CE Home > Occupational Therapy > OT07 Aging in Place, Part 1

According to the National Aging in Place Council, aging in place is “the ability to continue to live in one’s home safely, independently, and comfortably, regardless of age, income, or ability level. It means living in a familiar environment and being able to participate in family and other community activities.”¹ Aging in place occurs when older adults with a range of functional levels have choices about their occupational engagement, healthcare, and living arrangements. Comfort within the community occurs when universal design is incorporated into businesses and homes, promoting access for all. Universal design promotes ease of access and use in environments and with products for all people, regardless of age or disability.

Clinical Vignette

Martha, age 83, recently became a widow. Her daughter Sarah lives out of state and visits her mother regularly to monitor her care and help her decide where she wants to live. Martha has been depressed since her husband’s death. The depression complicates her short-term memory deficits, which are related to dementia, and makes future care planning more difficult. Martha survived a stroke two years ago and currently has coronary artery disease and thyroid disease.

Sarah would like her mother to live in a Continued Care Retirement Community that would provide her with supported services (e.g., medication management, opportunities for social engagement, and onsite medical care over the long term). Martha and Sarah visited several communities in her area; however, Martha is adamant that she wants to live in a single-family house in an area where she has friends. Martha no longer drives and relies on others for transportation. Sarah is concerned about Martha’s safety within the home and the surrounding community.

Because Sarah is committed to ensuring the greatest quality of life for her mother, she retained Zoe, an OT, to assess her mother’s independence, safety, and daily living skills.

Zoe completed an evaluation that included a home/environmental assessment to address safety as well as current and future home modification needs. She first used the SAFER Tool (Safety Assessment of Function and Environment for Rehabilitation Health Outcome Measurement and Evaluation) to assess Martha’s ability to function safely in the home.² Then the Allen Cognitive Level Test was administered to help determine Martha’s ability to complete activities of daily living (ADLs) and independent activities of daily living (IADLs), and to adapt her environment according to her cognitive abilities. Due to her declining memory, she was a poor historian and not fully accurate when reporting issues or conditions to her caregivers or physician. She also frequently forgot to take her medication and missed appointments.

The outcome of the evaluation indicated that Martha could age in place as long as systems were put in place to ensure her safety while supporting her independence and autonomy. For example, transportation to social and leisure activities, doctor appointments, and other outings would be coordinated and involve transportation provided by friends, family members, volunteers, and paid services. Zoe recommended that grab bars be installed in Martha’s bathroom to increase safety when showering and toileting.

During her daily conversations with Martha, Sarah had discovered that her mother would say that she took her medications or went for a walk, but this was not always accurate information. Sarah wanted to ensure that her mother took her medication as prescribed and engaged in some physical activity and social interaction each day. Sarah hoped to enlist one of Martha’s friends or hire a companion to be available daily to make sure that Martha took her medications and maintained an active lifestyle. She also wanted her mother to use a medical alert system so Martha would have someone to call in the event that she fell or had a medical emergency when she was alone.

Martha’s dignity is very important to her. She does not want her friends to be aware of her health status, including her memory deficits, and refuses to allow them to accompany her to medical appointments. Since Martha is becoming more forgetful and has difficulty reporting her symptoms and retaining the doctor’s instructions, it was agreed that a healthcare advocate of her choice from the community would accompany Martha to future doctors’ appointments and relay health information to Sarah. Combining all of these systems allowed Martha to age in place and maintain the highest quality of dignity possible.

A Frame of Reference

Occupational therapy supports the individual’s desire to age in place as part of its commitment to the client noted in Core Values and Attitudes of Occupational Therapy Practice, which specifically identifies the values of altruism, freedom, and dignity.³ These values emphasize the importance of caring and respecting individuals’ choices in defining their living circumstances and occupational engagement. Further, the Occupational Therapy Practice Framework: Domain & Process emphasizes the importance of our “… supporting health and participation in life through engagement in occupation.”⁴

Whenever an OT works with clients to support their aging-in-place goals, the Occupational Therapy Practice Framework can be used to analyze their living situations and support and to make recommendations that promote function, safety, independent living, and quality of life. The Occupational Therapy Practice Framework identifies areas of occupation, client factors, performance skills, performance patterns, context and environment, and activity demands:

Areas of occupation include ADLs, IADLs, rest and sleep, education, work, play, leisure, and social participation. The majority of these areas are relevant (although to varying degrees) as individuals age in place. It is the balance of the pursuit of these occupations that promotes life satisfaction.

