Home Adaptations: Flooring and Lighting (Rehabilitation Therapy)

ALERT

Provide special consideration to patients who are at an increased risk for falls due to impaired cognition or vision or to decreased strength or balance.

OVERVIEW

The Occupational Therapy Practice Guidelines for Home Modifications defines home modifications as adaptations to environments that are intended to increase use, safety, security, and independence.^{undefined#ref6">6} Modifications may include, but are not limited to, the use of medical equipment or universally designed products; architectural modifications or major home renovations; and education of the patient regarding new strategies to use in the home environment.⁶

Therapeutic intervention that includes home modifications may prevent premature long-term care by supporting aging in the home,³ as well as improve the patient’s functional performance and reduce the risk of falls and physical demands on caregivers.⁶ Additionally, home adaptations may reduce costs while older adults age in the home.²

When considering home modifications, the patient’s physical functionality is one of the main factors for the therapist to keep in mind.² The therapist must also take into consideration the patient’s perception of the home modifications, readiness to change the environment, and cost.⁴ The therapist must work with the patient or caregiver (or both) and have the patient’s consent before making any changes in the home.

The assessment of flooring includes its type and condition. The therapist must consider how well the patient can negotiate through the home and if the patient uses a walker, cane, or wheelchair. Additionally, determining if the patient’s home has sufficient lighting for safe movement through the home and for tasks such as reading or food preparation is an important component of the assessment. The therapist must take into consideration any visual deficits the patient has that will have implications for home modification recommendations.

SUPPLIES

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EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Educate the patient and caregiver on home modification recommendations.
• Educate the patient and caregiver on the use and installation of any adaptive equipment.
• Instruct the patient to report pain experienced during transfers and functional mobility.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Explain the procedure and ensure the patient agrees to treatment.
5. Assess the patient for pain.
6. Assess the patient's strength, balance, and vision.
7. Review risk factors that predispose the patient to falls or accidents in the home.

   Take note of preexisting conditions such as visual or hearing impairment, neuromuscular dysfunction, fatigue or reduced energy, or postural hypotension.

8. Assess the patient's thoughts and perceptions on home adaptations.
9. Partner with the patient and caregiver to conduct a home safety assessment of the patient's flooring and lighting.
10. Assess the patient’s functional mobility while proceeding through the home, turning on lights along the way, with assistance as needed. Observe and document the safety of the functional mobility, including any trouble the patient has navigating thresholds and turning lighting on and off.
11. Make specific flooring and lighting modification recommendations based on the patient's needs and comfort.
    1. Advise the patient on safe flooring in the home.
       1. Recommend that the patient remove throw rugs and install nonslip pads under any remaining rugs.

          Rationale: Throw rugs are a tripping hazard.

       2. Recommend that the patient secure the carpeting on the steps and ensure that the carpeting is in good condition in order to reduce the patient’s risk of falling.
       3. Recommend that the patient ensure that the exterior and interior stair treads are in good condition and that there are no weak or missing steps.
       4. Recommend that any uncarpeted steps have a nonslip surface such as adhesive strips.
       5. Recommend that the patient have the edge of steps painted a contrasting color.

          Rationale: A contrasting color increases the visibility of each step.

       6. Recommend that the patient keep all walkways free of clutter to avoid falls.
    2. Advise the patient on the type of flooring.
       1. Recommend one type of flooring throughout the house to decrease any thresholds.
          1. Any vertical change in height in flooring should be 0.6 cm (¼ inch) maximum (Figure 1).¹
          2. A threshold between 0.6 to 1.3 cm (¼ to ½ inch) should be beveled with a slope that is no steeper than 1:2 (Figure 2).¹
       2. Recommend that carpeting be dense and low pile (no more than 1.3 cm [½ inch]) (Figure 3), with a thin padding and tight weave to make it easier to walk or use wheels on.¹ Recommend avoiding busy patterns in carpets to reduce the risk of falls.¹
       3. Recommend that wood flooring have a matte finish, which is less slippery and creates less glare than a glossy finish, to reduce the risk of falls.
       4. Recommend that tile floors be slip resistant and maintained to avoid any broken pieces.
    3. Advise the patient on safe lighting in the home.
       1. Recommend that the hallways be well lit so the patient can see in front as well as behind.
       2. Recommend that the patient add lighting as needed to ensure that staircases are well lit. Ensure that there is an accessible light switch at both the top and bottom of staircases.
       3. Recommend that the patient place night-lights near all steps and staircases.
       4. Assess whether all light switches are easily accessible and recommend moving them as needed.
       5. Recommend that the patient have toggle switches installed.

