Creating Functional Homes for Dementia

Introduction

• Occupational Profile (At a Glance)
  • New York to Arizona
  • Russell Sage College
  • Nova Southeastern University
  • University of Southern California
  • Business Owner
  • Adjunct Instructor

I am originally from Upstate, New York. I did a lot of different schooling over the years, but I really did have an interest in working with people in the community. You can see that my occupational profile is pretty unbalanced as I am a business owner, and I recently started as an adjunct instructor at a local university here in Arizona. If I were to improve my occupational profile, I would get back to hiking, running, and spending some time outdoors. I love OT and all that we have the opportunity to do, especially serving seniors with dementia. 

Today, we are going to go over a lot of information. I hope by the end, you will be able to identify in-home functional design concepts to improve the quality of life for those living with dementia. This will be in a variety of contexts, not just in their homes. I want you also to list at least three factors to consider when assessing a home for someone living with dementia and their family and be able to recognize the value occupational therapists offer in decreasing caregiver burden when designing for dementia in the home context.

Model for Guiding Practice

• Considering the Person BEFORE the diagnosis
• Incorporate the Physical and Social Environment
• Occupations living with dementia

Considering the Person Before the Diagnosis

As occupational therapists, we often use a practice framework to help guide us. There are also many other models and theories. When you are looking at the person, the family, and the environment, you want to identify how that relationship correlates with each other to really optimize that person's function.

I chose the Person-Environment-Occupation (PEO) model. However, there are a lot of different ones that we could justify using and more than one that we could integrate to really serve this population.

When using the PEO model for clients with dementia, the service providers and caregivers interacting with the individual and their family become so focused on the current condition and symptoms associated with dementia that the person before the diagnosis gets forgotten. The individual can feel a sense of loss of what they have lost and what they cannot do, especially in the early stages. And, the family is usually preoccupied trying to cope with this new person.

Thinking about who the person was before the diagnosis can really create a much more successful outcome for occupational therapy intervention and the creation of functional spaces. This is true in the early interactions and context when working with these families, whether working with them in assisted living, independent living, or out in the community.

Incorporate the Physical and Social Environment

Next, we want to consider the physical and the social environments. People tend to stop doing the things they enjoy doing, become less active, and stay at home more frequently because they are embarrassed. Their social environment and their physical context change, and that can, of course, lead to isolation, depression, and increased risk for falls.

Occupations Living With Dementia

What are the occupations of the person that is living with dementia? Do they attend a social program? Do they attend church events? Are they engaged with their family, or are they staying at home and isolated? Are they watching TV and doing more sedentary activities? Of course, the current situation with COVID is negatively impacting this. These are the types of questions and considerations you will have during your initial evaluation if you are not working in a home modification niche.

Quick Facts on Dementia

There are 16 million Americans that are unpaid caregivers to loved ones living with dementia. They provide care for their loved ones to increase their quality of life or maintain their safety within their home. These caregivers are not skilled or trained. Many families are doing what they can just to get by. This can certainly impact the safety of the individual. They may be spending nights alone. They may frequently call safety emergency services (911) due to paranoia. There are also many risks when family members do not know exactly what to look for. They may know that their loved one or friend is confused, but they may not be well-versed in how to help. Many things can be addressed. Are there smoke detectors? Do they have a risk of wandering? Is cooking unsafe as they forget that the stove is on? This is more than forgetting names and faces. Occupational therapists can assess and design a comprehensive program to help keep this individual and their family safe.

One in three people dies in America from Alzheimer's or dementia-related illness. The rates are quickly increasing. Currently, more than 5 million Americans are living with Alzheimer's. Wyoming, Alaska, and Arizona will have the highest prevalence of dementia by 2025. It is an area of concern and has already surpassed cardiovascular disease and cancer.

There is a lot of room for occupational therapists to collaborate with medical teams and design-build teams.

Dementia Friendly Spaces

• Sensory-friendly
• Accessible
• Meaningful
• Adaptable
• Outdoor Access
• Inclusive

When you first think of a dementia-friendly space, you might think of the good lighting in a skilled nursing facility or a memory care unit. In addition to lighting, they use many different strategies to keep individuals safe, but certainly, more can be done in these long-term care and assisted living settings and in clients' homes.