Client factors include values, beliefs, spirituality, and body structures and functions. These factors can impact successful aging in place.

• Maintaining body functions and body structures will help to promote health necessary for independent living. Engaging in activities that stimulate body functions, such as swimming, ballroom dancing, and tai chi classes, will have a positive result on occupational performance.
• The client’s values, beliefs, and spirituality are closely related to core values mentioned earlier, which are important in sustaining a sense of self. For example, if attending religious services is an important part of a client’s life, it is important to help the individual continue this activity and keep connected to his or her beliefs and spirituality.

Activity demands are factors specific to each activity, including the tools, physical space, time required, physical actions, and social demands necessary to perform each task. OTs analyze the tasks associated with activities that are important to seniors. Adapting and modifying these activities when necessary allows individuals to continue to perform the activities within the home and community environments. Successful aging in place requires that activity demands are modified when necessary to meet an individual’s needs and promote health, wellness, personal safety, and satisfaction:

• For example, Bob is 79 years old and has had a passion for playing pinochle since he was a young man. He loves to play cards with his friends at the senior center; however, he is currently unable to meet the activity demands without modifications. Bob has low vision and arthritis in his hands, so he worked with the OT at the Senior Center to modify the objects (using large print cards and card holders) to compensate for his limitations. Space demands were also modified because Bob has arthritis in his hips and knees and uses a scooter. The OT arranged for a larger room with wider aisles to facilitate Bob’s mobility. Over time, the card players modified the social demands of the activity to allow extra time to manipulate the cards and recall the plays.

Performance skills include motor and praxis skills, sensory-perceptual skills, emotional regulation skills, cognitive skills, and communication and social skills.8 Changes in these skills can impact the performance of areas of occupation critical for independence and self-direction.

• Jo, a survivor of a brain injury, has difficulties in a number of these areas and benefits from the OT’s ability to modify activities to enhance her performance. For example, Jo’s memory, cognitive skills, motor and praxis skills, and emotional regulation skills were affected after the fall that resulted in her head injury. Jo and the OT constructed daily schedules that would help keep her on track and minimize short-term memory demands. Jo’s kitchen cupboards were reorganized, and the supplies that she needs more regularly were placed at eye level. This reduced the need for her to stand on chairs or step stools to reach items. When new activities are introduced, the OT creates instructions with pictures and an audiotape to describe the steps to complete the task. The more organized, predictable, and safe Jo’s day is, the better able she is to maintain her physical and emotional equilibrium.

Cultural Competence Key As our world becomes more diverse, OTs who serve older adults in their homes and communities have an obligation to be culturally aware and sensitive. Communities across the country have become more diverse, and languages, cultures, and beliefs are not as homogeneous as they were a few decades ago. Cultural sensitivity needs to extend beyond appreciation of ethnic and racial group differences and beliefs to those of the deaf and lesbian, gay, bisexual, and transgendered communities. Various cultures may practice healthcare beyond traditional western medicine medical models. According to the National Center for Complementary and Alternative Medicine, approximately 38% of U.S. adults (about 4 in 10) and approximately 12% of U.S. children (about 1 in 9) are using some form of complementary and alternative medicine.5 The use of these practices may influence clients’ interactions with western practitioners and, if the healthcare community doesn’t understand complementary practices, create barriers to communication. This appreciation is important if OTs want to understand beliefs, behaviors, and customs that may influence an individual or family’s participation in healthcare and community-based programs.6 Cultural competence — the capacity to respond to the needs of populations whose cultures are different from what might be called dominant or mainstream7 — is a lifelong learning process. It requires the appreciation of beliefs, customs, values, and experiences when engaging in a therapeutic relationship. The OT gains this exposure to understanding by listening, observing, and asking questions.

 

Performance patterns are important for the individual and consider habits, routines, rituals, and roles. The OT needs to observe the sequence of behaviors the individuals depict as they perform a wide range of productive and meaningful occupations within their own personal, social, and cultural contexts.⁷

• Martha has familiar habits and routines that are associated with her community and neighborhood. For example, Martha participates in the neighbor lady’s gardening group and tends the roses in her garden.

