab bar attached to the bathtub added more support. I also suggested mounting a liquid soap dispenser on the wall so Mr. Fox would no longer risk slipping while retrieving a dropped bar of soap.
. . . . .
q
m .O
/
..,i So Ms. King would no longer slip when she got out of bed, we decided to place nonslip strips on the floor along the length of the bed. It was important to him to stand while bathing. A vertical nonslip grab bar contrasted to the wall solved the shower-rod problem.
These solutions were fine at home, but Mr. Fox likes to travel. I advised him to get a portable bathtub-rim grab bar to take with him when he visits his children.
-z
In the bathroom, a raised toilet seat with armrests was installed, and nonslip strips were placed on the floor in front of the toilet.
•
_,]k==._
A horizontal grab bar installed along the side wall and a slip-resis-
We agreed to add a nonslip mat to the bathtub surface--another item Mr. Fox could take with him when he travels.
Geriatric
Nursing
November/December
1989 283
hold onto for support. Ms. Ludwig's children donated the stool and I observed her using it safely, though I would have preferred one with handrails and wider steps.
¢
I also suggested nonslip strips for the floor near the sink so Ms. Ludwig Would not risk slipping on spilled water.
Mr. Fox's sitting-down problem was solved by installing a raised toilet seat: and a nonslip grab bar mounted at a 45-degree angle on the wall next to the toilet. When considering a toilet riser, choose one that is sturdy enough to provide good support. The type of grab bar and height of placement depends on the person's size, degree of disability, and the structure of the bathroom. A person with hemiplegia, for example, cannot use a bar placed on his dysfunctional side, A good alternative to a wall-mounted bar is the double-type grab bar that attaches directly to the toilet seat.
Resisting Remodeling It's not uncommon to encounter resistance as you propose changes in a person's home. To help the elder adjust, make sure he understands why his environment needs to be modified. Mr. Fox, for example, resisted making the changes at first, perhaps because he did not want to be reminded of his frailty. Once he understood how the devices could enhance his safety, he agreed. Another strategy for getting the person to make the needed modifications is to invite him to make decisions along the way, and only recommend devices, appliances, and supplies that he can afford and obtain easily.
,RIBKY
'REACN-G.. Ninety-year-old Mary Ludwig had fallen repeatedly in her kitchen, in part because she tried to stand on an unstable stool to get objects down from high shelves. Shelves placed between a person's eye and hip levels (between 16 and 63 inches from the floor) are reasonably safe. Because space limitations made rearranging Ms. Ludwig's shelves impractical, we decided to replace the unstable stool with a safe o n e - with nonslip treads and a back to
References
A hand-held reacher device eliminated Ms. Ludwig's_need to use the stool for getting lightweight objects offthe shelves.
2 8 4 G e r i a t r i c N u r s i n g N o v e m b e r / D e c e m b e r 1989
!. Campbell, A. J., and others. Falls in the old age: a study of frequency and related clinical factors. Age Ageing 10:264-270, Nov. 1981. 2. National Safety Council. Accident Facts, Chicago, The Council, 1983. 3. Combs, K. L. Preventive care in the elderly. Am.J.Nurs. 78:1339-134 I, Aug. 1978. 4. Morfitt, J. M. Falls in old people at home: intrinsic versus environmental factors in causation. Public ttealth 97:115-120, Mar. 1983. 5. Prudham, D., and Evans, J. G. Factors associated "with falls in the elderly: a community study. Age Ageing 10:.141-146, Aug. 1981.
Safe Home Practical tips for
fall-proofing.
REIN TIDEIKSAAR s many as one-third of the elderly population fall at least once each year at home(l). Many of those falls result in serious injury or death. In fact, it has been found that falls are the leading cause of accidental death among persons over age 65(2). Elders who fall suffer hip fractures, wrist fractures, head trauma, and hot water burns (from falling into the bathtub), as well as immobility-induced hypothermia, pressure ulcers, and urinary tract infections. Psychologically, falls diminish self-esteem and create a fear of falling again. As a result, elderly persons who have fallen may gradually become less and less mobile. About 85 percent of elders' falls occur at home, usually in bedrooms, bathrooms, and kitchens(3). Elders fall most often while transferring
A
Rein Tideiksaar, PhD, is the director of the
Falls and Immobility Clinic at the Department of Geriatrics, Mount Sinai Medical Center, NewYork. NY and assistant professor of geriatrics, Jewish Home and Hospital for Aged, New York, NY.
from beds, chairs, and toilets; getting into or out of bathtubs; tripping over carpet edges or doorway thresholds; slipping on wet surfaces, and descending stairs(4,5).
reach or bend to get objects from shelves. Ifa home visit is unrealistic, you can teach the person how to evaluate his home himself and then propose the necessary changes. The guiding principle for making a home safer for an eider is that function takes priority over aesthetics. Walk with us through the following situations to see exactly how to find and fix environmental hazards in seniors' homes.