Sensory-friendly

Creating a sensory-friendly environment does not just mean stimulating the senses. It means maximizing the senses that the individual has to help manage behaviors and elicit engagement in everyday occupations. If somebody tends to be reactive to certain sounds or smells, occupational therapists can help identify what is happening and at what time of day. OTs can work closely with the individual and their family/caregivers to get a good idea of when behaviors like agitation or frustration may worsen.

We can also look at vision. We want to make sure there is natural lighting to minimize glare and any shadows. When they show signs of paranoia or confusion, they may be seeing a reflection or a shadow. We need to be mindful of how their vision and spatial awareness change. 

We also want to look at the auditory sensation in the environment. Are they paranoid or getting agitated because of loud or repetitive noises? For example, a squeaky cabinet door can set somebody off. Another example is that their bedroom may be located next to the garage, and every time the garage door opens and closes, this disturbs their sleep. As a result, they may be up until 2:00 or 3:00 in the morning.

There are a lot of details that we can identify to help caregivers. Managing the environment can improve a client's sleep quality, improve appetite stimulation, calm their mind, and decrease some of that stress response.

Accessible

Accessible environments may have wheelchairs, walkers, adaptive equipment, and durable medical equipment. We also want it to be cognitively accessible. We want to help improve an individual's ability to participate in everyday activities. Often, families take away things like keys or the person's responsibility for managing things at home. However, if we create accessible spaces, this could allow the individual to continue participating in whatever capacity they still have. We can look at lighting and the physical accessibility of the space via intuitive design. For example, the light switches can have automatic timers, or there could be reminders set up to alert them to lock the doors or feed pets. Technology and floor plans can help them to be a little bit more successful.

Meaningful

Making things meaningful is one of our favorite things as occupational therapists. Unfortunately, in some situations and settings, we cannot always focus on meaningful things due to constraints. However, in dementia-friendly spaces, we have to try to make the tasks meaningful. I have a client that does really well with one caregiver. They eat their meals, take a shower, get dressed, and can overall perform their daily routine. They are calm, and everything proceeds in a pretty streamlined fashion. Are they independent? No. However, this caregiver employs a different approach when engaging them in different tasks. They are not asking them things that the individual is culturally not aligned with or asking them to do tasks that they had no interest in before dementia. This could be anything from the actual structure of their day. For example, they may have liked to wake up in the morning and shower before breakfast, and a different caregiver is trying to have them have breakfast before they shower. Or, they are laying out their clothes in a certain manner. When a task is more meaningful, then the individual will be much more successful.

This could also involve the context of how you are designing and laying out a room. If you want them to be more social and they are always in their bedroom, then create a space outside of the bedroom where they can eat their meals and participate in social activities. A bedroom can be a sanctuary where the individual has a TV, phone, and a chair. Families end up catering to that type of lifestyle and social isolation, and then the individual tends to lose that sense of meaning. They do not have to come out into the rest of the home or step outside to get fresh air and enjoy their garden.

Of course, it is difficult to find something that is meaningful to an individual, especially in the later stages. In the early stages, they may still participate in activities but become easily frustrated and want to quit because it is hard or embarrassing. It can be more difficult to find something meaningful for them in the later stages as they are often non-verbal, seemingly aggressive, and easily agitated. Thus, people try to stimulate them by turning on the television or playing music. It is important to try to incorporate some of their likes into these functional floor plans. To do so, we can work closely with interior designers and builders. 

Adaptable

As we know, dementia is progressive. It can be a rapid progression and decline in function or a steady, slow progression. No matter which course, the person is going to have more difficulty as the disease progresses. If the family is adamant about keeping their loved one at home and being their primary care providers, we need to help them understand what to expect. As everybody presents differently, it is not our job to anticipate all of the changes. Instead, we need to work with the care team (physicians and other specialists) to help make that home adaptable.

Initially, they may be mobile, and getting in and out of the shower is not a problem. However, if you anticipate the need for caregiver assistance or the need for equipment such as a wheelchair, shower chair, grab bars, you can encourage the planning of that. And when you are doing more of a built environment, you can help them determine some of the needed accommodations. For example, they may not be open to a full shower bench yet, but if they have some of this in the structural plans, they can go as long as they can without installing those items. Then, when they are ready, they will not have to research it or have the construction disrupt their lives. They are already set up. It also could be a much smaller job requiring only a handyperson to come in and install those items.

Creating adaptable spaces also does not have to require a big home modification project. Adaptable spaces can be simply where you are putting the furniture. If you are concerned about falls, you may want to see how the bedroom is set up if they are getting up at night by themselves. One example might be a grab bar along the wall that can be behind a curtain when not in use. At night, you could pull the curtain open to allow them to guide them to the bathroom.

