Evaluating home environments of persons with dementia: interrater reliability and validity of the Home Environmental Assessment Protocol (HEAP)

Development of the Home Environmental Scale of Accessibility Instrument for Spain

BACKGROUND

Universal accessibility is one of the most active lines of intervention for people with disabilities and older adults. This accessibility has become a topic of growing interest regarding home access and use. Therefore, the main objective of this study was to create and validate a home assessment tool: the HESA II.

METHODS

The study was conducted in four phases: (1) agreement on variables by an expert panel; (2) development of 90 items according to the AOTA framework; (3) pilot test with n = 20; and (4) final study with 156 subjects where confirmatory factor analysis was performed.

RESULTS

The tool consisted of 85 items divided into five subscales related to each of the main spaces of Spanish homes: living room; kitchen; bedroom; and bathroom.

CONCLUSIONS

The tool demonstrates good psychometric properties of reliability. The HESA II assesses home accessibility based on limitations in activity and participation restriction of the evaluated person as per the International Classification of Functioning, Disability, and Health rather than on a diagnosis, making it applicable to a wide range of groups.

Risk assessment for people living with dementia: a systematic review

OBJECTIVE

This systematic review identified key components of risk assessment for people with dementia, examined attitudes toward risk identification and risk assessment, and appraised existing risk assessment tools.

METHODS

Systematic searches of five databases on two platforms (EBSCO, OVID) and gray literature databases (Open Grey, Base) were conducted. Studies were screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesized using thematic synthesis.

RESULTS

Our review found people with dementia, their family carers, and healthcare professionals differed in how risk is conceptualized, with views being shaped by media perceptions, personal experiences, socio-cultural influences, dementia knowledge, and dementia severity. We found that mobilization (causing falls inside and getting lost outside) is the most frequently identified risk factor. Our findings show people with dementia are generally risk-tolerant, while healthcare professionals may adopt risk-averse approaches because of organizational requirements. We found factors that disrupt daily routines, living and caring arrangements, medication management, and unclear care pathways contribute toward adverse risk events. We discovered that most studies about risk and risk assessment scales did not consider insight of the person with dementia into risks although this is important for the impact of a risk. No risk instrument identified had sufficient evidence that it was useful.

CONCLUSION

Accurate risk assessment and effective communication strategies that include the perspectives of people with dementia are needed to enable risk-tolerant practice. No risk instrument to date was shown to be widely acceptable and useful in practice.

Understanding the home environment of older adults living with dementia: A scoping review of assessment tools

Rigorous assessments to better understand the person-environment interaction are essential to comprehend how neurocognitive disorders influence in-home functioning of older people living with dementia. No recent synthesis identifies validated instruments targeting the human (e.g. caregivers) and nonhuman (e.g. objects) elements of the home environment interacting with this population and used with the perspective of aging in place. Consequently, following Arksey and O'Malley's (2005) scoping review method, 2,182 articles were identified in six databases and in gray literature. Two reviewers independently selected 23 relevant articles describing 19 validated assessment tools targeting elements of the home interacting with older people with dementia, namely: nonhuman environment (n = 13), human environment (n = 3), and person-environment interaction (n = 3). This overview highlights the scarcity of tools addressing the human environment and the person-environment interaction to foster sustainable at-home living for older people with neurocognitive disorders, demonstrating the need to incorporate new evidence-based, holistic methods into dementia home care.

What are the factors associated with people with advanced dementia refusing assistance with personal care?

BACKGROUND

People with dementia sometimes refuse assistance with personal care activities such as washing or dressing. We aimed to investigate the factors associated with refusals of care in advanced dementia.

METHODS

A cross-sectional study using informant-based measures. Participants were people with advanced dementia and their caregivers (family carers or care-home staff) (n = 260, 130 dyads) in the UK. Mixed effects linear models were used to examine the effects of neuropsychiatric behaviours, ability with activities of daily living, professional input, co-morbidities, psychotropic medications, environment modifications, and caregiver factors including type and training status on refusals of care. The Refusal of Care Informant Scale was used, range 1-13; higher scores indicate more refusal behaviours.

RESULTS

Higher independence in activities of daily living was associated with less refusal behaviours (coefficient = -0.11, p < 0.001 [95% confidence interval -0.15, -0.07]). Higher agitation was associated with more refusal behaviours (0.11, p < 0.001 [0.06, 0.15]). No other statistically significant differences were found. There was no demonstrable evidence of differences in number of refusals of care between family and care-home caregivers or between dementia-trained or -untrained caregivers.

CONCLUSIONS

Results suggest refusals of care have similar prevalence regardless of caregiver type (family or care home) or dementia training status, indicating that current dementia training has no impact on refusals of care or may not be implemented as intended. Improving independence in activities of daily living and reducing agitations may help prevent refusals of care. To establish causality, future research should consider embedding these factors into interventions targeting refusal of care.

Cross-Cultural Adaptation and Reliability of the Home Falls and Accidents Screening Tool (HOME FAST) in Assessing Fall-Risk Home Hazards for Stroke Using Technologies over a Conventional Home Visit

Objective

This study is aimed at translating the Home Falls and Accidents Screening Tool (HOME FAST) into the three main languages spoken in Malaysia and investigating its reliability through an alternative technology-based evaluation.

Methods

Translation into three languages and cross-cultural adaptation of the HOME FAST was conducted via the five steps adopted from the Mapi Institute. For interrater reliability, occupational therapists who attended a face-to-face home hazard workshop were recruited. Each therapist rated the HOME FAST by using the provided combination of videos and photographs of stroke survivors manoeuvring in their home. For test-retest reliability, the same occupational therapists were invited to rate the same combination of photographs and videos again. Reliability was analysed using Gwet's AC₁ and Bland and Altman's plot to describe agreement.

Results

The translation challenges were minimal and rectifiable. A Bahasa Melayu, Mandarin, and Tamil versions of the HOME FAST were developed. Overall interrater reliability for both video (AC₁ = 0.91) and photograph (AC₁ = 0.91) were good. The test-retest reliability yielded similar outcome (video: overall AC₁ = 0.92 and photograph: overall AC₁ = 0.93).

Conclusion

Using alternative technology (video and photograph) to do a home hazard assessment was feasible. However, the asynchronous nature of these methods has limitations in clarifying certain aspects in the home. Moving forward, potential investigation on other technologies such as telehealth for synchronous and real-time interaction is warranted.

A New and Tidier Setting: How Does Environmental Clutter Affect People With Dementia's Ability to Perform Activities of Daily Living?

BACKGROUND

The relationship between the physical environment and the person with dementia's (PwD) activities of daily living (ADLs) task performance is controversial. Although the general assumption is that this population benefits from their home environment when performing ADLs, very few experimental studies have been conducted to date.

OBJECTIVES

The aim was to investigate the influence of the environment (home vs. Research-lab) and the role of clutter on ADL performance.

METHODS

Sixty-five PwD were evaluated with a performance-based ADL assessment (at home and clutter-free Research-lab). Paired t tests compared ADL performance and level of clutter in both environments. Multiple regression analysis investigated factors associated with better ADL performance.

