Module 6 : Safety and Independence

Identify an area of the home where all important information can be posted.  People often use the kitchen. Most emergency workers such as firefighters and police officers are trained to go to the kitchen and check the inside and outside of refrigerators for emergency information.

Make sure that all family members and anyone who routinely comes into the home knows where the communication center is, including neighbors, home health care workers, and others.

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• Hang a bulletin board or marker board.
• Post emergency medical and personal information at the Communication Center. Open this link to a handout to record the information.
  Important Medical and Personal Information (PDF).  This information includes a listing of
• Legal name of care receiver.
• Emergency contact information.
• Physician`s name.
• Medications person is taking.
• Insurance information.
• Emergency personnel also often look for the Vial of Life stored in the refrigerator.
• Use a copy of the completed Important Medical and Personal Information (PDF) document.
• Fold the list into fourths, roll it, and slip into an 80 dram medicine vial.  Use of the lid optional.
• Place this medicine bottle into the butter keeper of the refrigerator.
• Place a note at the Information Center or on the Refrigerator about the location of this information.
• Contact local pharmacies or ask physicians about Vial of Life containers or sources where you can obtain them.
• Keep a current photo of the older adult available for use in emergency.
• Keep first aid kit close by.
• Alert nearest fire station of individual’s needs prior to need.
• Display calendar and clock easily visible.
• Position phone near Communication Center.
• Store phone directory near Communication Center.
• Post medical and other appointments.
• Post other important information such as the location of fire extinguishers.
• Provide Post-it notes, pens, and pencils by Communication Center.

• To ensure Fire Safety hang or store fully charged fire extinguishers in sight and make sure that everyone knows how to use it.  (See detailed fire safety precautions below)
• Identify escape routes and make sure that everyone knows where they are.
• Keep first aid kit close to the Communication Center.
• Develop plans for weather and fire emergencies.
• Install outside lighting to increase safety and security.
• Use emergency response systems such as Life Line, Voice Care or others
• Modify to provide 36″ doors for wheelchair clearance.

Fire Safety

• Encourage the family member to call 9-1-1 first even before he or she calls family members.
• Plan at two escape routes out of each room if the person is able to move on their own.
• Teach the family member to stay low to the ground when escaping from a fire.
• Teach the family member never to open doors that are hot. In a fire, feel the bottom of the door with the palm of the hand. If it is hot, do not open the door. Find another way out.
• Install smoke detectors. Clean and test smoke detectors once a month.
• Change batteries at least once a year.
• Keep a whistle in each bedroom to awaken household members in case of fire.
• Check electrical outlets. Do not overload outlets.
• Purchase a fire extinguisher (5 lb., A-B-C type).
• Have a collapsible ladder on each upper floor of your house.
• Consider installing home sprinklers.

• Finding out which disasters could occur in your area.
• Asking how to prepare for each disaster.
• Asking how you would be warned of an emergency.
• Learning your community`s evacuation routes.
• Asking about special assistance for elderly or disabled persons.
• For example, for older persons living in the 14 counties around the Dallas/Fort Worth, Texas Metroplex each county has an emergency plan coordinated with the local emergency plan and elder service providers.

Emergency Checklist

• Discuss what the care receiver is to do in case of an emergency or disaster such as Calling 9-1-1.  Notify local fire and police departments about an older adult with health problems.
• Discuss what to do about power outages.
• Draw a floor plan of the home. Mark two escape routes from each room.
• Instruct household members to turn on the radio for emergency information.
• Have at least two people to contact in case of emergency and place at the Communication Center.
• Keep family records in a water and fire-proof container.

Prepare a Disaster Supplies Kit

Assemble supplies you might need in an evacuation. Store them in an easy-to-carry container such as a backpack or duffle bag to.

Include:

• Special items for the older adult including a list of medications and emergency phone numbers.
• A supply of water (one gallon per person per day). Store water in sealed, unbreakable containers. Identify the storage date and replace every six months.
• An extra pair of glasses.
• A list of family physicians.
• A list of important family information; the style and serial number of medical devices, such as pacemakers.

Go to the American Red Cross Emergency Preparedness.