          Rationale: Toggle switches are easier to turn on and off.

       6. Recommend that the patient use light-emitting diode (LED) bulbs.

          Rationale: LED bulbs create less glare than other lighting sources.

       7. Recommend that the patient use task lighting or additional lighting in areas where tasks that require more light are completed. This may involve:
          1. Adding lamps or lighting to areas where the patient reads, pays bills, or keeps medications
          2. Adding swivel lamps for direct light on tasks
          3. Adding low-wattage lamps closer to the tasks at hand instead of high-wattage overhead lights
       8. Recommend that the patient use dimmer switches to obtain the best lighting for the patient’s needs.

          Rationale: Dimmer switches allow the patient to adjust lighting for specific activities (e.g., task lighting) versus having a specific wattage and then turning the lights off.

12. Remove PPE and perform hand hygiene.
13. Document the procedure in the patient's record.

MONITORING

1. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.
2. Observe the patient for signs and symptoms of orthostatic hypertension. If this condition is suspected, report it to the authorized practitioner.
3. Observe the patient's functional mobility throughout the home while going over the flooring recommendations. If the patient is unable to complete functional mobility safely, educate the patient and caregiver.
4. Observe the patient turning on and off the lighting in the home. If the patient is unable to complete this safely, educate the patient and caregiver.

EXPECTED OUTCOMES

• Patient participates in home safety assessment of the flooring and lighting.
• Patient understands and implements home safety modification recommendations.

UNEXPECTED OUTCOMES

• Patient and caregiver do not acknowledge risks identified from the home safety flooring and lighting assessment.
• Patient or caregiver fails to implement modifications agreed upon during evaluation and intervention.
• Patient suffers a fall or injury in the home.

DOCUMENTATION

• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions
• Flooring and lighting safety assessment and recommendations
• Changes made within the environment
• Assessment of pain

OLDER ADULT CONSIDERATIONS

• Older adults are at greater risk for falls due to age-related physiologic changes.⁵
• Age-related neurologic and musculoskeletal changes place older adults at risk for decreased balance.

REFERENCES

1. Department of Justice. (2010). 2010 ADA standards for accessible design. Retrieved June 5, 2024, from https://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards.pdf
2. Lim, Y.M., Kim, H., Cha, Y.J. (2020). Effects of environmental modification on activities of daily living, social participation and quality of life in the older adults: A meta-analysis of randomized controlled trials. Disability and Rehabilitation. Assistive Technology, 15(2), 132-140. doi:10.1080/17483107.2018.1533595
3. Maggi, P. and others. (2018). Fall determinants and home modifications by occupational therapists to prevent falls: Facteurs déterminants des chutes et modifications du domicile effectuées par les ergothérapeutes pour prévenir les chutes. Canadian Journal of Occupational Therapy, 85(1), 79-87. doi:10.1177/0008417417714284
4. Naseri, C. and others. (2018). Reducing falls in older adults recently discharged from hospital: A systematic review and meta-analysis. Age and Ageing, 47(4), 512-519. doi:10.1093/ageing/afy043
5. Roy, N. and others. (2018). Choosing between staying at home or moving: A systematic review of factors influencing housing decisions among frail older adults. PloS One, 13(1), Art. No.: e0189266. doi:10.1371/journal.pone.0189266
6. Siebert, C., Smallfield, S., Stark, S. (2014). Occupational therapy process for home modifications. In Occupational therapy practice guidelines for home modifications (pp. 11-40). Bethesda, MD: AOTA Press.

Clinical Review: Meghan Jackson, OTR/L

Published: July 2024