RESULTS

Overall, PwD performed better at home even though clutter was significantly lower in the Research-lab. When stratified by dementia stage, PwD in the moderate stage of the disease performed better at home.

CONCLUSION

Absence of clutter in the Research-Lab did not appear to play a beneficial role in ADLs. When stratified by dementia stage, only PwD in the moderate stage appeared to benefit from their home environment when performing ADL tasks. Future studies are required to elucidate the wider role of the environment in supporting engagement in daily activities in different dementia stages.

Environmental Features Contributing to Falls in Persons With Vision Impairment: The Role of Home Lighting and Home Hazards

PURPOSE

To evaluate whether home hazards and lighting levels are associated with higher fall rates in adults with varying degrees of visual field (VF) damage from glaucoma.

METHODS

Participants with diagnosed or suspected glaucoma provided three years of prospective falls data via monthly falls diaries. A post-fall telephone questionnaire determined fall locations. Seven home areas were evaluated for hazards and lighting via an in-home assessment. Multivariate models adjusting for relevant confounders, including age, sex, comorbidity, and severity of VF damage, evaluated the influence of hazards and lighting on fall rates in each home region.

RESULTS

Mean baseline age for the 170 participants was 71.0 (7.6) years and 78 (46%) of participants were female. Fifty-nine participants experienced a total of 83 home falls, with the greatest number of falls occurring on the indoor stairs (n = 24, 29%) and bedroom (n = 17, 21%). Neither the number nor the percentage of hazardous items graded as hazardous was associated with the rate of falls (P > .26). Each 10-fold increase in room lighting was associated with 35% fewer falls in that home region (P = .02). The relation between lighting and the rate of falls did not differ with the degree of visual field damage (P > .3), and a lower fall rate was noted with better lighting even in participants with mild or no VF damage (rate ratio = 0.52/10-fold better lighting; P = 0.01).

CONCLUSIONS

Fewer home falls were found with better lighting, but not with fewer home hazards. Lighting improvements at home may reduce fall rates in older adults. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Late Life in the Living Room: Room Décor, Functional Limitations, and Personality

BACKGROUND AND OBJECTIVES

Environmental gerontology and environmental psychology theories address adaptations of living space for disability and individual preferences. This study combines these perspectives to examine how room décor (i.e., furnishings, design, decoration) corresponds with functional limitations and personality in late life.

RESEARCH DESIGN AND METHODS

Older adults aged 65+ (N = 286) completed interviews regarding living arrangements, functional limitations, personality and depressive symptoms. Participants provided three to four photographs of the room where they spend the most time. Raters coded photographs for physical adaptations for functional limitations and 19 features of décor (e.g., crowding, color), fitting three categories: a) newness, b) comfort, and c) cheerfulness. We estimated linear regression models to examine how functional limitations or personality are associated with room décor, and whether living arrangement moderates these links. We also assessed whether room décor moderates functional limitations or personality predicting depressive symptoms.

RESULTS

Functional limitations were associated with greater clutter, and less brightness. Extraversion was associated with newness and cheerfulness (but not comfort); conscientiousness with newness and comfort (but not cheerfulness). Openness was associated with more newness and cheerfulness for those who live alone. Moderation models revealed functional limitations were associated with fewer depressive symptoms if the room was more cluttered. Conscientiousness was negatively associated with depressive symptoms when the room was higher on newness or comfort.

DISCUSSION

Findings generally supported environmental psychology and environmental gerontology perspectives, and suggest "goodness of fit" between functional abilities, personal desires and room characteristics may contribute to benefits of aging in place.

Home Modification Assessments for Accessibility and Aesthetics: A Rapid Review

PURPOSE

The purpose of this study was to identify assessments used to evaluate the homes of people with disabilities in terms of accessibility, usability, activities, comfort/satisfaction, and aesthetics.

BACKGROUND

The home is increasingly becoming an environment for healthcare as more people desire to age in place. Research indicates home environmental modifications to be beneficial to promote a better person-environment fit, especially when using a standardized assessment approach. There is not a comprehensive list of assessments that address home modifications, adaptations, or interior designs for people with disabilities.

METHOD

Researchers conducted a rapid review of articles, with data collection scales, instruments, and procedures for home modifications published between 2000 and 2017.

RESULTS

A total of 26 articles met the inclusion criteria, resulting in the identification of 33 distinct assessments, including 18 assessments evaluating the accessibility of home modifications, 3 assessments examining usability, 15 assessments addressing activities of daily living or functional activities, and 5 assessments addressing comfort and/or satisfaction. No assessments for aesthetics were located.

CONCLUSION

Researchers developed a list of assessments that could be used for research or practice. Further research is needed to address the lack of assessments focusing on the aesthetics or attractiveness of home modifications, as well as more assessments tailored to specific diagnoses and population groups.

Development and Psychometrics Test of Home Environment Assessment Checklist for Community-Dwelling Older Adults with Dementia

BACKGROUND

Home environment is a core domain in the care of community-dwelling older adults with dementia, but there is no suitable instrument to measure it in China.

OBJECTIVE

To develop and psychometrically test the home environment assessment checklist for community-dwelling older adults with dementia.

METHODS

A three-step process was performed to develop and test this instrument: 1) based on the evidence-based theory, the checklist was summarized as the main points of evidence from living environment settings among older adults with dementia, 2) the draft tool was assigned to an iterative process of evaluation by a panel of examiners consisting of experts from treatment, nursing and caring, people with dementia and their caregivers, 3) inter-rater reliability and internal consistency were calculated with a sample of 348 caregivers of the older adults with dementia.

RESULTS

The HEAC consisted of 71 items in domains addressing safety, stability and familiarity, visual cues, and sensory stimulation. Psychometric evaluation showed that this tool demonstrated sound reliability and validity. Content validity was 0.969 which was established by a panel of experts (n = 10). Inter-rater reliability of two researchers was 0.978, and 0.848 for researchers and caregivers. Test-retest reliability was excellent (ICC = 0.757-0.877) in community-dwelling older adults with dementia 2 week apart.

CONCLUSION

The HEAC is a new tool to help collect the reliable information on the barriers and facilitators of home environment for community-dwelling older adults with dementia and to precipitate the home modification process to improve the quality of care for people with dementia and their caregivers in daily life.

Home Environmental Assessment Protocol-Revised Initial Psychometrics: A Pilot Study

Efficient home assessments are needed for persons with dementia and their caregivers. Pilot studies to establish a content validity index (CVI), measure concurrent criterion validity, and examine test-retest reliability of the Home Environment Assessment Protocol-Revised (HEAP-R). Six experts reviewed the tool and scored content validity items. Twenty-one caregiver/person with dementia dyads engaged with HEAP and HEAP-R to examine concurrent criterion validity. Seventeen occupational therapists viewed 10 videos of home environments to examine reliability. The CVI score was .980. Concurrent criterion validity for domains: hazards (r =.792), adaptations (r = .742), clutter (r = .843), and comfort (r = .958). Test-retest reliability: hazards (r = .820), adaptations (r = .887), visual cues (r = .487), and clutter (r = .696). Pilot data suggest the HEAP-R has preliminary content and concurrent criterion validity and test-retest reliability. Robust psychometric analysis is needed prior to use in clinical practice.