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• 1 of every 3 adults age 65 or older falls each year.
• Falls are the leading cause of injury deaths among people age 65 and older. In 1997 (the most recent data available), about 9,000 people over the age of 65 died from fall-related injuries.
• Of all fractures, hip fractures cause the greatest number of deaths and lead to the most severe health problems. There were approximately 340,000 hospital admissions for hip fractures in 1996 (the most recent data available).
• Falls account for 87% of all fractures for people age 65 or older. Falls are also the second leading cause of spinal cord and brain injury among older adults.
• Among individuals age 65 and older:
• 60% of fatal falls happen at home.
• 30% occur in public places
• 10% occur in health care institutions.
• In addition to the physical and emotional trauma caused by falls, in 1994 (the most recent data available), falls among people age 65 and older cost an estimated $20.2 billion.

• History of a previous fall
  People who have fallen previously are far more likely to fall again. Older adults with a history of falling should also have a careful physical work-up to identify treatable problems.
• Dizziness
  Dizziness also raises an older adult`s risk for falling. Dizziness may be due to a variety of causes such as medicines, heart arrhythmias, getting up too quickly, or inner ear problems. Ask about feelings of dizziness.
• Drop attacks
  Drop attacks are sudden spontaneous falls while standing or walking, with complete recovery in seconds or minutes and no loss of consciousness. A person with a history of drop attacks is at very high risk for falls and injury.  Drop attacks can be caused by heart arrhythmias (syncope), seizures, or inner ear disease. In most cases, however, the cause of a drop attack is never identified.
• Balance and gait
  Muscle atrophy (smaller and less strong) is one common reason for balance and gait problems. This can reduce the mobility and balance needed to maneuver and continue tasks of daily living.
• Neurological and musculoskeletal problems such as Multiple Sclerosis, Parkinson`s Disease,  stroke, Arthritis, and Osteoporosis.

• Medications may raise the probability of falling for a number of reasons.
• Interactions of multiple drugs leading to increased confusion, sedation, or dizziness.
• Less ablility process and detoxify medications than when someone is younger.
• Additionally, reactions to drugs may be altered by the presence of more body fat and less muscle mass that are common as people age.
• Medications may also stay in the body longer because of decreased kidney and liver function that may produce dizziness, drowsiness, unsteadiness, confusion, blurred vision, slowed reactions, and fatigue for an older adult.
• Self-treatment may also produce problems leading to increased fall risk.
• Not buying medications or sharing medications to save money on prescriptions.
• Herbal remedies may also be used instead of, or in addition to, prescribed medications.
• Going to Mexico and purchasing medicines for self-treatment without the knowledge of the physician.

• Diuretics (water pills) or laxatives increase the urgency to get to the bathroom
• Digitalis can slow the heart so much that dizziness results
• Blood pressure medication can produce dizziness, especially when changing positions from lying or sitting to standing

• Sedatives can decrease judgment and reaction time.

• Confusion can result in falls when a person is unaware of his/her surroundings and unable to think clearly or react fast enough to catch him- or herself. Causes can include Dementia including Alzheimer`s Disease, Delirium,  or depression. ( See module on Chronic Illlness for more information on these conditions).
• Visual impairments causing less ability to see contrast in objects, such as stairs, and details.  (See module on Sensory Loss for more information).
• Fear of falling can create tremendous anxiety,  particularly among those who have fallen before or know someone who has. Families may become overly protective and attempt to restrict their older relative`s independence.

• Environmental hazards such as slippery surfaces, uneven floors, poor lighting, loose rugs, unstable furniture, improper bed height, and clutter.

• Exercising, particularly a combination of aerobic, strength, and flexibility-type exercises. One example of exercise shown to improve balance among older adults is Tai Chi, a form of Eastern movement sequences. (For more on exercise see the box entitled “Important types of exercise” below.)

Types of exercise

Maintaining a regular exercise program can improve strength, balance and coordination. Making and maintaining these improvements requires three important types of exercise that can be done individually, as a single routine/program, or through daily tasks.

• Participating in balance training such as weight shifting and learning to anticipate body adjustments to improve gait or balance.  (Ask the physician about this after he or she has ruled out a medical cause).
• Reduce fear by
• Learning ways to avoid falls through use of assistive devices such as canes and walkers; wear safe footwear, and modify the environment.
• Learning ways to get up as taught by a physical therapist or other health care provider.
• Have an emergency response plan – Have a neighbor, friend, or relative who will call daily to check on the person daily or use a commercial personal emergency response system such as Life Line.
• Remove hazards from the home and everyday environment  to provide easier movement.