Harry Rose, 82, had fallen repeatedly in his bathroom. During the environmental evaluation, Mr. Rose, who uses a walker because of poor balance; left his walker in the hallway and entered the bathroom, remarking that the bathroom wasn't roomy enough for the walker. I watched as Mr. Rose leaned on the towel bar, sink edge, and toilet rank for support. Bingo. I'd found the cause of his falls. Those structures weren't designed to provide support. A sink edge or tank top is slippery, especially when it's wet. And a towel bar separates from the wall as soon as any weight is applied to it.
Evaluate the Environment Before designing a program for preventing falls at home, we need to know whyanelder falls so we can correct the factors that contribute to the falling. Usually, falls stem from an interplay of intrinsic (illness, drug therapy, alcohol use) and extrinsic (environmental hazards) factors. Of course, an obstacle in the environment may also be the sole cause of a fall. Although we cannot necessarily remove the intrinsic factors, we can modify a senior's home to help compensate for any limitations imposed by functional changes and/or any disease state. Begin by just observing the elder as he maneuvers and functions in his usual living environment. Watch him walk from room to room over different floor surfaces, climb and descend stairs,-transfer to and from beds, chairs, and toilets; get in and out of the bathtub or shower, and
280 Geriatric Nursing November/December 1989
Since Mr. Rose needs to use the bathroom fixtures for support, we had to modify them. The towel bar was replaced with a nonslip grab bar, se-
curdy fixed into the wall studs so it won't pull out. A grab bar in a color that contrasts with the wall behind it is best. If a grab bar is already in place, or if the color choices of a new bar are limited, applying nonslip colored adhesive tape to the bar can help make it more visible.
Eighty-year-old Anna Brady's vision is poor as a result ofmacular degeneration and parkinsonism. She'd fallen several times in her home. During the evaluation, I saw that her stepping height was inadequate: She shuffled when she walked, so any irregular or slippery ground surfaces were hazardous for her. As if to prove the point, she tripped on the bathroom door threshold while I watched and then lost her balance when she stepped on a scatter rug. To help Ms. Brady see the glass-top coffee table she'd also tripped over, I suggested placing nonslip strips along the table's edges.
Nonslip adhesive strips can also be placed along the sink and tank top. This provides Mr. Rose with a nonslip surface for grasping. Matching colors is a better idea for these surfaces, because older people who have problems with depth perception may see contrasting strips as a hazard to be avoided. (We used contrasting strips here only so they'd show up for the photographs.)
tm Since Ms. Brady couldn't afford to replace all of her rugs, we decided to make them slip-proof by putting double-sided nonslip adhesive tape on the back.
P
Mr. Rose's fear that he'd fall and be unable to get up made him agreeable to modifying his home.
/
To help Ms. Brady see tripping hazards and step over them, I suggested placing color-contrasted, nonskid strips along the length of all thresholds. If necessary,-you can plane thresholds down to a height of V4inch or remove them entirely.
Whenever Ms. Brady lost her balance, she'd try to grasp something nearby for support---frequently leaning on her pedestal-type table. My only alternative in this case was to teach Ms. Brady to avoid using such a table for support because it can tip over so easily. When testing a table for stability, look for straight legs that don't extend beyond the table edges, have no casters or wheels, and have nonslip grips fastened to the bottom surfaces. Push and lean on the table to see if it gives way. A table top and legs that contrast in color with floors and walls improve the table's visibility.
Geriatric Nursing November/December 1989 281
k
........
........ Y
Rosa Sanchez, 76, has bilateral cataracts and an old right-sided CVA that left her with a slight foot drop. She has difficulty negotiating the stairs to her basement, and she'd fallen twice while climbing them. When I evaluated the staircase area in her home, I found that the handrails, steps, and surrounding walls were all similar in color. To make matters even worse, the illumination in the stairwell was poor and the steps were slippery. No wonder Ms. Sanchez had trouble locating the handrails and finding the first step with her foot. To highlight the handrails and steps visdally, I suggested painting them to contrast with the walls, bearing in mind that light-colored walls reflect available light best. We also decided to add fluorescent lighting to the stairwellma better choice than incandescent bulbs because fluorescence provides more light for less electricity. To cue Ms. Sanchez visually to the step edges, we decided to place nonskid rubber strips parallel to each step.
est when they are round, positioned about 30 inches above the stairs, and set out far enough from the wall to be grasped firmly. Worn step runners or carpet should be replaced. Nonslip strips or rubber runners on steps are safest when they contrast in color with the steps. Keep in mind that the older eye can see warm colors (red, yellow, and orange) better than cool (blue and green).
[ t3K ,OF LEVEGE......) Winifred King, 83, has a long-standing history ofosteoarthritis, primarily affecting her knees, and proximal muscle weakness from prolonged immobility. She has difficulty transferring from chairs, her bed, and the toilet. Typically, people with arthritic knees and weak muscles lack quadricep strength and cannot flex their knees enough to position their legs under the buttocks for leverage. When I evaluated Ms. King, I saw that she would rock back and forth until she built enough momentum to get up from her low-seated chairs and toilet. Occasionally, the rocking thrust her too far forward and she lost her balance and fell. When getting out of bed, her feet slid away on the floor.