Cognition, Cognitive Rehabilitation, and Occupational Performance

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, through the use of occupations and activities, facilitate clients’ cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Cognitive processes are integral to effective performance across the broad range of daily occupations such as work, educational pursuits, home management, and play and leisure. Cognition plays an integral role in human development and in the ability to learn, retain, and use new information to enable occupational performance across the lifespan.

This statement defines the role of occupational therapy in evaluating and addressing cognitive functioning to help clients maintain and improve occupational performance. The intended primary audience is practitioners1 within the profession of occupational therapy. The statement also may be used to inform recipients of occupational therapy services, practitioners in other disciplines, and the wider community regarding occupational therapy theory and methods and to articulate the expertise of occupational therapy practitioners in addressing cognition and challenges in adapting to cognitive dysfunction.

Scoring, Clinical Utility, and Psychometric Properties of the In-Home Medication Management Performance Evaluation (HOME-Rx)

IMPORTANCE

Forty percent to 75% of community-dwelling older adults are not able to adhere to their medication routine. A medication management assessment can correctly identify the reasons for nonadherence and the barriers contributing to it.

OBJECTIVE

To further develop the HOME-Rx, an in-home medication management assessment, by modifying scoring metrics, improving clinical utility, and establishing psychometric properties.

DESIGN

In Phase 1, the scoring metrics were modified, and the clinical procedures were evaluated. In Phase 2, the psychometric properties were established.

SETTING

The homes of older adults.

PARTICIPANTS

Older adults who took three or more medications, managed their own medications, and lived in their own home were eligible. Older adults with cognitive impairment were ineligible.

OUTCOMES AND MEASURES

We assessed concurrent validity with the Performance Assessment for Self-Care Skills (PASS) and Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) and established interrater reliability.

RESULTS

The PASS was positively correlated with the HOME-Rx Performance and Safety subscales; the MedMaIDE was negatively correlated with the HOME-Rx Performance subscale and positively correlated with the Barriers subscale. Interrater reliability was excellent (ICCs = .87-1.00).

CONCLUSIONS AND RELEVANCE

All relationships were as predicted: The HOME-Rx is a valid and reliable performance-based assessment that provides clinicians and researchers with a measure of older adults' actual medication management ability in the home using their medications. The results can potentially be used to guide treatment planning and improve medication management.

WHAT THIS ARTICLE ADDS

Occupational therapy practitioners can use the HOME-Rx to adequately determine performance problems, safety concerns, and environmental barriers and potentially to guide treatment planning and improve medication management for older adults.

The Multidisciplinary Approach to Alzheimer's Disease and Dementia. A Narrative Review of Non-Pharmacological Treatment

Background: Alzheimer's disease (AD) and dementia are chronic diseases with progressive deterioration of cognition, function, and behavior leading to severe disability and death. The prevalence of AD and dementia is constantly increasing because of the progressive aging of the population. These conditions represent a considerable challenge to patients, their family and caregivers, and the health system, because of the considerable need for resources allocation. There is no disease modifying intervention for AD and dementia, and the symptomatic pharmacological treatments has limited efficacy and considerable side effects. Non-pharmacological treatment (NPT), which includes a wide range of approaches and techniques, may play a role in the treatment of AD and dementia. Aim: To review, with a narrative approach, current evidence on main NPTs for AD and dementia. Methods: PubMed and the Cochrane database of systematic reviews were searched for studies written in English and published from 2000 to 2018. The bibliography of the main articles was checked to detect other relevant papers. Results: The role of NPT has been largely explored in AD and dementia. The main NPT types, which were reviewed here, include exercise and motor rehabilitation, cognitive rehabilitation, NPT for behavioral and psychological symptoms of dementia, occupational therapy, psychological therapy, complementary and alternative medicine, and new technologies, including information and communication technologies, assistive technology and domotics, virtual reality, gaming, and telemedicine. We also summarized the role of NPT to address caregivers' burden. Conclusions: Although NPT is often applied in the multidisciplinary approach to AD and dementia, supporting evidence for their use is still preliminary. Some studies showed statistically significant effect of NPT on some outcomes, but their clinical significance is uncertain. Well-designed randomized controlled trials with innovative designs are needed to explore the efficacy of NPT in AD and dementia. Further studies are required to offer robust neurobiological grounds for the effect of NPT, and to examine its cost-efficacy profile in patients with dementia.

A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: results of a scoping review

BACKGROUND

Falls occurring on stairs or in bathrooms are associated with a high risk of injuries among older adults. Home environmental assessments are frequently used to guide fall-prevention interventions. The aims of this review were to describe how, where, by whom, and for whom environmental hazard checklists are used, and to examine the characteristics of environmental hazard assessment checklists with specific attention to features of bathrooms and stairs/steps assessed in them.

METHODS

Studies published before January 5, 2018, were identified using several databases. Publications reporting the use and/or evaluation of environmental hazard checklists were eligible if they assessed bathrooms or stairs/steps in homes of older adults (≥65 years). Content analysis was conducted on publications that provided a complete list of specific environmental hazards assessed. Checklist items related to bathrooms and stairs/steps were extracted and categorized as structural or non-structural and as objective or subjective.

RESULTS

1119 studies were appraised. A pool of 136 published articles and 4 checklists from the grey literature were included in this scoping review. Content analysis was conducted on 42 unique checklists. There was no widely used checklist and no obvious consensus definition of either environmental hazards overall or of single hazards listed in checklists. Checklists varied greatly with respect to what rooms were assessed, whether or not outdoor stair/steps hazards were assessed, and how responses were coded. Few checklists examined person-environment fit. The majority of checklists were not oriented towards structural hazards in bathrooms. Although the majority of checklists assessing stair/steps hazards evaluated structural hazards, most features assessed were not related to the construction geometry of stairs/steps. Objective features of bathrooms and stairs/steps that would deem them safe were rarely specified. Rather, adequacy of their characteristics was mostly subjectively determined by the evaluator with little or no guidance or training.

CONCLUSION

The lack of standard definitions and objective criteria for assessing environmental hazards for falls is limiting meaningful cross-study comparisons and slowing advances in this field. To inform population health interventions aimed at preventing falls, such as building code regulations or municipal housing by-laws, it is essential to include objectively-assessed structural hazards in environmental checklists.

Development and usability of a decision support App for nurses to facilitate aging in place of people with dementia

AIM

The aim of this study was to develop a decision support tool for nurses to facilitate aging in place of people with dementia and to test its usability.

BACKGROUND

Nurses play an important role in detecting practical problems preventing persons with dementia (PwD) from aging in place and advising them on possible solutions. These are complex and challenging tasks for nurses.