Contexts and environments include cultural, personal, temporal, virtual, physical environment, and social, referring to a variety of interrelated conditions within and surrounding the client that influence performance.⁷ In other words, although sometimes used interchangeably, environments can be considered external and contexts internal to the person.

• Martha’s contexts and environments, especially the personal, physical, and social environments, are important to her and critical to her life satisfaction. Zoe and Sarah devised ways that her daily living involved friends of her socioeconomic status who shared similar values and carried out their activities in social and environmental contexts that were familiar and safe for her.

Choice or Circumstance?

Aging in place is a choice or desire for many older adults. For others, it’s a matter of circumstance. Sometimes seniors prefer to live closer to relatives or downsize their current homes. Given the current housing market in some communities, selling a home may be a barrier for those who want to relocate. Additionally, moving expenses may be too great, making the transition impossible. Those whose general health is good and who prefer their current living situation may also be challenged by diminished functioning or physical environment barriers that reduce their independence in their current environment. These individuals can age in place as long as they are provided with needed support.

According to AARP, the majority of Americans want to remain in their homes as they age.⁸ However, in a 2008 presentation at the National Association of Home Builders Remodelers Show, Michael O’Neal, an urban sociologist with AARP, reported that only 16% of homeowners have made home modifications that would accommodate functional changes consistent with aging.⁹ Social marketing programs can change public perceptions about remodeling homes for accessibility and encourage collaboration with aging-in-place professionals, such as contractors and OTs, to incorporate these changes into their homes.

Stats For the older population, there is a great need for consultation, education, and advocacy for aging in place. Research data support the need for OTs’ knowledge and training concerning aging in place. For example, 90% of older adults age in place, including those who are frail.10 According to AARP11 and the United Jewish Communities,10 more than 75% of seniors prefer to age in place. Living at home is significantly less expensive than paying for nursing home care.10 People 65 and older were 10 times more likely to be hospitalized for injuries related to getting in and out of cars than younger people.12

Homes and communities need to be able to support independent living and healthy aging. Residents of homes that are well designed for their needs, as well as residents who live in communities with a range of well-designed features and services, are much more likely to be socially involved and active in their communities.¹³

Roles for OTs

The roles for OTs engaged in practices that support aging in place can include a focus on clinical, educational, advocacy, research, and consultative services, as well as volunteer roles. These services may be delivered directly or through consultation.

Home and Community Environments: OTs help people who are living with chronic illnesses, disabilities, and typical aging consider how aging may affect their futures. When the environment doesn’t fit the individual living or working in it, modifications can be made to facilitate independence. Changes also can be made for older adults and people with disabilities to accommodate their ability and changes in health. A home modified for greater accessibility promotes energy conservation and helps prevent falls and other in-home injuries. This may open the door to exploration of ways to adapt the environment to increase accessibility and the use of assistive technologies. The roles OTs assume are broad and flexible. Within the home, OTs have the opportunity to work with individuals and their families or caregivers on occupational performance, such as ADLs and IADLs. In addition to dressing, feeding, and care of the home environment, OTs may also address energy conservation, caregiver education, social participation, and strategies to stimulate cognition.

Occupational therapy provides education about the home and community in general within these environments through the provision of in-services and workshops geared to consumers and professionals on topics ranging from fall prevention to home modifications and community mobility. Research initiatives can be aimed at understanding the efficacy of specific interventions and the needs of community-living elders. Volunteer roles benefit communities when they are provided, fulfilling membership and advocacy roles on boards and commissions. Finally, OTs can participate in research studies as participants, coordinators, or principal investigators. Faculty in occupational therapy university programs is available as research partners for research with clinicians. Whenever possible, seek academic partners in research with occupational therapy faculty at nearby universities.