Adapting The Home Environment to Reduce Fall Risk

Each room in the home can be adapted and modified to create a safer environment and reduce the potential for falls. Below are some general suggestions.

Bathroom
The bathroom is the room in the home where most falls take place. Problems occur due to difficulties getting in and out of the tub, on and off the toilet, difficulty seeing in dim lighting, slippery or wet surfaces, and dizziness standing at the sink. With minor modifications, the bathroom can become protected.

Modifications include:

• Installing grab bars or side bars around toilet, tub, and sink areas. (Note: vertical bars are often easier to catch in case of a fall than those installed horizontally.)
• Providing a bath bench for the tub, hand-held shower nozzle, and rubber mat for the shower.
• Providing nonskid rugs or mats.
• Providing adequate lighting.
• Installing a raised toilet seat (an extension that is placed on the toilet seat and raises the height of the seat).
• Providing a stool for sitting at the sink/vanity area.

• Adjustable height hospital bed.
• Flashlight/night light by the bed. (This light should also be attachable to a walker or cane.)
• Remote control light switches can be a real help if you need to rise in the night (available at hardware or electronics stores).
• Nonskid wax or no wax on the floors if it is not carpeted.
• Secured thresholds with metal stripping, tacked down, or striped with tape to make the change noticeable.
• Make sure edges of rugs and carpets are secure. Remove throw rugs completely.
• Dense, low-pile carpeting offers a safer floor covering and reduces tripping.
• Place assistive devices such as wheelchairs, walkers, or canes next to the bed for easy access and use at night.
• Place clothes or other belongings in easy to reach spaces (shelves or drawers at reachable height), and lower rods in the closet if necessary.
• Step stools with sturdy handrails are a must . Do not stand on a chair to reach objects that are above your reach (don`t strain to reach objects).
• Remove caster wheels from furniture, not only in the bedroom, but throughout the home to prevent the furniture from rolling.
• Keep the path from bed to bathroom clutter free.
• Consider a bedside commode or urinal if you are far from the bathroom and awaken nightly to use the restroom.

• Moving obstructing furniture in order to create a clear walking path that is free of barriers.
• Ensuring that extension cords are anchored to walls, under sturdy furniture, or taped down.
• Installing light switches that are illuminated is helpful, as are touch sensitive or voice activated switches.
• Replacing swivel chairs. Chairs at inadequate height may be adjusted by adding a platform to the base of the chair. Automatic lift chairs may be helpful.

• Installing handrails on either side of the steps. Handrails 2-3 inches from the wall permit good hand grasp.
• Applying nonskid surfaces to steps can prevent slipping.
• Applying a piece of brightly colored tape to the bottom and top step signal the beginning and end of the stairway.
• Ramps and elevators can be used for those who are unable to get up and down the steps safely.
• If unable to use a walker, cane, wheelchair, or other mobility aid on the steps, provide a second aid at the top or bottom of the steps.

• Laundry – Providing a stool for sitting on while getting clothes out of front loading washers and dryers; a table to sit at while folding laundry; a bag for carrying up and down stairs; as well as a cart to roll between working areas. If needed, utilize a professional laundry service or offer to help with the laundry.
• Housekeeping – Cleaning up spills immediately to avoid a fall on slippery surfaces; keeping the floor uncluttered; using no-bend dust pans and mops, or using a lightweight all-surface sweeper/vacuum. If needed, consider using a professional cleaning service.
• Mail – For easy access, installing a mailbox, mail slot, or mail basket on or next to the front door. Ask the newspaper carrier to place items in a specific location for easy accessibility.
• Doors – Installing lever-type door handles instead of knobs. Automatic door openers are also available (check hardware or electronics stores).
• Windows – Install a lever and crank system window. Remote control options are also available (consult hardware or electronics store).
• Telephone –
• Keeping the path to the phone clear.
• Using a cordless phone (and possibly optional headsets)
• Informing friends, family members, and neighbors  to allow 10 rings to allow the person time to answer the phone.
• Using answering machines, telephone company messaging systems, and call-back options.

• Arranging a trip to an eye doctor once a year to check vision and adjust or replace ill-fitting glasses and screen for cataracts or glaucoma.
• Adding additional lights to avoid tripping over objects that are not easy to see.
• Putting night lights in the hallway, bedroom, and bathroom.
• Using multiple lamps (three 100 watt bulbs are more functional than one 300 watt bulb).
• Outdoor lighting is just as important as indoor lighting. Use all outdoor lights available when possible. Sensor lights that turn on whenever there is movement may be a good idea, as well.