METHODS

A mixed methods study was conducted. The content development of the App comprised a literature and internet search, and individual and group interviews with professionals (n = 8) and researchers (n = 5). The technical development was an iterative process in which usability was tested by the project team (n = 4), experts (n = 6), and end-users (n = 9), using heuristic evaluation, a think-aloud approach, and a questionnaire (PSSUQ).

RESULTS

The App contains a structured problem assessment for three problem domains-self-reliance, safety, and informal care-based on validated questionnaires and self-formulated questions. The problem assessment is linked to an overview of possible solutions for the problems detected. Three prototypes have been developed. The users of the third prototype were overall satisfied with the App as they scored on average 1.7 on the PSSUQ (range 1-7 and lower scores indicating higher satisfaction).

CONCLUSIONS

A user-friendly prototype of the decision support App is now available. Users indicated to be very willing to use to App in daily practice. However, besides further technical development, implementation of the App into practice requires evidence supporting its efficacy, feasibility and effectiveness.

Reducing safety risk among underserved caregivers with an Alzheimer's home safety program

OBJECTIVES

Older adults living with Alzheimer's disease (AD) experience more of the types of accidents and injuries prevalent among older adults. Relatively few studies specifically on safety risks have included older adults of color and tested interventions. This pilot study tested the feasibility and evaluability of educating Hispanic and African American caregivers of patients living with AD about reducing safety risks in their homes.

METHODS

This outpatient memory clinic-based intervention study included a pre-/post-test survey design with two nonequivalent groups and predominately serves Hispanic and African Americans. Of 60 eligible caregivers, 67% participated in a tailored, safety training class with an optional follow-up call.

RESULTS

The results indicate a reduction in some safety risks compared to baseline and/or a no intervention group, respectively, including leaving patients at home alone part-time (p < .01 and p < .01), getting lost (p < .05 and p < .05), going outdoors alone less often (p < .05 and p < .01), and giving themselves medicine (p < .05 and p < .01). At post-test, 47 clinically significant instances occurred, in which caregivers who participated in the intervention self-reported patients living with AD to be 'completely safe' in one or more of the safety risk items compared to 8 instances among those who did not.

CONCLUSIONS

This pilot pre/post design with non-equivalent groups study needs refinement in a future randomized control trial. Despite limitations, this pilot study demonstrates the first feasible and evaluable intervention with both statistically and clinically significant results that suggest potential for reducing safety risks among at-risk minority patients living with AD in future research.

The interrater and test-retest reliability of the Home Falls and Accidents Screening Tool (HOME FAST) in Malaysia: Using raters with a range of professional backgrounds

RATIONALE, AIMS AND OBJECTIVES

Falls can be a devastating issue for older people living in the community, including those living in Malaysia. Health professionals and community members have a responsibility to ensure that older people have a safe home environment to reduce the risk of falls. Using a standardised screening tool is beneficial to intervene early with this group. The Home Falls and Accidents Screening Tool (HOME FAST) should be considered for this purpose; however, its use in Malaysia has not been studied. Therefore, the aim of this study was to evaluate the interrater and test-retest reliability of the HOME FAST with multiple professionals in the Malaysian context.

METHODS

A cross-sectional design was used to evaluate interrater reliability where the HOME FAST was used simultaneously in the homes of older people by 2 raters and a prospective design was used to evaluate test-retest reliability with a separate group of older people at different times in their homes. Both studies took place in an urban area of Kuala Lumpur.

RESULTS

Professionals from 9 professional backgrounds participated as raters in this study, and a group of 51 community older people were recruited for the interrater reliability study and another group of 30 for the test-retest reliability study. The overall agreement was moderate for interrater reliability and good for test-retest reliability. The HOME FAST was consistently rated by different professionals, and no bias was found among the multiple raters.

CONCLUSION

The HOME FAST can be used with confidence by a variety of professionals across different settings. The HOME FAST can become a universal tool to screen for home hazards related to falls.

The Clinimetric Properties of Instruments Measuring Home Hazards for Older People at Risk of Falling: A Systematic Review

Home hazards are associated with falls among older people living in the community. However, evaluating home hazards is a complex process as environmental factors vary according to geography, culture, and architectural design. As a result, many health practitioners commonly use nonstandardized assessment methods that may lead to inaccurate findings. Thus, the aim of this systematic review was to identify standardized instruments for evaluating home hazards related to falls and evaluate the clinimetric properties of these instruments for use by health practitioners. A systematic search was conducted in the Medline, CINAHL, AgeLine, Web of Science databases, and the University of Sydney Library CrossSearch Engine. Study screening, assessment, and quality ratings were conducted independently. Thirty-six studies were identified describing 19 instruments and three assessment techniques. The clinimetric properties varied between instruments. The Home Falls and Accidents Screening Tool, Home Safety Self-Assessment Tool, In-Home Occupational Performance Evaluation, and Westmead Home Safety Assessment were the instruments with high potential for evaluating home hazards associated with falls. Health practitioners can choose the most appropriate instruments for their practice, as a range of standardized instruments with established clinimetric properties are available.

Quantifying Fall-Related Hazards in the Homes of Persons with Glaucoma

OBJECTIVE

To characterize fall-related hazards in the homes of persons with suspected or diagnosed glaucoma, and to determine whether those with worse visual field (VF) damage have fewer home hazards.

DESIGN

Cross-sectional study using baseline (2013-2015) data from the ongoing Falls in Glaucoma Study (FIGS).

PARTICIPANTS

One-hundred seventy-four of 245 (71.0%) FIGS participants agreeing to the home assessment.

METHODS

Participants' homes were assessed using the Home Environment Assessment for the Visually Impaired (HEAVI). A single evaluator assessed up to 127 potential hazards in 8 home regions. In the clinic, binocular contrast sensitivity (CS) and better-eye visual acuity (VA) were evaluated, and 24-2 VFs were obtained to calculate average integrated VF (IVF) sensitivity.

MAIN OUTCOME MEASURES

Total number of home hazards.

RESULTS

No significant visual or demographic differences were noted between participants who did and did not complete the home assessment (P > 0.09 for all measures). Mean age among those completing the home assessment (n = 174) was 71.1 years, and IVF sensitivity ranged from 5.6 to 33.4 dB (mean = 27.2 dB, standard deviation [SD] = 4.0 dB). The mean number of items graded per home was 85.2 (SD = 13.2), and an average of 32.7 (38.3%) were identified as hazards. IVF sensitivity, CS, and VA were not associated with total home hazards or the number of hazards in any given room (P > 0.06 for all visual measures and rooms). The bathroom contained the greatest number of hazards (mean = 7.9; 54.2% of graded items classified as hazardous), and the most common hazards identified in at least 1 room were ambient lighting <300 lux and exposed light bulbs. Only 27.9% of graded rooms had adequate lighting. IVF sensitivity, CS, and VA were not associated with home lighting levels (P > 0.18 for all), but brighter room lighting was noted in the homes of participants with higher median income (P < 0.001).