Kitchens can also be adapted. People with dementia may want to help with meal prep and planning. There is now so much technology available. Samsung just came out with a new refrigerator with a touch screen. With this, you can order groceries, track things like a grocery list, and you can play music. There are also hands-free faucets. These are both adaptable and inclusive as anybody can use them. It does not take a lot of skill or effort to be able to use these items. These new technologies can also prolong the length of time somebody can participate in some of these tasks.

Outdoor Access

Outdoor access is also important. Many outdoor activities and hobbies are the first things that people with dementia often give up. We want these clients to be able to access the outdoors if this is important to them. They want to go for a walk or sit outside on the patio. This may be very difficult for people due to safety and mobility concerns. Many homes are not designed in a way that allows for easy in and out. They have to deal with curbs or thresholds.  The backyard may also have cobblestones or stepping stone bricks, or even a pool. Thus, allowing somebody to spend time outdoors can be really cumbersome, and family caregivers often tend to get rid of that pretty quickly. There are so many benefits of spending time outdoors, like vitamins, sunshine, and fresh air. There are so many health benefits to our body and mind, and this is a great opportunity to emphasize different strategies to allow that outdoor access.

This access may look different for somebody in the advanced stages of dementia and/or are bed-bound, but it does not take away the benefits and the value to being able to spend time outdoors. We may help the family create a space in the bedroom where they are next to a window. A bird feeder or wind chimes can then be placed at the window to increase that sensory experience.

Those that are still mobile and are an elopement risk can be a little bit more challenging. Perhaps, we can create a walking path for them. This is often seen in memory care units where they have circular walking paths and high built-up walls to minimize those risks. It allows them to go out and be outside but in a safe manner. We can also add herb gardens and flower gardens where they see colors and get the smells. You can also easily pick a flower and bring it to the individual. 

Inclusive

We touched a little bit on inclusive spaces, but we need to make any recommended changes functional and intuitive for everybody. Many different ages may need to be able to access the spaces. When an individual with dementia is isolated in one accessible space, friends and family members may spend a short amount of time in the room, standing next to the bed or wheelchair to visit. Then, they step away and congregate somewhere elsewhere with more room. You want to help the family to create a layout that is going to optimize that space. With technology, we have a little bit more at our fingertips with intercom systems and FaceTime, but it is still important to connect in person.

Barriers

• Physical Environment
• Participation
• Cognition
• Mobility
• Health Literacy
• Disease Progression

Barriers are usually the reason we, as occupational therapists, come in on a case. We can work with the family to help minimize these barriers. There are similar things that we do when we are in a clinical setting. This is similar to an environmental assessment and recommendations for home modification done in a clinic. This is a holistic, comprehensive assessment, but we are limited and have to prioritize what the primary outcome will be. However, in the community space, we have more flexibility to work one-on-one on specific goals and concerns of the family caregivers.

Physical Environment

Looking at the physical environment can be anything from getting in and out of the house for doctor's appointments to going out to getting their mail. On the inside, we look at the structural environment, like accessing the shower and kitchen and performing tasks in those spaces. There may also be stairs or inadequate lighting. Physical environment barriers can be self-explanatory. Can they do their ADLs? Are they a fall risk? What can we do to minimize those things? Simple barrier eliminators can be added like adaptive equipment and DME. We want to create a physical environment where we empower the individual to participate as much as they can. We also want the caregivers to be able to help. Good design is going to ease their burden and streamline their processes.

Participation

Ultimately, what is impacting their participation? Barriers often cause people to stop participating. When they are not participating in ADLs, it is either due to cognitive or physical limitations. For example, doing laundry can be a really challenging task. People with dementia may start experiencing incontinence episodes that can be really embarrassing. They may have an accident or miss the toilet, causing them to cover this up by cleaning up the toilet and floor, putting on new clothes, and then trying to get to both the trash and laundry locations. If the washer and dryer are not right there in the bathroom, this may require them to go across the house, through many doorways, and even outside in some Arizona homes as their washer and dryers can be on the patio. Again, we need to look at the barriers that are impacting a person's ability to participate. Can we streamline the process to allow them to continue that task?