• Avoiding self-treatment.
• Taking a list of all over the counter (OTC) and prescription drugs to each doctor`s visit.
• Reviewing medications with the doctor or pharmacist often.
• Discussing with the doctor effects of taking different types of medicines at the same time in order to evaluate possible interactions between the medicines.
• Telling the doctor about any problems with side effects or with taking medications as directed.

• A physician recommends that the person no longer drive.
• Eyesight worsens and cannot be corrected to a legal driving level due to an illness or decreasing vision.
• The person has traffic accidents and citations due to slower response time, vision problems, or medication problems.
• The person loses their license due to accidents, citations, or driving while intoxicated.

The most effective approach to limit or stop driving involves progressive steps and a combination of strategies that fit the family’s circumstances, resources and relationships. Driving is best reduced over time rather than all at once. Families can help by finding ways to let others drive or reduce the need to drive. Caregivers and families should be sure to address the important social needs of the person that were met through driving. When possible, include the older adult in planning ahead to limit driving.

In some cases, the older adult themselves may recognize limitations and may begin to limit driving themselves.   Fortunately, in many cases, people with dementia begin limiting where and when they drive.

Options Other Than Driving

• Asking friends and relatives to drive the person to appointments, shopping, and other activities.
• Letting others do more of the driving over time until the person no longer drives at all.
• Using public transportation such as buses or services provided through senior centers, the Red Cross Wheels Program, and others. This option may work for people with mild dementia who live in urban areas and are already accustomed to using these methods. Public transportation may become too complicated for those with advanced dementia.
• Using Taxis when the person can afford it if there are no behavioral problems or dementia that might interfere with the person`s ability to tell the driver where they are going. Some taxi companies will set up accounts for family caregivers so a person with dementia has easy access to transportation without worrying about payment.

Co-Piloting Is Not The Answer

Some caregivers act as co-pilots to keep a person driving longer. The co-pilot gives directions and instructions on how to drive. This strategy may work for a limited time. But in hazardous situations, there is rarely time for the passenger to foresee the danger and give instructions, and for the driver to respond quickly enough to avoid the accident. Finding opportunities for the caregiver to drive and the person to co-pilot is a safer strategy.

Reduce the Need to Drive

Resolving the driving issue involves not only substituting other drivers or modes of transportation, but also addressing the reasons people want to go places. Caregivers can look for ways that others can help meet the physical needs of the person, such as:

• Arranging to have prescription medicines, groceries and meals delivered, reducing the need to go shopping.
• Having hairdressers make home visits.
• Scheduling people to visit regularly, either as volunteers or for pay.
• Arranging for friends, neighbors or church members to take the person on errands or to social or religious events.

Balancing the Social Needs

While caregivers consider ways to reduce the need to drive, it’s also important to remember the social benefits the person derives from interacting with others. As one person reflected: “When I went to the bank or drug store, I would stop at the local bakery for some pastries. Sometimes it would take most of the morning because I could take my time and chat with different friends along the way.” If caregivers consider the social needs that were met through driving, the transition to not driving will be more successful.

• Where does the person go? When and how often (e.g., grocery store, barbershop, appointments, library or religious activities)?
• What services can be brought to the home (e.g., groceries delivered or in-home barber)?
• Who can offer to provide transportation (e.g., neighbors running errands, relatives for doctors’ appointments or a friend going to religious services)?
• Can visits from family or friends include outings (e.g., eating out or going to a park)?

Take the Keys as a Last Resort

Taking away the car keys or a driver’s license, or selling or disabling the car should be a last resort. To the family member, such actions may create fear of losing independence, seem extreme, disrespectful and perhaps even punitive.

Even though the person may agree to limit or stop driving the person may ignore, undo or maneuver around the agreement by driving without a license, enabling the disabled car or buying a new car to replace one that was sold. As one person with dementia noted, “If they disabled my car, I would call someone to fix it.”

Once a person has stopped driving, caregivers must decide whether taking away the keys, license and car will help the person adjust or make it more difficult. Some caregivers remove the keys or the car from sight to avoid having the driving issue resurface. Others allow people to keep their keys, car and license to help them maintain a sense of dignity. Some people stop driving but carry their license as photo identification.

