Safety and Independence

Learning Objective
After completing this module, you will be able to:

• Assess and modify home and environment for safety
• Learn how to set up a communication center in the home
• Know ways to deal with issues related to driving and older adults
• Identify ways in which older adult become victims of fraud and scams and how to lower the risk

Index/Content of this Module 

In this module you will learn techniques to assess the home and environment of your family member for health and safety risks. You will also learn room by room changes to make to create a safer environment. You will also learn some of the common ways that older adults become the victims of fraud and scam and ways to avoid them. You will learn how to evaluate living arrangements and the level of independence that your family member is able to maintain.

Click on a topic below to go to that area of the page:

1  Assessing the Environment and Making Changes to Ensure Safety
2  Setting up a Home Communication Center
3  Home Safety
4  Fall Prevention
5  Home Modifications for People with Impaired Mobility
6  Transportation and Driving
7  Living Arrangements and Housing Options
8  Resources
9  Sources 

Assessing the Environment and Making Changes to Ensure Safety  
Maintaining a safe environment is important in not only preventing injury but also ensuring independence for older family members.  A safe environment includes removing obstacles that could cause falls or injury; providing enough light; installing lever door handles or other simple adjustments.  A safe environment also includes helping the older adult not become a victim of frauds or scams.


Click here for our home safety check list.

 The best conditions for access include:

The least amount of stairs possible.
At least one sturdy railing.
Step depth as deep as possible to be able to safely use a walker on them.
Step height of 6 inches or less.
If there is a ramp, the legal elevation is 1 foot of ramp for each 1 inch of height you have the ramp. If you have to extend a ramp up a 2 foot height, for instance, you will need 24 feet of ramp. This legal ramp requirement assumes that a person will be negotiating it alone in a wheelchair.
Make sure steps or ramp have non-slip surface.

Adapted from Assessment and Intervention in the Home Environment, Texas Cooperative Extension, The Texas A&M University System, Fall Prevention for the Home. 

Setting up a Home Communication Center  

Having one central communication center in the home of a care receiver is important in ensuring that information is easy to find and use on a routine basis. This communication center becomes critical when there is an emergency.

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.

Communication Center · 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 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.

Keeping emergency information updated is essential!  Review often and use the form linked above to keep the information current.

Notify local public safety officers, both police and fire departments, if someone in the home has a chronic illness or is medically fragile. These professionals appreciate knowing this information should a call from this home come in. Some communities have a `fragile persons` registry. Check with your local city administrative or emergency offices.

Adapted from information developed by Chris Kyker, LMSW, Abilene, TX ckyker@aol.com 

Home Safety  
Assess the care receiver`s home and make modifications, as needed.

Basic Safety Measures
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.

Emergency Preparedness  
Checklist of the American Red Cross and Federal Emergency Management Agency

The next time disaster strikes, you may not have much time to act. Prepare now for a sudden emergency. Discuss these ideas with your family, then prepare an emergency plan.   Post the plan where everyone will see it — on the refrigerator or at the Communication Center. Contact your local emergency management or civil defense office and American Red Cross chapter to find out local information including:

· 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 website for more details at <http://www.disasterrelief.org/Library/Prepare/emerprep.html>  [link opens in a new window]   Adapted from Health Hints  Health Education and Rural Outreach (HERO) Texas Cooperative Extension and the Texas A & M University System,  Health Science Center School of Rural Public Health Volume 5, Number 2 – February, 2001

Fall Prevention  
Falls among older people are an important cause of injury, disability, and death. Falls are also an important indication of declining abilities.  Reducing fall risk requires careful assessment of the person who has fallen and   his or her home and environment. Issues surrounding falls are complex. Reducing fall risk requires careful assessment of the person who has fallen, as well as his or her surrounding environment. Once the risks are identified, actions must be taken to reduce the risks such as:

• Ensure adequate lighting.
• Eliminate obstacles such as throw rugs and electrical cords.
• Install handrails on stairs and grab bars near toilet and bathtubs.
• Keep eyeglass prescription updated.
• Determine possible side effects of medications.
• Do weight training with 3-5 # weights to improve strength.
• Get enough calcium and vitamin D (check with doctor about drug interaction or other precautions):
• 1,500 mg for women
• 1,200 mg for men
• 800 units of vitamin D

Impact of Falls
According to the Centers for Disease Control and Prevention, in the United States:

· 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:  o 60% of fatal falls happen at home.
· 30% occur in public places  o 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.

Home Modifications for People with Impaired Mobility
People with impaired mobility may require additional changes in the home environment:

• Assess for wheelchair/walker barriers; i.e.,
• Carpet (remove pad if wheelchair or Hoyer lift is used).
• Bathrooms (retrofit for wheelchair).
• Buy portable sound monitor ($40) to place by individual’s bed.
• Have access to recliner for bedfast person or a recliner with a lift.
• Install ramps: • Wooden ramp for entrance to home.
• Steel ramps from house to attached garage area
• Usually about 2 ½” at highest end, slanted 14” long by 34” wide.
• Consider installing an outside deck for someone sitting in a wheelchair.