Assistive Technologies: While OTs may be familiar with the range of assistive devices that are available to support the performance of ADLs and IADLs, the typical older adult and his or her family may not be. The use of devices in daily life can help to sustain independence, enable employment, conserve energy, facilitate mobility and communication, and promote safety. They are used to meet the sensory, motor, and cognitive needs of users. OTs identify, acquire, and train their clients in the use of assistive technologies. Devices are generally divided into two categories: low tech and high tech. Low-tech items are typically off the shelf and do not require batteries or electronics for their operation, e.g., reachers, Velcro, knob-turners, or eyeglasses. High-tech devices incorporate computer technology or electronics and include power wheelchairs, augmentative communication devices, talking calculators, and environmental control units. Free, public websites, such as AbleData, contain information and descriptions about products and devices.

Occupational therapy service delivery can include evaluation, education, and training in the identification and use of assistive technologies that can support the occupational performance for people with or without disabilities. Assistive technologies that promote safety and independence within the home to well elders and those with disabilities include medication dispensing machines, motion detectors, wearable emergency alert systems, and grab bars. OTs can be instrumental in recommending and training the senior in the proper use of these devices. There is an extensive variety of devices for individuals with sensory impairments. Self-care and kitchen aids are available in large print, Braille, and talking versions. There are also technologies that can assist seniors in the workplace and getting around the community.

Clients with hearing loss or deafness may incorporate a variety of technologies into their homes to support their independent living. Strobe, vibrating, or flashing lights can alert the individual that the phone or doorbell is ringing, or that the alarm on the smoke detector has been activated. Telephones and cell phones are available for use by people wearing hearing amplification devices. Telephonic communication is supported in all states through telephone relay services, and many businesses are equipped to receive calls from people using telecommunications devices for the deaf (TDDs).

Individuals with visual impairments can take advantage of products that display Braille or large print. Blood pressure cuffs, calculators, and computers are available with speech output functions. For those who love to read, there are magnifying aids, books, and newspapers available through reading services, libraries with specialized services for people with visual impairments, and electronic devices like the Kindle and iPad.

More recent advancements in technology include digital technologies that can help concerned family members, caregivers, and healthcare providers monitor the activities of elders within the home. Research is leading to prototype development at the Massachusetts Institute of Technology, Microsoft HealthVault, and the Georgia Institute of Technology. The American Occupational Therapy Association’s (AOTA’s) Technology Special Interest Section, RESNA, National Resource Center on Supportive Housing and Home Modifications, and similar organizations are also good resources for technology information. Integrating technology into the elder’s home environment can reduce caregiving demands, promote client safety and independence, and enhance quality of life for the client and caregiver.¹⁴

Driving and Community Mobility: The Occupational Therapy Practice Framework defines community mobility as “moving self in the community and using public or private transportation, such as driving or accessing buses, taxi cabs, or other public transportation systems.” The AOTA has information about driving and community mobility on its website and through a variety of publications. OTs can play a major role in helping seniors transition from driving. This life event is as significant as learning to drive and obtain a first driver’s license. Retiring from driving is intertwined with one’s social roles and can impact the individual’s social and occupational engagement. OTs can collaborate with the senior to make this change less traumatic by planning alternate means of transportation.

Senior Centers and Community Programs: Occupational Therapy in Senior Centers¹⁵ identified a number of areas that occupational therapy can fill in the senior centers. These ideas can be expanded to services that OTs can deliver to older adults who wish to age in place. OTs can provide seniors and those they care about with information about energy conservation and compensatory strategies for changes in roles and daily occupations. They can also explain how to use assistive technologies to help them perform ADLs and IADLs. Information about environmental modifications may be made available to homeowners, those who manage assisted living facilities, builders and contractors, and volunteer organizations that help improve the habitability of residences.

OTs and occupational therapy assistants (OTAs) may offer program development and administration for adult day care, senior center, and senior plus programs. The interventions available can support independence in the home and community. These practitioners may design health and education programs targeted to seniors and members of the community. Fall prevention, energy conservation, and driver safety are just some of the specialized programs that may be offered, depending on the specific population.

Certification OTs can play a pivotal role in increasing the quality of living for older adults. Furthermore, OTs can have an impact on changing public policies to help this population. OTs may obtain certifications that support their roles with older adults in the community. The credentialing that identifies professionals’ expertise in areas relevant to aging in place may be issued from different organizations, including the AOTA, which offers credentials relevant to aging in place (e.g., gerontology, driving and community mobility, and environmental modification); the Association for Driver Rehabilitation Specialists certifies driving rehabilitation specialists; and the National Association of Home Builders certifies aging-in-place specialists. These are just a sample of organizations that can help OTs obtain additional credentialing that may increase public awareness so they make changes necessary to age in place. While additional credentialing is not required beyond initial certification by the National Board for Certification in Occupational Therapy and licensure, added specializations may build public awareness of occupational therapy’s roles in aging in place.

