Home, Safe Home: Minimizing the Risks for the Cognitively Impaired in the Community
David B. Hogan, MD, FACP, FRCPC, Professor and Brenda Strafford Foundation Chair in Geriatric Medicine, University of Calgary, Calgary, AB.
Dementia is a common condition that places its victims at risk for injury. This article provides an overview of home safety for those with dementia. A conceptual approach to this management challenge is the Home Safety / Injury Model described by Hurley and colleagues. I focus on two common safety concerns: wandering and falls. Unfortunately, most recommendations are based on “common sense” (i.e., what seems reasonable). Whether these approaches actually decrease the likelihood of harm is largely unknown. It is anticipated that future research will lead to evidence-based recommendations.
Key words: dementia, home safety, wandering, falls.
Introduction
Dementia affects 8% of older Canadians (65 years of age or greater).1 Approximately one-half of older Canadians with dementia live in the community at large and, of this group, a third reside alone.2 The cognitive, functional, and behavioural manifestations of dementia can place the older individual with dementia at risk for harm. Trying to balance respect of autonomy with personal and public safety is challenging for the clinician.3 Unfortunately, little data is available on which to derive evidence-based recommendations. This paper discusses an approach to increasing the home safety of cognitively impaired older adults.
Risks for Injury in the Home
Relatively common risks for injury in the home for those with dementia include wandering, falls, fire from smoking or leaving the stove on, and access to potentially harmful items like knives and firearms. With regard to the latter, an American study found that firearms were present in most (60.4%) households that had a demented member.4 Gun ownership did not become less likely when the dementia was severe or if the demented individual had behavioural and psychological symptoms. Only 16.9% of families reported that guns were stored in an unloaded state.
Continuous supervision 24 hours a day, seven days a week would be one strategy to deal with these risks, but this is often not feasible in the general community. Caregivers may take chances, leaving the person with dementia alone for prolonged periods of time. Deciding whether this represents a reasonable risk requires careful consideration. Questions to ask about the person with dementia in trying to weigh the degree of danger would include asking whether s/he
– becomes confused or unpredictable under stress
– recognizes a dangerous situation (e.g., fire)
– knows how to use the telephone in an emergency
– knows how to get help
– stays content within the home
– wanders and becomes disoriented
– shows signs of agitation, depression, or withdrawal when left alone
– attempts to pursue former interests or hobbies that might now warrant supervision (e.g., cooking, repairs, woodworking)5
General Approach to Home Safety
It is possible to screen for some of the home safety risks encountered by those with a dementia. Louise Poulin de Courval and colleagues developed, tested, and validated the Safety Assessment Scale to determine the likelihood for select accidents (i.e., fires/burns, malnutrition, food poisoning, nonadherence with medications, wandering, hypo/hyperthermia) in individuals suffering from a dementia.6 According to their website (http://www.clsccote-des-neiges.qc.ca/sas/), scores of 11 to 14 indicate a moderate risk while those 15 or higher denote a high risk for an accident.
A good general reference for caregivers is the National Institutes of Health brochure, “Home Safety for People with Alzheimer’s Disease.”5 The recommended guiding principles for caregivers are think prevention, adapt the environment, and minimize danger. General and specific (room-by-room and behaviour-by-behaviour) suggestions are made to improve safety. In the rest of this paper we’ll focus on two