Often, family members stop them from doing certain tasks. "Oh, do not worry about it. I'll come after work once or twice a week, or I'll just take it to my house." This may be really great initially, but with the progressive nature of dementia, after a few weeks or months, this may get burdensome. We want to look at different strategies and resources that can maximize an individual's ability to perform different tasks as long as possible until it is not feasible anymore.

Cognition

Declining cognition will impact their ability to make choices, decisions, phone calls, managing doctor's appointments, and sequencing cooking tasks. As an example, they may not be able to decide when to go out for that walk safely. They may choose to go out at 5:30 at night when it is about to get dark. We have to help them to find some strategies to help with this. I had a family that bought a new home to help improve their loved one's ability to remain in a residential space. However, disrupting that routine and moving into a new space was much more harmful to this person's wellbeing. The caregivers had to step up their role, which was very difficult as they were out of state. Once they were near their loved ones, they found that the individual's cognition was significantly more impaired than they realized. They were able to mask this as they could hold a conversation and coast over some of those things that we as occupational therapists look at.

When an individual is in a mild to moderate cognitive phase, technology can help support the loved one. We can explore with the families. For example, they can help support the individual with routines like taking a shower or medications. 

Mobility

To support mobility, open concept spaces make this easier. Not everybody's floor plan is ideal, but if we can kind of maximize an L-shaped format or open floor plan, this can be helpful. Different types of pocket or barn doors may make it easier. We may want to close certain doors at night to decrease confusion. Wider doorways are better in the bathroom. This is another way to create an open-concept space to help the individual navigate and path-find within their home. We especially want to think about a person's mobility throughout these important rooms. We also want to make sure that they can safely enter and exit those areas.

Health Literacy

A diagnosis of dementia or Alzheimer's is really difficult for families. They may not understand all that this involves. We need to help the families to understand some of the changes, both physically and cognitively, and work with them to create a plan. They need to know how to improve communication and coping, and much of this has to do with the environment. An example is an individual's change in appetite. Many times you hear, "They will not eat," or "They do not like the food." The person with dementia may have a failure to thrive due to a progression in their condition. As an occupational therapist, you may identify that the individual is having difficulty initiating the task of eating. They may not be able to pick up the spoon and bring it to their mouth or pick up a drink, as examples. This may be due to an environment is overstimulating and distracting. This can impact somebody with cognitive decline and their ability to participate in that self-feeding and mealtime. We can help families understand the diagnosis and grow their health literacy to be more successful.

Disease Progression

Disease progression, of course, is another barrier to remaining in the home.

Assessment

• Consult with ALL the residents in the home
• Include measurement of the individual living with dementia AND their caregiver
• Complete the occupational profile
• Observe natural interactions
• Identify internal and external barriers
• Consider primary spaces

We will not spend too much time here on the assessment phase because it is similar to what we do in a clinical setting and a nonclinical setting.

Consult With All Residents in the Home

One thing that is different in a home assessment is that you can consult with everybody who lives there. Even though it may be only one individual with dementia and one primary caregiver, many people may reside there. You will need to assess the routines and responsibilities in the home. You also want to get everybody's perspective on the individual and what will make things easier.

Include Measurement of Individual Living With Dementia and Their Caregiver

You want to include the measurements of the individual living with dementia and their caregiver. The bathroom is one of the most common remodels that people want to be done. As such, I often use that as my example. The bathroom may be tiny. You want to assess how the individual goes from sitting to standing and moves in the space. You also want to assess and take measurements of at least the primary caregiver using the space. We need to also look at bending, lifting, stooping, reaching the shower hose, and helping the individual with all transfers. You may need to take an average measurement of both parties. The individual with dementia may be very tall, but the caregiver may be short. You need to make sure that both the client and caregiver can access the important equipment. 

Complete the Occupational Profile

Completing an occupational profile is going to help you to do a comprehensive assessment. Your result should be functional and hone in on those areas of needs for that family. 

Observe Natural Interactions

Observing natural interactions is a huge piece of the assessment process. You want to see how they interact with the environment and with individuals to do their day-to-day tasks. What their communication style? What is the organization of the space? Are they getting somebody on the toilet or in the shower and then having to run to let the dog out or gather the clothes/incontinence supplies? What are they actually doing, and how are they doing it? Can we help them to streamline the process? Ultimately, the caregiver may be feeling burnt out and frustrated. They may not know what they are doing in a day nor how to fix it. An outsider may be able to observe and give some good suggestions. People can explain their home to us, but it is essential to see it for ourselves and have the opportunity to observe the individual within this space as well.