CONCLUSIONS

Multiple home fall hazards were identified in the study population, and hazard numbers were not lower for persons with worse VF damage, suggesting that individuals with more advanced glaucoma do not adapt their homes for safety. Further work should investigate whether addressing home hazards is an effective intervention for preventing falls in this high-risk group.

Evaluation of the Home Environment Assessment for the Visually Impaired (HEAVI): an instrument designed to quantify fall-related hazards in the visually impaired

BACKGROUND

To (1) develop and refine the Home Environment Assessment for the Visually Impaired (HEAVI), and (2) determine the interrater reliability of this instrument, which was designed to quantify the number of fall-related hazards in the homes of individuals with visual impairment.

METHODS

Twenty homes of community-dwelling adults were included in this study. Each home was graded by an occupational therapist (OT) and two non-expert (NE) graders. Seventy-three HEAVI items were evaluated in eight rooms, for a total of 185 potential hazards per home (some items were assessed in multiple rooms). Pairwise and three-way agreement between graders was evaluated at the item, room, and home level using Krippendorff's alpha and intraclass correlation coefficients (ICC). Additionally, the most hazardous home locations and items were determined by comparing the mean and standard deviation of the number of hazards by room and grader.

RESULTS

Of the 73 items, 45 (62%) demonstrated at least moderate agreement overall and for each OT/NE pair (Krippendorff's alpha >0.4), and remained in the final instrument (a total of 119 potential hazards per home as some items were assessed in multiple rooms). Of these 119 potential hazards, an average of 35.7, 33.2, and 33.3 hazards per home were identified by the OT and NE graders, respectively. Moderate to almost perfect agreement on the number of hazards per home and number of hazards per room, except the dining room, was found (ICCs of 0.58 to 0.93). Bathroom items were most often classified as hazards (>40% of items for all graders). The item classes most commonly graded as hazardous were handrails and lighting (>30% of items).

CONCLUSION

Our results indicate that NE graders can accurately administer the HEAVI tool to identify fall-related hazards. Items in the bathroom and those related to handrails and lighting were most often identified as hazards, making these areas and items important targets for interventions when addressing falls.

Home functioning profiles in people with multiple sclerosis and their relation to disease characteristics and psychosocial functioning

BACKGROUND

For people with multiple sclerosis (MS), limitations in performing activities of daily living can have a significant impact on personal independence, residential safety, and quality of life. In this study we explored the utility of the Home Functioning Scale in identifying home functioning profiles and generating rehabilitation interventions.

OBJECTIVE

The objective of this study was to determine whether distinctive and meaningful home functioning profiles could be identified among adults with MS based on Home Functioning Scale scores.

METHODS

Home Functioning Scale scores and additional data from a representative national sample of 3,834 adults were analyzed. We used cluster analysis and MANOVA to identify and evaluate group differences.

RESULTS

Three distinct home functioning profiles emerged in the analysis: (1) minimal impairment (31.1% of participants); (2) moderate impairment (52.4%); and (3) severe impairment (16.5%). The three groups exhibited significant differences on demographic and MS related characteristics, perceived cognitive function, perceived MS impact on physical and psychological function, and life satisfaction.

CONCLUSION

The profile characteristics of the identified groups are presented and the implications of the results for rehabilitation practitioners and the investigation of home functioning in activities of daily living are discussed.

Measuring the impact of informal elderly caregiving: a systematic review of tools

PURPOSE

To classify and identify the main characteristics of the tools used in practice to assess the impact of elderly caregiving on the informal carers' life.

METHODS

A systematic review of literature was performed searching in Embase, MEDLINE, PsycINFO, CINAHL, IBECS, LILACS, SiiS, SSCI and Cochrane Library from 2009 to 2013 in English, Spanish, Portuguese and French, and in reference lists of included papers.

RESULTS

The review included 79 studies, among them several in languages other than English. Their inclusion increased the variety of identified tools to measure this impact (n = 93) and allowed a wider analysis of their geographical use. While confirming their overlapping nature, instruments were classified according to the degree of integration of dimensions they evaluated and their specificity to the caregiving process: caregiver burden (n = 20), quality of life and well-being (n = 11), management and coping (n = 21), emotional and mental health (n = 29), psychosocial impact (n = 10), physical health and healthy habits (n = 2), and other measures. A high use in practice of tools not validated yet and not caregiver-specific was identified.

CONCLUSIONS

The great variety and characteristics of instruments identified in this review confirm the complexity and multidimensionality of the effects of elderly caregiving on the informal carer's life and explain the difficulties to assess these effects in practice. According to the classification provided, caregiver burden and emotional and mental health are the most evaluated dimensions. However, further work is required to develop integrated and caregiving focused procedures that can appraise this complexity across different countries and cultures.

Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background

The needs of people with dementia and their carers are inadequately addressed at all key points in the illness trajectory, from diagnosis through to end-of-life care. The EVIDEM (Evidence-based Interventions in Dementia) research and development programme (2007–12) was designed to help change this situation within real-life settings.

Objectives

The EVIDEM projects were (1) evaluation of an educational package designed to enhance general practitioners’ (GPs’) diagnostic and management skills; (2) evaluation of exercise as therapy for behavioural and psychological symptoms of dementia (BPSD); (3) development of a toolkit for managing incontinence in people with dementia living at home; (4) development of a toolkit for palliative care for people with dementia; and (5) development of practice guidance on the use of the Mental Capacity Act (MCA) 2005.

Design

Mixed quantitative and qualitative methods from case studies to large database analyses, including longitudinal surveys, randomised controlled trials and research register development, with patient and public involvement built into all projects.

Setting

General practices, community services, third-sector organisations and care homes in the area of the North Thames Dementia and Neurodegenerative Diseases Research Network local research network.

Participants

People with dementia, their family and professional carers, GPs and community mental health team members, staff in local authority social services and third-sector bodies, and care home staff.

Main outcome measures

Dementia management reviews and case identification in general practice; changes in behavioural and psychological symptoms measured with the Neuropsychiatric Inventory (NPI); extent and impact of incontinence in community-dwelling people with dementia; mapping of pathways to death of people with dementia in care homes, and testing of a model of collaborative working between primary care and care homes; and understandings of the MCA 2005 among practitioners working with people with dementia.

Results

An educational intervention in general practice did not alter management or case identification. Exercise as a therapy for BPSD did not reduce NPI scores significantly, but had a significant positive effect on carer burden. Incontinence is twice as common in community-dwelling people with dementia than their peers, and is a hidden taboo within a stigma. Distinct trajectories of dying were identified (anticipated, unexpected and uncertain), and collaboration between NHS primary care and care homes was improved, with cost savings. The MCA 2005 legislation provided a useful working framework for practitioners working with people with dementia.

Conclusions

A tailored educational intervention for general practice does not change practice, even when incentives, policy pressure and consumer demand create a favourable environment for change; exercise has potential as a therapy for BPSD and deserves further investigation; incontinence is a common but unrecognised problem for people with dementia in the community; changes in relationships between care homes and general practice can be achieved, with benefits for people with dementia at the end of life and for the UK NHS; application of the MCA 2005 will continue to improve but educational reinforcements will help this. Increased research capacity in dementia in the community was achieved. This study suggests that further work is required to enhance clinical practice around dementia in general practice; investigate the apparent beneficial effect of physical activity on BPSD and carer well-being; develop case-finding methods for incontinence in people with dementia; optimise working relationships between NHS staff and care homes; and reinforce practitioner understanding of the MCA 2005.