Transportation and Driving  
Older adults need to be able to drive as long as it is safe for them to do so.

When and How to Limit Driving 
Driving may need to be limited or stopped completely to ensure safety when any of these factors are involved:
• 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.

Initiate a conversation about options for when the person must limit and eventually stop driving. Respect the individual’s dignity by focusing on the condition that is causing problems with driving, not the individual, as the reason for driving restrictions. Discuss matters and agree on a course of action before a crisis and while the loved one is capable of making decisions.  Not everyone will grant advance permission for someone to stop him or her from driving and it does not ensure that the person will comply even if a decision is made.

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.

Progressive Steps to Limit Driving 
• Driving shorter distances.
• Driving on familiar roads.
• Avoiding difficult unprotected left-hand turns.
• Avoiding driving at night, in heavy traffic, on heavily traveled roads or during bad weather.

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.

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. The following questions can help families and caregivers identify the social needs and develop ways to address them to ease the transition to not driving.

· 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)?

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.

Transportation Tips for Caregivers
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.

Living Arrangements and Housing Options  
Maintaining the highest level of independence is the goal for all older adults. The level of independence will depend on health and financial resources but a factor must include the choice and preference of the care receiver!  Changes may need to be made on an ongoing basis as these and other factors change.

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.

Options may be available to help maintain independence. Local city and county governments and the Area Agencies on Aging may provide help with services. Family caregivers will need to contact individual community resources.

Start by contacting the local access and referral lines such as United Way`s First Call in Tarrant County or the Community Council of Greater Dallas Helpline.

Check the local phone books or call a United Way agency to find other phone numbers. Other sources of information may be health care providers and hospital social workers who know about resources through other patients, caregivers, and work in the local community.

Services that may be available include
· Home repair, rehabilitation and modification.
· Winterization and fuel bill assistance.
· Rent subsidies.
· Property tax reductions, deferrals, and exemptions.
· In-home and community-based services.

Care managers may be available in some communities through the local Area Agencies on Aging can help family members evaluate the options and make informed decisions saving time and resources as well as making decision making easier.

In addition, paid geriatric case managers or care managers can provide invaluable assistance.   Although you can ask your local resources for information about care managers and case managers, you can also go to this link to learn about care managers and how to find them:.

When Home is No Longer an Option
When chronic health problems prevent the older adult from being able to safely live at home and manage the complex responsibilities of maintaining a home the person and family members have often difficult decisions to make.

· 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.

When Decisions Have to Be Made Without The Care Receiver 

· 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.

Assess the Options for Long Term care.

· 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?

Click here http://www.familycaregiversonline.com/static/elder_housing_options.html for our senior housing options resource links page.

Despite many stereotypes only a small percentage of older adults live in nursing homes.
Other options are available and may include:
· Retirement communities or retirement villages.
· Assisted living.
· Congregate housing or senior housing.
· Shared housing or group living.
· Foster care.
· Board and care homes.    


Resources for Caregivers

Call
•  2-1-1 throughout Texas. Provides information and access to health and human service information for all ages
•  1-800-252-9240 to find local Texas Area Agency on Aging
•  1-800-677-1116 – Elder Care Locator to find help throughout the U.S.

Online
•  Online education, resources, links, frequently asked questions
•  Benefits Check-up for an online way to determine benefits for which someone qualifies.

To schedule a caregiver presentation for your church, business, library, civic group, or other organization call your local area agency on aging or contact us

Assistance available through the Area Agency on Aging for caregivers:
•  Information and referral
•  Caregiver education and training
•  Caregiver respite
•  Caregiver support coordination
•  Case management
•  Transportation assistance 

Assistance available through the Area Agency on Aging for persons age 60 and older:
•  Benefits counseling
•  Ombudsman – advocacy for those who live in nursing homes and assisted living facilities
•  Home delivered meals
•  Congregate meals
•  Light housekeeping

Note:  Not all services are available in all counties. Call the Area Agency on Aging for information about a specific community.

Sources

Written by:  Zanda Hilger, M Ed, LPC, Family Caregiver Education, Area Agency on Aging, Revised by Zanda Hilger and Betty Purkey 2009

Includes other materials written or adapted from:
As People Grow Olderrevised by Jane Oderberg and Sue Smith, 2000
•National Family Caregivers Association

Permission is granted to duplicate any and all parts of this program to use in education programs supporting family members caring for elders.

This program is one module of a comprehensive caregiver education program provided by the area agency on aging.