Although these changes were all Ms. Sanchez needed, other elders may require positioning lights to avoid glare or shadows, installing light switches at the top and bottom of the stairs to avoid having to travel in either direction in the dark, and placing night-lights by the first and last steps. Installing handrails on both sides is also a good idea. Handrails are saf-
282 Geriatric Nursing November/I)ecember 1989
The first thing I did was instruct Ms. King to use only chairs equipped with armrests to increase her leverage. An average-sized person can achieve maximum leverage in a chair that has the armrests positioned about seven inches above the seat. The seat's height is appropriate when the person can sit in it with feet planted firmly on the floor and knees flexed 90 degrees and can rise without difficulty. Avoid chairs with crossbars spanning the legs, as they can impede sliding the legs underneath the seat for leverage.
I suggest pneumatic-spring catap a r chairs for those who have extreme difficulty rising from a chair.
Contrasting the chair's color with its surroundings makes it more visible. Ifthe person uses a chair back for support while walking, you should test the chair to see if it gives way and make sure the legs do not rest on casters or metal tips.
tumm•ttD
m
_
_
Eighty-year-old Bill Fox has problems with balance. He'd fallen seweral times when he used the shower rod to balance himself while getting in and out of the tub. He had also slipped on the wet bathroom floor and had lost his balance when sitting down on his low toilet seat.
tant grab bar attached to the bathtub added more support. I also suggested mounting a liquid soap dispenser on the wall so Mr. Fox would no longer risk slipping while retrieving a dropped bar of soap.
. . . . .
q
m .O
/
..,i So Ms. King would no longer slip when she got out of bed, we decided to place nonslip strips on the floor along the length of the bed. It was important to him to stand while bathing. A vertical nonslip grab bar contrasted to the wall solved the shower-rod problem.
These solutions were fine at home, but Mr. Fox likes to travel. I advised him to get a portable bathtub-rim grab bar to take with him when he visits his children.
-z
In the bathroom, a raised toilet seat with armrests was installed, and nonslip strips were placed on the floor in front of the toilet.
•
_,]k==._
A horizontal grab bar installed along the side wall and a slip-resis-
We agreed to add a nonslip mat to the bathtub surface--another item Mr. Fox could take with him when he travels.
Geriatric
Nursing
November/December
1989 283
hold onto for support. Ms. Ludwig's children donated the stool and I observed her using it safely, though I would have preferred one with handrails and wider steps.
¢
I also suggested nonslip strips for the floor near the sink so Ms. Ludwig Would not risk slipping on spilled water.
Mr. Fox's sitting-down problem was solved by installing a raised toilet seat: and a nonslip grab bar mounted at a 45-degree angle on the wall next to the toilet. When considering a toilet riser, choose one that is sturdy enough to provide good support. The type of grab bar and height of placement depends on the person's size, degree of disability, and the structure of the bathroom. A person with hemiplegia, for example, cannot use a bar placed on his dysfunctional side, A good alternative to a wall-mounted bar is the double-type grab bar that attaches directly to the toilet seat.
Resisting Remodeling It's not uncommon to encounter resistance as you propose changes in a person's home. To help the elder adjust, make sure he understands why his environment needs to be modified. Mr. Fox, for example, resisted making the changes at first, perhaps because he did not want to be reminded of his frailty. Once he understood how the devices could enhance his safety, he agreed. Another strategy for getting the person to make the needed modifications is to invite him to make decisions along the way, and only recommend devices, appliances, and supplies that he can afford and obtain easily.
,RIBKY
'REACN-G.. Ninety-year-old Mary Ludwig had fallen repeatedly in her kitchen, in part because she tried to stand on an unstable stool to get objects down from high shelves. Shelves placed between a person's eye and hip levels (between 16 and 63 inches from the floor) are reasonably safe. Because space limitations made rearranging Ms. Ludwig's shelves impractical, we decided to replace the unstable stool with a safe o n e - with nonslip treads and a back to
References
A hand-held reacher device eliminated Ms. Ludwig's_need to use the stool for getting lightweight objects offthe shelves.
2 8 4 G e r i a t r i c N u r s i n g N o v e m b e r / D e c e m b e r 1989
!. Campbell, A. J., and others. Falls in the old age: a study of frequency and related clinical factors. Age Ageing 10:264-270, Nov. 1981. 2. National Safety Council. Accident Facts, Chicago, The Council, 1983. 3. Combs, K. L. Preventive care in the elderly. Am.J.Nurs. 78:1339-134 I, Aug. 1978. 4. Morfitt, J. M. Falls in old people at home: intrinsic versus environmental factors in causation. Public ttealth 97:115-120, Mar. 1983. 5. Prudham, D., and Evans, J. G. Factors associated "with falls in the elderly: a community study. Age Ageing 10:.141-146, Aug. 1981.