Trial registration

EVIDEM: ED-NCT00866099; EVIDEM: E-ISRCTN01423159.

Funding

This project was funded by the Programme Grants for Applied Research programme of the National Institute for Health Research.

Quality of informal care for persons with dementia: dimensions and correlates

OBJECTIVES

The majority of persons with dementia live in the community where most of their care is provided by family members. We aimed to expand our limited knowledge about the styles of high-quality care, such as person-centered care, and poor-quality care adopted by these informal caregivers and the characteristics of those who provide better care.

METHOD

We conducted a mail survey of 148 family caregivers. Caregiving styles were measured with items from existing scales that had not been analyzed together before. Factor analysis of these items was used to identify styles of caregiving, and structural equation modeling was used to identify their relationships with caregiver and care-recipient characteristics.

RESULTS

Three high quality-of-care factors (personalized, respectful, and compensatory) and three poor quality-of-care factors (punitive, controlling, and withdrawing) were found. The personality traits of agreeableness, openness, conscientiousness, and neuroticism were related to higher quality of care, and the trait of extraversion was related to poorer quality of care. Wishful coping - an avoidance/escape strategy - was linked to poorer quality of care.

CONCLUSION

We discovered new dimensions of quality of care, some consistent with person-centered care and some antithetical to this model, and we identified for the first time caregiver personality traits and coping strategies associated with better quality of care. These results may be useful in targeting caregiver interventions to benefit both caregivers and care recipients.

Correlates of quality of life for individuals with dementia living at home: the role of home environment, caregiver, and patient-related characteristics

OBJECTIVES

To examine prevalence of modifiable risk factors and their contribution to patient quality of life (QoL) as rated by dementia patients and family caregivers.

DESIGN

Cross-sectional.

SETTING

Home environment.

PARTICIPANTS

88 patients and their caregivers.

MEASUREMENTS

Modifiable characteristics of home environments, patients, and caregivers were observed or obtained through interview. Demographics and ratings of patients' QoL were obtained from patients and caregivers.

RESULTS

Patients had mean Mini-mental Status Examination (MMSE) score = 17.7 ± 4.6, (range: 10-28) on an average 7.7 ± 2.4 neuropsychiatric behaviors, 6.0 ± 3.1 health conditions and moderate functional challenges; 70.7% (N = 58) had fall risk; 60.5% (N = 52) had sleep problems at least once weekly; and 42.5% (N = 37) had pain. An average of 8.1 ± 5.2 home hazards and 5.4 ± 4.1 adaptations were observed; 51.7% had unmet device/navigation needs. Patients' and caregivers' QoL ratings were unrelated to MMSE; and patients' self-rated QoL was higher than rated by caregivers. Number of health conditions and unmet device/navigation needs were inversely associated with patient self-rated QoL, and number of health conditions, frequency of behaviors, and level of negative communications were inversely associated with caregiver's assessment of patient QoL. Positive endorsement of caregiving was positively associated with caregiver's appraisal of patient QoL. Other factors were unrelated.

CONCLUSIONS

Most patients lived at home with high fall risk, unmanaged behavioral symptoms, pain, sleep disturbances, environmental challenges, and multiple hazards. Except for health, factors associated with lower QoL differed for patients and caregivers. Results suggest need to improve QoL by addressing modifiable risk factors and tailoring interventions to patient and caregiver perspectives.

The role of the occupational therapist in the management of neuropsychiatric symptoms of dementia in clinical settings

Neuropsychiatric symptoms (NPS) of dementia include aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, and disinhibition. NPS affect dementia patients nearly universally across dementia stages and etiologies. They are associated with poor patient and caregiver outcomes, including increased health care utilization, excess morbidity and mortality, and earlier nursing home placement, as well as caregiver stress, depression and reduced employment. There are no FDA-approved medications for NPS, but it is a common clinical practice to use psychotropic medications such as antipsychotics, to control symptoms; however, antipsychotics show only modest efficacy in improving NPS and have significant risks for patients, including side effects and mortality. Nonpharmacologic treatments are considered first-line by multiple medical bodies and expert consensus, as they show evidence for efficacy and have limited potential for adverse effects. Ideally, nonpharmacological management of NPS in clinical settings occurs in multidisciplinary teams, where occupational therapists play an important collaborative role in the care of the person with dementia. Our group has articulated an evidence-informed structured approach to the management of NPS that can be integrated into diverse practice settings and used by providers of various disciplines. The "DICE" (Describe, Investigate, Create, and Evaluate) approach is inherently patient- and caregiver-centered, as patient and caregiver concerns are integral to each step of the process. DICE offers a clinical reasoning approach through which providers can more efficiently and effectively choose optimal treatment plans. The purpose of this paper is to describe the role of the occupational therapy in using the DICE approach for NPS management.

Clinical trial of a home safety toolkit for Alzheimer's disease

This randomized clinical trial tested a new self-directed educational intervention to improve caregiver competence to create a safer home environment for persons with dementia living in the community. The sample included 108 patient/caregiver dyads: the intervention group (n = 60) received the Home Safety Toolkit (HST), including a new booklet based on health literacy principles, and sample safety items to enhance self-efficacy to make home safety modifications. The control group (n = 48) received customary care. Participants completed measures at baseline and at twelve-week follow-up. Multivariate Analysis of Covariance (MANCOVA) was used to test for significant group differences. All caregiver outcome variables improved in the intervention group more than in the control. Home safety was significant at P ≤ 0.001, caregiver strain at P ≤ 0.001, and caregiver self-efficacy at P = 0.002. Similarly, the care receiver outcome of risky behaviors and accidents was lower in the intervention group (P ≤ 0.001). The self-directed use of this Home Safety Toolkit activated the primary family caregiver to make the home safer for the person with dementia of Alzheimer's type (DAT) or related disorder. Improving the competence of informal caregivers is especially important for patients with DAT in light of all stakeholders reliance on their unpaid care.

Assistive devices in context: cross-sectional association between challenges in the home environment and use of assistive devices for mobility

PURPOSE

A primary goal for aging policy is to optimize independence in later life. We estimate the cross-sectional association between physical and social challenge in the home environment and use of assistive devices (AD) for mobility in the home, controlling for lower extremity physical performance (short physical performance battery [SPPB]) and other factors.

DESIGN AND METHODS

Data are from the Women's Health and Aging Study I, a prospective study of the factors related to physical disability in a sample of moderately to severely disabled older women. We describe these associations in the baseline sample overall and also within subsets who do and do not have both a baseline and a 3-year follow-up observation.

RESULTS

On average, physical challenge in the home environment is inversely associated with level of AD use (p < .05) in the overall sample, independent of SPPB, living alone, and other factors. We do not find a significant (p < .05) association between social challenge and the level of AD use in the overall sample. Findings by follow-up responder status were similar (with minor variability).