Identifying Internal and External Barriers/Consider Primary Spaces

Of course, we need to identify the barriers within those primary spaces, like the bathroom, the living room, and the bedroom. Those are typically the most common spaces where the individual is receiving care and may be spending a lot of their time.

Dementia-Friendly Concepts

• Remove Clutter
• Improve Natural Lighting
• Relocate Door Handle Locks
• Hide or Lock Hazardous Items
• Install Video Monitoring Devices
• Install Alarm Systems
• Appliance controls (auto-shutoff)

Remove Clutter/Improve Natural Lighting

We want to remove the clutter. This is a good and easy start. Another easy improvement is adding in natural lighting. We can look at the types of window coverings and change those out. Light bulbs or shades can be updated. Many times, older people like it dark with dim lighting. Perhaps, we can open up windows or use lighter-colored curtains. 

Relocating Door Handle Locks

We can adjust where the door handles are located. We can put them out of reach or camouflage them to protect the individual.  

Hide or Lock Hazardous Items

We may need to lock or hide hazardous items such as chemicals, medications, et cetera. For example, I had a client who mopped the floor with a chemical not made for the floor. When I entered his home, I sensed a strong chemical smell. When I asked him what he had been doing and took a look underneath his sink, I found a cleaner that had been overlooked. Some people think that they have to padlock every door to keep a loved one from getting into things, but they now have some great options to protect individuals that do not have to change the aesthetic.

Install Video Monitoring Devices

Video monitoring devices can allow for interaction and engagement when the caregiver is in another room, at an overnight shift, or even further away. 

Install Alarm Systems/Appliance Controls

Alarm systems can be beneficial, but they can also be a challenge if that individual accidentally sets that off. Instead, you may want to use those that tell you which windows or doors are being opened. Appliance controls also have auto shut-off options.

Clinically Guided Concepts

• Pathfinding
• Adaptive Devices
• Support Cognitive Decline
• Spatial Awareness
• Optimize Current Functional Capacity

Clinically guided concepts include pathfinding, using adaptive devices, supporting the cognitive decline, helping with spatial awareness, and then optimizing their current functional capacity. This is where we, as occupational therapists in this context and setting, are different from aging-in-place specialists, builders that specialize in age-friendly design, and interior designers that may be specialized in this area. We can use our background as OTs to supplement the information of these other trades or professions that they may not think about.

Support the Caregiver

• Effective communication
• Streamline Systems and Processes
• Coping Strategies and Behavioral Modification
• Cognitive and Physical Adaptations

Ultimately, our role is to support the caregiver, whether they live with the individual, are a remote caregiver, or stop in once in a while. We need to use our skills to help them improve their communication. What is it that they are saying, and how are they saying it? That is one of the biggest challenges faced when trying to communicate with somebody with dementia. This can also be affected by the type of environment that the individual is in. If this is a high-stress, very loud environment and the caregiver is trying to multitask by cooking dinner with the TV on and children running around, this might not be very conducive to appropriate communication. This caregiver may feel like the individual with dementia is always combative and hard to communicate with. We need to help them find a more appropriate space for that communication. They also need to understand what their body language is conveying in addition to the words that they are saying to the client. We need to help them to streamline their systems and processes. We can help them to organize and create a routine. Consistency is so important, which will improve how they interact and provide care for their loved ones. Additionally, we can help them develop coping strategies and appropriately use behavioral modification and cognitive adaptations.

Dementia Enabling Environment Principles

• 10 principles on enabling quality of life for individuals living with dementia
• Evidence-based and researched to improve physical design
• Professor Richard Fleming and Kirsty Bennett, University of Wollongong
• Create a living environment that promotes engagement while minimizing risks.
• Intuitive concepts to promote autonomy

There are 10 principles to encourage a dementia-enabling environment from a great resource based out of Australia. These key concepts are many things that we already do as occupational therapists. The concepts include providing autonomy for the individual, easing the burden, empowering the individual to participate as best they can, and using the environment to enhance that function. Again, this could be relocating furniture, using different features, or using more simplistic styles. It is also important to declutter and simplify. This is not only great for us, but it is conducive for people living with dementia. Over the years, as they collect items, this can overload their system. This resource is listed in the references. In summary, it is empowering the individual through the adaptation of the environment.