 

Health, Wellness, and Prevention

Fall prevention programs: Each year, an estimated one third of older adults fall, and the likelihood increases substantially with advancing age. Falls are the leading cause of fatal and nonfatal injuries for persons older than age 65.¹⁵ By 2020, the estimated annual cost for fall-related injuries for people age 65 and older is expected to reach $43.8 billion.¹⁶

OTs can tell attendees at home health programs, public education seminars, and fall prevention classes at senior centers how to reduce injuries and possible death by minimizing fall hazards in the home. They can increase awareness about the role that poor lighting, medications, and improper footwear can play in falls, and how physical activity and personal assertiveness can reduce the potential for falls. Fear of falling limits the continuation of habits and routines, engagement in work and leisure, and ultimately leads to diminished performance skills. OTs lead interventions that help older adults develop compensatory skills to address their fears and return to more active lives.

Leisure occupations: Older adults may become unable to pursue former leisure and educational occupations due to physical and cognitive changes. Therefore, OTs can consult with older adults regarding adapting former leisure activities or developing new ones. Assessments such as the Activities Card Sort can focus interventions on adapting or learning new pursuits.

Mental health and substance abuse: Some community-dwelling elders are at risk for or have a mental illness or a substance abuse problem. OTs working with this population should be knowledgeable about the warning signs for these issues and have resources at hand that may direct interventions. The Substance Abuse and Mental Health Services Administration’s 2005 publication, Substance Abuse Among Older Adults: A Guide for Treatment Providers,¹⁷ offers information about self-screening, and administered tools and questionnaires that may be incorporated into occupational therapy practices.

Occupational therapy in aging in place also presents the opportunity to consider whether individuals are at risk for substance abuse. OTs should investigate when their older clients have had car crashes, falls, bruises or fractures, changes in hygiene, agitation, or other behavior changes. A system of inquiry can provide an entrée for the OT to ask the client about behavior patterns, which leads to opportunities to screen for substance misuse or abuse.¹⁴ OTs can also screen for mental illness, particularly depression, although the adaptations listed previously will help to prevent depression.

Advocacy, Ethics, and Promotion

Principle 2 of the Occupational Therapy Code of Ethics states: “Occupational therapy personnel shall take measures to ensure a recipient’s safety and avoid imposing or inflicting harm.”¹⁸ OTs and students can use this statement to advocate for aging in place. For example, universal design reduces environmental barriers and often incorporates safety features that promote energy conservation and reduce the risk of falls. OTs can advocate through their local community housing agencies for the incorporation of these features as standards in new home construction and age-restricted housing. Additionally, it is important to serve on committees that focus on aging. OTs’ participation in these groups helps community providers and advocates receive additional perspectives on aging in place, expanding it from solely a discussion of home modifications to one of prevention, wellness, transportation, recreation, and other service options. Advocacy for the profession occurs by making sure the community is aware of the services available and in what contexts.

Adherence to the Occupational Therapy Code of Ethics, state regulations, and policies and procedures of employers is also a requirement for this practice area. The principles articulated in the Occupational Therapy Code of Ethics are all relevant to serving older adults who wish to age in place, from the duty to the client to the obligation to be competent in the services delivered, and to make sure that communications with clients and the public are accurate.

A Glimpse of the Future

As the baby boomers age, more and more are choosing to age in place. Although there is an anticipated growth in the number of OTs over the next several years, that increase will not meet future projected needs for occupational therapy services, particularly among the elderly.¹⁹ People need access to reliable information on where to go for services, and the eligibility for those services. OTs working in the community should make sure they let aging populations and networks know about the services they offer.

EDITOR’S NOTE: Part 2 of this series will provide an overview of living options (home, continued care retirement communities, and assisted living) and funding sources that support aging in place. It will also explore support services necessary for daily living in a community context. Finally, there will be a discussion of occupational therapy’s potential community partners and the various roles that OTs may assume independently and in those relationships.