IMPLICATIONS

Future cohorts who are better educated and more receptive to technology may confront challenges in the home environment that limit their ability to age in place. Our findings suggest that the physical challenges of the home are significantly related to AD use. Future analyses that explore the mechanisms of the home environment as a source of challenges to independent functioning could help in the design of future interventions for these cohorts as they age.

Nonpharmacologic management of behavioral symptoms in dementia

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behaviors can accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, and result in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case, we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction.

Current Developments of the Housing Enabler Methodology

Twenty years of methodological development, empirical research and practice application have resulted in an updated version of the Housing Enabler instrument and a screening version. The methodology rests on Lawton's and Nahemow's ecological model, with accessibility defined as the relationship between the individual's functional capacity and the demands of the physical environment. The complete instrument is based on one checklist of functional capacity in the individual (personal component) and another of environmental barriers (environmental component), followed by an analysis of person-environment fit giving an accessibility score. The Housing Enabler Screening Tool requires a less complex and less time-consuming procedure.

A Descriptive Study of Home Modifications for People with Dementia and Barriers to Implementation

This study describes home environmental features, safety issues, and health-related modifications in a community dwelling sample of 82 elderly people with dementia. Main barriers to the accessibility of the homes were steps, both inside and outside the house. The majority of the caregivers had made home modifications, which pertained mainly to physical limitations. Home modifications to support cognitive deficits were made to a lesser extent. The main barrier to the implementation of home modifications to accommodate the care recipient's memory loss was skepticism about their usefulness. Regarding the removal of physical barriers, financial constraints were most frequently mentioned.

Measuring impact of environmental factors on human functioning and disability: a review of various scientific approaches

PURPOSE

The objective of this paper is to present a framework for systematically describing different approaches to measure environmental factors (EF) and to discuss some strengths and weaknesses of these approaches.

METHODS

Identification of suitable criteria for ordering measurements of EF was based on an analysis of existing reviews, a qualitative literature review and feedback from experts. Items of selected EF measures were linked to the International Classification of Functioning, Disability and Health.

RESULTS

Experimental and observational designs for the study of EF are distinguished and illustrated with examples. Approaches to study EF are differentiated into those directly measuring an environmental interaction with function and those relying on an independent assessment of environmental features. By applying these criteria, a three-dimensional matrix framework for measurement of EF in observational studies is developed.

CONCLUSION

The acknowledgement of different measurement approaches to the scientific study of EF is one pathway towards an increased understanding of the connection between environments and functioning. Many different measures may be used to approximate the realities of disabling or enabling environments. This review provides an initial framework for improving our fundamental comprehension of the complexity of the measurement of EF in the context of human health and disability.

The role of behavior analysis in the rehabilitation of persons with dementia

With the rapidly aging population, it is expected that increases in cases of dementia will double over the next 20 years. Currently, there is no cure for diseases such as Alzheimer's disease or frontotemporal dementia (FTD) that cause progressive dementia, and only a few pharmacological interventions that slow the progression of the decline exist. Given that there is no cure available, a rehabilitation approach that emphasizes maintaining existing abilities and removing excess disability (as opposed to emphasizing cure or recovery) for as long as possible is warranted. The current paper proposes that nonpharmacological rehabilitation efforts need to target 5 broad areas/targets: memory enhancement, altering social contingencies and communication styles, improving self-care skills, the arrangement of physical environments to maintain and improve functioning, and increasing physical fitness/physical activity. The purpose of this paper is to review specific behaviorally oriented interventions that target these 5 areas and show promise for inclusion in comprehensive rehabilitation efforts for individuals with dementia.

Association of the spatial layout of the home and ADL abilities among older adults with dementia

We investigated the relationship between architectural space syntax measures describing the spatial layout of a home and activities of daily living (ADL) among people with dementia. We visited the homes of 82 participants in a dementia care comparative effectiveness clinical trial and measured the space syntax variables intelligibility and convexity along with several clinical variables, including ADLs. In regression models, we estimated the cross-sectional association between space syntax measures and ADLs. Higher convexity was associated with worse performance of basic but not instrumental ADLs (adjusted β =19.2, P = .02). Intelligibility was not associated with ADLs. These results imply that enclosed rooms with a clearly legible meaning and function might be better memorized and associated with the spatial layout of the home resulting in better basic ADL performance. These results warrant further research on space syntax measures in the home environment of people with dementia, including longitudinal study, which we are pursuing.

In-Home Occupational Performance Evaluation (I-HOPE)

OBJECTIVE

We describe the development and preliminary psychometric properties of an assessment to quantify the magnitude of an environmental barrier's influence on occupational performance.

METHOD

The assessment was developed and then piloted on a group of 77 older adults before and after an occupational therapy intervention focused on environmental barrier removal. Refinements were made to the assessment before it was evaluated for interrater reliability in a sample of 10 older adults using 2 raters.

RESULTS

The In-Home Occupational Performance Evaluation (I-HOPE) is a performance-based measure that evaluates 44 activities in the home. The 4 subscales of Activity Participation, Client's Rating of Performance, Client's Satisfaction With Performance, and Severity of Environmental Barriers are sensitive to change in the environment. The subscales' internal consistency from .77 to .85, and intraclass correlation coefficients ranged from .99 to 1.0.

CONCLUSION

This preliminary study suggests that the I-HOPE is a psychometrically sound instrument that can be used to examine person-environment fit in the home.

Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention

OBJECTIVES

To test the effects of an intervention that helps families manage distressing behaviors in family members with dementia.

DESIGN

Two-group randomized trial.

SETTING

In home.

PARTICIPANTS

Two hundred seventy-two caregivers and people with dementia.

INTERVENTION

Up to 11 home and telephone contacts over 16 weeks by health professionals who identified potential triggers of patient behaviors, including communication and environmental factors and patient undiagnosed medical conditions (by obtaining blood and urine samples) and trained caregivers in strategies to modify triggers and reduce their upset. Between 16 and 24 weeks, three telephone contacts reinforced strategy use.

MEASUREMENTS

Primary outcomes were frequency of targeted problem behavior and caregiver upset with and confidence managing it at 16 weeks. Secondary outcomes were caregiver well-being and management skills at 16 and 24 weeks and caregiver perceived benefits. Prevalence of medical conditions for intervention patients were also examined.

RESULTS

At 16 weeks, 67.5% of intervention caregivers reported improvement in targeted problem behavior, compared with 45.8% of caregivers in a no-treatment control group (P=.002), and reduced upset with (P=.03) and enhanced confidence managing (P=.01) the behavior. Additionally, intervention caregivers reported less upset with all problem behaviors (P=.001), less negative communication (P=.02), less burden (P=.05), and better well-being (P=.001) than controls. Fewer intervention caregivers had depressive symptoms (53.0%) than control group caregivers (67.8%, P=.02). Similar caregiver outcomes occurred at 24 weeks. Intervention caregivers perceived more study benefits (P<.05), including ability to keep family members home, than controls. Blood and urine samples of intervention patients with dementia showed that 40 (34.1%) had undiagnosed illnesses requiring physician follow-up.