Priorities for Success

• Caregiver Engagement and Training
• Collaborative Approach (Assessment/Intervention)
• Multifactoral Modifications

To increase the success, we want to have the caregiver and the family involved from the very beginning and all the way to the end using a collaborative approach. By doing this, we can hone in on their biggest fears and hardship. We can then tap into multifactorial modifications. Besides our typical OT interventions, we can adapt the environment and make suggestions for routines and systems. Again, these can be low-cost recommendations all the way to bigger projects with a design-build team.

OT Design for Dementia

• Open Floor Plans
• Plain and Simple Color and Patterns
• Natural Lighting
• Familiarity
• Durability
• Sound Control
• Signs and Labels
• Incorporate Plants and Greenery

Open Floor Plans

As much as we can, we want to focus on open floor plans. As I mentioned, this is not always feasible. We want to brighten up windows, modify doorways, and improve the line of sight between the individual and the caregiver. If we cannot do that structurally, can we make some changes to their routine? We do not want the caregiver to feel like they have to sit in the same room the whole time, but we want to see what we can do to ease their loved one's worry and stress if they are in a room alone. 

Plain and Simple Color and Patterns

Plain and simple color patterns minimize confusion. Many with dementia have changes in their vision. We want to make sure that they do not think floor tiles are holes in the floor or that their depth perception is affected due to busy floor patterns.

Natural Lighting/Familiarity

For lighting, it is important to keep it simple and use natural lighting when possible. It is also important to keep things familiar. People tend to buy new furniture, new bedding, et cetera, but this can disrupt a person's function. They are already struggling, and new, unfamiliar objects add to that confusion.

Durability

Things are going to progress. Whatever choices we make need to be long-lasting. Caregivers do not want to have to replace furniture, bedding, or other home features. For example, if the individual pulls up on the sink to stand, we may want to suggest a sturdier option than a floating sink attached to the wall or a pedestal style. We need to choose durable options.

Sound Control

We also want to minimize sounds control and echoes. Like I mentioned earlier, we may want to look at the location of the garage door in relation to their bedroom. We also may want to think about background, extraneous noises like a TV. This may impact the individual's mood and behavior.

Signs and Labels

We can provide signs and labels throughout the home. For the kitchen, we may want to label where the snacks and utensils are, for example. We can also create cards with the menu on them like a restaurant. We can label their seat. Putting labels within their line of sight can guide them to go to that chair and sit down for dinner.

Incorporate Plants and Greenery

It is important to incorporate plants and greenery into spaces. Everybody likes this, and there are many great benefits to our well-being.

Color Palette

• Manage Behavior
• Enhance Mood
• Stimulate Appetite
• Visual Barriers
• Path Finding

Sometimes people want to know what colors to use. Most of this is by preference. There is a lot of research showing that some colors can help improve behavior and stimulate appetite; however, how many people are you going to convince to paint their kitchen red or change their living room to blue if their favorite color is peach? There are different ways to incorporate those features to help improve those moods, but it is difficult to convince families to change the whole color scheme of their home completely. It is good to be aware that certain color palettes help manage behavior, enhance mood, and stimulate the appetite if people are amenable to that.

Another use of color in the home is for visual barriers, as I mentioned. You can use camouflage the hide doors and doorknobs. Different pieces of vinyl stick to a door to make it look like a wall or bookshelf. You often see this in memory care units. We can incorporate these decoration styles in the home to make it look aesthetically pleasing while increasing safety.

We can also use color to enhance pathfinding and navigation within their home. We could paint the doorways or doorknobs different colors to cue the individual. 

Technology to Enhance Function

• Motion sensor lighting
• Temperature controlled faucets
• Auto-shutoff controls
• Medication management systems
• Tracking/tagging
• Monitoring for fall prevention
• Audio/visual remote monitoring

There are many different tech ideas that we can incorporate to help improve the safety and independence of individuals. These include motion sensor lighting, temperature-controlled faucets (anti-scald as well), and auto-shutoff controls for those that still insist on cooking. There are also medication management systems and tracking devices that are great for safety. Lastly, the audio/visual remote monitoring as mentioned earlier, is great to have in place for caregivers.

Assessment Tools

• Safety Assessment Scale (Specific for Dementia)
• Canadian Occupational Performance Measure (COPM)
• Home for Life (Assessment and documentation tool).
• Med Box Assessment
• Photometer
• Bluetooth Laser Measure
• What Have You Used in Your Practice to Help Guide Recommendations?

Some specific assessment tools can be used. A photometer gives you a light measurement of the space. A Bluetooth laser measure is great to get the specs of a space to make recommendations or share with a contractor.