To make transporting a loved one a successful venture, follow these steps:

• “The slower you go, the faster things get done.”
• Give yourself and your loved one enough time.
• Be patient.
• Ask for help and new ideas.
• Take your cues from you loves one`s behaviors.
• Try to see things from your loved one`s perspective (it`s hard for him/her to see it from yours).
• Be prepared with an activity to offer during the ride.
• Be mindful of your own body language.
• Try and keep calm-especially your tone of voice.
• Break tasks down into small steps; reintroduce steps when necessary.
• Try different approaches on different days to see what works.
• Seat your loved one with Dementia in the back seat–passenger side–and be sure to have the child safety lock on.
• Seat your loved one who had a stroke with his /her affected side nearest the door (for example, left sided weakness; left of driver`s side back seat; right sided weakness: passenger side front or back.
• Use good body mechanics.
• Don`t give up.
• Try and try again; each try is a step toward success.

Source: “Transportation Tips for Caregivers,” Easter Seals National Headquarters, 2002.

The physician and health care providers will play a key role in helping to determine the level of independence that the care receiver needs.  For some older adults the final decision to move from their own home is when a physician says that it is not in the person`s best health and safety interests to live alone.

Home repair, rehabilitation and modification.

• Winterization and fuel bill
• assistance.
• Rent subsidies.
• Property tax reductions, deferrals, and exemptions.
• In-home and community-based services.

Although you can ask your local resources for information about care managers and case managers.

• Discuss the situation with the care receiver.
• Plan with, and not for, the care receiver.
• Evaluate the current living arrangements.
• Consider individual assets, needs and interests.
• Make a decision on a trial basis.
• Re-evaluate the situation.
• Makes changes as necessary.

• Be realistic.
• Thoroughly evaluate the situation.
• Get professional medical advice regarding health and mental condition and capacity.
• Consider your needs and those of your family.
• Make a decision on a trial basis.
• Re-evaluate the situation.
• Make changes as necessary.
• Continue to involve the care receiver as much as possible.

• What is the care receiver`s preference?
• Does the person`s health and well being match their preference?
• Can the person move in with other family members?
• What will the impact of this arrangement be on other family members?
• Can the person move in and share a home with another person?

• Retirement communities or retirement villages.
• Assisted living.
• Congregate housing or senior housing.
• Shared housing or group living.
• Foster care.
• Board and care homes.

• 600,000 to 1 million are in assisted living
• Less than 1% of older adults live in a nursing home.
• 1.8 million total nursing facility beds; 17,000 total facilities
• 43% of those people who turned age 65 in 1990 will enter a nursing home at some time during their life.
• 1 in 3 will spend three months or more in a nursing home
• 1 in 4 will spend one year or more in a nursing home
• Only about 1 in 11 will spend five years or more in a nursing home.

• Each person lives in his or her own apartment.
• Emergency staff is available 24 hours a day.
• Recreation activities are offered.
• Meals, housekeeping, medication management and nursing assessment are provided.
• Transportation to and access to medical service available.

Currently no national control or monitoring of the quality for nursing facilities exists but they are regulated by state licensing and health and other regulations.

• Providing assistance with useful advice on
• Finding a good nursing home
• Assisting with admissions
• Investigating complaints
• Monitoring quality of care issues
• Assisting with financial information
• Provide information about Medicaid eligibility
• Advocating for the rights of residents.

• “Dropping by” unannounced and observe the facility and residents and staff interaction.
• Finding out who owns the facility and review the owner`s financial status.
• Asking for a copy of the contract and review it with an attorney or financial advisory.
• Not rely on verbal promises.
• Make sure the contract is geared to the resident’s individual needs.
• Reading the state inspection report on the facility.
• Read all the rules and policies of the facility that are not in the contract.
• Ask to see the facility`s license.

The transition from living in a home or other facility can be stressful on the care receiver and the family.  Because a family member is in a facility does not mean that the caregiver role is ended.  The role changes to that of supporting your loved one; monitoring care, and advocating for the care receiver.

Family caregivers do everything that they can to ensure the highest quality of care. They also need to do everything that they can to make sure that the family member is as content and at peace with the situation as is possible.

• Visiting regularly.
• Phoning often.
• Monitoring all aspects of care about medications, behaviors, socialization.
• Observing the facility and interactions between staff, with the family member and with other residents.
• Building a partnership with the facility staff including care providers and administrative staff.
• Communicating pleasantly but assertively when you question care.