Assessing Home Safety in Homebound Older Adults

Elizabeth K. Tanner, PhD, RN


Geriatr Nurs. 2003;24(4) 

In This Article

Home Safety Instrument Development

Numerous instruments are available to assess risk within the home.[2] Because falls are associated with multi-factorial causes, it is important to include all plausible factors relative to the population assessed. The tool used to assess risk in this population was developed by incorporating a variety of questions from multiple existing home safety instruments, including those available from the Department of Health and Human Services, and adapted to the needs of project participants to determine risk in this vulnerable, underserved population.

Components of the Home Safety Assessment Tool were categorized into the following subscales:
Subscale (SSC)-1 Risk for Falls: External Factors
SSC 2– Risk for Falls: Internal Factors
SSC 3– History of Falls
SSC 4– Risk for Injury: Use of Personal Precautions
SSC 5– Risk and Preparation for Fire and Disasters
SSC 6– Risk for Crime

It is important to assess areas of risk within the older adult s residence. Hazards within the home place persons at greater risk for falls and injury. Not surprising, 95% of falls in older adults happen in and around the home, most in the bedroom or bathroom.[3] For example, bathroom lighting is often inadequate, and the bathtub and toilet areas lack proper hand rails. In addition, unsecured scatter rugs and personal items placed close by for convenience often create a cluttered, dangerous pathway between the bedroom and bathroom, creating a high risk for falling, particularly at night.

Other examples of external environmental safety hazards include pets underfoot, piles of papers and personal belongings, uneven flooring or lack of home repairs, and extension cords that present mobility hazards in common walkways. Identifying such hazards and implementing an environmental modification plan can greatly reduce risk within the home.

Factors intrinsic to the individual elder also increase the threat of injury. Decreased vision, equilibrium, sensory perception, and reaction time all increase the risk of falling. Decreased strength and mobility also threaten balance. Polypharmacy is a common problem among older adults, resulting in nocturia or dizziness. Medication side effects or drug interactions, along with increased confusion, also are often associated with increased age and greatly raise the chance of falling.

These problems are examples of innate factors that can threaten sense of safety, placing a person at an increased risk for falls. Cognitive decision-making factors, such as being aware of pets or holding onto a grab bar when getting out of the bath, also are considered internal factors for purposes of this tool. Assessing internal risks and teaching clients how to maintain a safe, healthy environment are paramount to any nurse working within the home setting.

Clients must be assessed for a history of falls, including near falls and previous actual falls, particularly at home. A positive history of falls places an older adult at significantly higher risk for subsequent falls. In fact, a fall resulting in soft tissue injury in the home is a strong predictor that a future major fall with injury will occur. Reviewing the circumstances of previous risks can be useful in educating older adults about methods to avoid falls in the future and can reduce risk.[5,6]

A certain level of risk within the home can be accounted for by assessing an older adult s behavior there. Personal precautions can minimize risk and the effects posed by existing hazards. For example, a telephone should be available for easy access, with emergency and other essential numbers, including the resident's home number, placed close by. It is important that the older adult know how to call and to whom emergency calls should be made; therefore, all important phone numbers should be displayed in large, legible print.

Older adults with limited resources often use space heaters to heat the home and save money. This and other sources of heat that emanate carbon monoxide can be quite dangerous. Ventilation within the home should be checked regularly, and the presence of carbon monoxide should be evaluated. Also, the temperature of the home environment should be checked during a 24-hour period. A common time in which falls occur among older adults is at night, resulting in potential exposure to hypothermia during winter months in cold regions.

In addition, first aid supplies should be available within every home, and each client should be instructed in emergency first aid techniques. A list of all current medications should be kept readily available and identifiable for an emergency response team to locate. Vials of Life are prescription vials in which records of current prescriptions, including dosages and schedules, are recorded and kept in the refrigerator in case of an emergency.

Finally, body movement associated with mobility and activities of daily living can greatly increase the risk of falling in elders with compromised balance, strength, range of motion, and postural sway. Thus, the use of personal precautions when moving should be assessed. Exercise interventions accompanied by education about personal precautions that use methods to improve body mechanics and enhance safe mobility can greatly reduce behavioral risk.[7,8]

The home should be carefully assessed for electrical and fire hazards. Many elders living in their own homes on fixed incomes cannot afford home repairs, placing them at risk for fire. A fire escape plan from every room in the home should be formulated and practiced by the adults living in the home, particularly clients with limited mobility.

Working smoke detectors and fire extinguishers should be available in every home, and a plan should be devised for checking them regularly. If a fire extinguisher is available, the client should be taught to operate it.

Finally, every older client should have a plan for responding to disasters that are feasible for that geographic area. For example, tornadoes are common in Alabama, and every older adult should be prepared to seek protection when the threat occurs.

Home safety assessment also includes level of risk for crime in the home. It is important to determine whether the client has ever been a victim of crime and whether or not he or she fears being a victim. This assessment includes fraud and intangible forms of crime in addition to physical trauma. Fear of crime, with or without risk, frequently leads to social isolation and diminished quality of life.


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