Home for Life is an assessment and documentation tool that will create an accessibility report. If you are making recommendations for modifications, this tool can give you a one-stop place. You can use your OT language and share that with families and contractors.

Case Study: "Alan"

(Local Chapter for Dementia Support Referral for Home Assessment)

Client Factors

• 73-year-old male
• The spouse is the primary caregiver
• Currently, Alan is mobile without AD
• Has difficulty with safety awareness
• Easily frustrated with erratic behavior (throwing items, yelling)
• He forgets to change clothes daily
• Poor hygiene
• Occasional Incontinence

Home Environment

• Two-story home
• Tub-shower combination with sliding glass door
• Uneven brick walkway with 4-inch step to entryway
• Woodworking shop with a lathe and other tools
• The home is adjacent to a forest area with a creek bed
• Interior dim lighting, heavy drapes, lampshades
• Landline phone, cable, internet

The local chapter for Dementia Support gives you a referral for this home assessment for Alan. He is 73, and his spouse is the primary caregiver. He is mobile currently, but his safety awareness is poor, and he is easily frustrated. He is in an early stage of dementia where he is aware of his deficits and gets mad when he cannot do something. He ends up yelling and throwing items. He forgets to change his clothes and has poor hygiene. He also has occasional incontinence. When he takes a shower, he forgets to use soap.

The two-story home has a tub-shower combination. To enter, there is an uneven brick walkway. There is also a woodworking shop with a lathe and other tools that he really enjoys using, but it is really not safe anymore. The home is adjacent to a forest area with a creek bed. Often, when he goes for walks, they have to find him because he cannot find his way back.

In the interior of the house, there is dim lighting, heavy drapes, and dark lampshades. They have a landline phone, cable, and internet.

Discuss

• Client factors
• Environmental factors
• Assessment tools
• Modification recommendations
• Considerations

These are the areas that we would want to address. Even if they do not need adaptive equipment early on, it is a good idea to introduce the concept and highlight how that alleviates the burden on the caregiver down the road. It can be overwhelming when we provide a lot of different information all at once. However, if we can easily integrate some small changes, like adding a bench or a seat by the door so they can put on shoes easily, this can help. You can also try to establish routines early so that it is engrained later on. This will help the caregiver later with the individual is used to that normal pattern.

Working with rural and low-income populations can be difficult as they may not have the resources for construction and renovations. There are some low cost-effective ways that you can modify spaces. Again, one simple way is changing the layout of the furniture. If they are a fall risk, you can move the bed closer to the bathroom.

You can remove heavy window coverings to allow more light in. For privacy, some of my clients have covered the lower portion of the window with paper and left the top of the window uncovered for more light. You can also remove or shift the location of the nightstand or dresser. Then, they only have to take a few steps to the toilet instead of 15 and do not have to maneuver around furniture and cords.

I also recommend decluttering and organizing the house. Camouflaging doorknobs is a great way to prevent someone from leaving the house. I actually have removed door knobs completely and replaced them with a deadbolt lock. Perhaps, during the day, the deadbolt could be unlocked so that they can get in and out. However, at night, it could be locked, and the key moved to a secure location. This has been a really effective strategy because it does not require a lot of time or effort. Most people like this option as they do not want an extra hole in their door to raise it higher. Again, for more involved clients, the doorknob can be painted. If the door is white, the doorknob can also be painted white so that it blends in. Using low-profile door knobs has been helpful as well.

Tagging is using a tracker with a GPS. Another option is having the individual wear an identity bracelet that says, "I have dementia." It is similar to a medical ID with identifying information. 

Helping people to change clothes can be a common challenge. Often, individuals will not change into their pajamas at night or keep the same clothes on for many days in a row. You can put some outfits on hangers or fold them together and label them with the days of the week. You can also use a contrasting sign on each hanger with the days of the week clearly marked. The caregiver can then lay that out for them. Sometimes, it is also helpful for them to look at the calendar. Of course, there will be situations where the person is insistent that it is not the right day, but labeling clothes has been a helpful strategy.

For medication management, outside of the pill organizers, I have recommended pill packs and automatic dispensers. I have trained the family caregivers on how to set those up. This minimizes the client having to open bottles, find the correct medication, et cetera.

Summary

I am more than happy to answer any questions outside of this talk. Please feel free to email me. Thank you all so much for attending, and I hope that you found some helpful tips. 

References

Available in the handout.