CONCLUSION

Targeting behaviors upsetting to caregivers and modifying potential triggers improves symptomatology in people with dementia and caregiver well-being and skills.

The Tailored Activity Program to reduce behavioral symptoms in individuals with dementia: feasibility, acceptability, and replication potential

PURPOSE

The Tailored Activity Program (TAP) is a home-based occupational therapy intervention shown to reduce behavioral symptoms and caregiver burden in a randomized trial. This article describes TAP, its assessments, acceptability, and replication potential.

DESIGN AND METHODS

TAP involves 8 sessions for a period of 4 months. Interventionists identify preserved capabilities, previous roles, habits, and interests of individuals with dementia; develop activities customized to individual profiles; and train families in activity use. Interventionists documented time spent and ease conducting assessments, and observed receptivity of TAP. For each implemented prescribed activity, caregivers reported the amount of time their relative spent in activity and perceived benefits.

RESULTS

The TAP assessment, a combination of neuropsychological tests, standardized performance-based observations, and clinical interviewing, yielded information on capabilities from which to identify and tailor activities. Assessments were easy to administer, taking an average of two 1-hr sessions. Of 170 prescribed activities, 81.5% were used, for an average of 4 times for 23 min by families between treatment sessions for a period of months. Caregivers reported high confidence in using activities, being less upset with behavioral symptoms (86%), and enhanced skills (93%) and personal control (95%). Interventionists observed enhanced engagement (100%) and pleasure (98%) in individuals with dementia during sessions.

IMPLICATIONS

TAP offers families knowledge of their relative's capabilities and easy-to-use activities. The program was well received by caregivers. Prescribed activities appeared to be pleasurable and engaging to individuals with dementia. TAP merits further evaluation to establish efficacy with larger more diverse populations and consideration as a nonpharmacological approach to manage behavioral symptoms.

The home environment and disability-related outcomes in aging individuals: what is the empirical evidence?

PURPOSE

Building on the disablement process model and the concept of person-environment fit (p-e fit), this review article examines 2 critical questions concerning the role of home environments: (a) What is the recent evidence supporting a relationship between home environments and disability-related outcomes? and (b) What is the recent evidence regarding the effects of home modifications on disability-related outcomes?

DESIGN AND METHODS

Using computerized and manual search, we identified relevant peer-reviewed original publications and review articles published between January 1, 1997, and August 31, 2006. For Research Question 1, 25 original investigations and for Research Question 2, 29 original investigations and 10 review articles were identified.

RESULTS

For Research Question 1, evidence for a relationship between home environments and disability-related outcomes for older adults exists but is limited by cross-sectional designs and poor research quality. For Research Question 2, evidence based on randomized controlled trials shows that improving home environments enhances functional ability outcomes but not so much falls-related outcomes. Some evidence also exists that studies using a p-e fit perspective result in more supportive findings than studies that do not use this framework.

IMPLICATIONS

Considerable evidence exists that supports the role of home environments in the disablement process, but there are also inconsistencies in findings across studies. Future research should optimize psychometric properties of home environment assessment tools and explore the role of both objective characteristics and perceived attributions of home environments to understand person-environment dynamics and their impact on disability-related outcomes in old age.

Cognitive Functional Evaluation (CFE) Process for Individuals with Suspected Cognitive Disabilities

The purpose of this paper is to conceptualize the evaluation process for individuals with suspected cognitive disabilities. The Cognitive Functional Evaluation (CFE) process yields a comprehensive profile of the clients' cognitive strengths and weaknesses in occupational performance. The components of the CFE are outlined in six stages as a decision tree with examples of standardized instruments from which to choose the assessments for each client evaluated: (1) interview and background information; (2) cognitive screening and baseline status tests; (3) general measures of cognition and executive functions in occupation; (4) cognitive tests for specific domains; (5) measures of specific cognitive domains in occupations; and (6) environmental assessment. The first three stages are required to ascertain basic cognitive abilities underlying occupational performance. Tests for each stage can be chosen from the ones listed according to the client characteristics and the theory utilized, there is no need to use all of them. Once this data is available a further decision is made whether a more in-depth assessment is needed (stages (4) and (5)). The environmental component is evaluated in all instances with at least one of the assessments. The CFE process for individuals with suspected cognitive disabilities is recommended to be used by occupational therapists as a common ground for evaluation, documentation, and communicating information.

Conducting research on home environments: lessons learned and new directions

The study of home environments is a research domain within the field of environmental gerontology that addresses issues related to aging in place. Despite the importance of aging at home, there are few recent studies in this area and most are descriptive and lack theoretical direction. This article examines the current state of research on home environments from which methodological challenges and new directions for future research are identified. Three broad research queries are posed: What should we measure and why in home environments? How do older people and their family members use the home environment in health, illness, and caregiving? What are the interrelationships between the home environment, psychological well-being, and daily functioning throughout the aging process? Suggestions for future research on home environments are discussed and the implications for advancing environmental gerontology highlighted. Specifically, the home environment offers a testing ground for generic environmental constructs and their measurement as well as a unique setting from which new understandings and constructs of person-environment fit can emerge.

Strategies used by families to simplify tasks for individuals with Alzheimer's disease and related disorders: psychometric analysis of the Task Management Strategy Index (TMSI)

PURPOSE

Little is known about the specific behavioral strategies used by families to manage the physical dependency of persons with Alzheimer's disease and related disorders (ADRD). This study reports the psychometric properties of the Task Management Strategy Index (TMSI), a measure designed to identify actions taken by caregivers to simplify everyday self-care tasks for persons with ADRD. Relationships between use of these strategies and caregiver and care-recipient characteristics were also examined.

DESIGN AND METHODS

A pool of 20 items was developed and initially tested with 202 family caregivers (Sample 1) recruited for a dementia-management intervention study. Principal axis factor analysis was performed to determine scale structure. Convergent and discriminant evidence was examined using Pearson cor-relation and multiple regression analyses with a separate sample of 255 family caregivers (Sample 2) recruited for the Philadelphia site of the National Institutes of Health multisite initiative, Resources for Enhancing Alzheimer's Caregiver Health.

RESULTS

Exploratory principal axis factoring yielded one general factor accounting for 60.2% of variance in the first sample. Nineteen items, loading at.3 or above, constituted the final scale (Cronbach's alpha =.81 in Sample 1 and.74 in Sample 2). In Sample 2, TMSI scores were significantly associated with greater functional dependency of ADRD patients, high self-efficacy, and greater use of positive coping strategies. As expected, caregiver upset with disruptive behaviors and caregiver use of criticism-based strategies were not associated with TMSI scores. Higher caregiver education was significantly associated with greater use of task strategies.

IMPLICATIONS

Results provide preliminary evidence that the TMSI is an easily administered, reliable, valid scale. Caregivers with lower education may benefit from instruction in the use of these strategies.