Hi, I'm Quincy Samus, I'm an applied gerontologist with experience in dementia care research in the community, helping people and their families with dementia stay at home. In this talk, we'll be assessing the role of home and community environments in supporting families who are dealing with loved ones suffering from dementia. The goal of assessing home and community supports is really to provide a safe, supportive, and engaging environment to promote independence, quality of life, and dignity for the patient and also to minimize and alleviate carer stress. Assessing environmental supports is really important for dementia patients because dementia often leads to poor judgement, poor reasoning, and poor decision making, executive function. It also creates confusion in time and place orientation, and impaired acuity of the senses, including visuospatial abilities and language. Over 90% of patients suffer also from behavioral problems at some point in the disorder. These could include agitation, delusions, hallucinations, wandering, and night-time sleep disturbances. Some examples of the risk areas in the home and community should be assessed include things like fall risk safety, wander risk, self-neglect, driving safety, risky behaviors including fraud, abuse, and exploitation, and also medication management problems. It's ideal to assess for these risk areas by collecting information from the patients, from the families, and also from doing home inspections of the environment to see the living conditions that people are living in. For fall risk safety, some of the important things to assess for are home environment hazards. These could include things like clutter, lack of grab bars, scatter rugs, hoarding. Also, people who have a history of falls, gait problems, muscle weakness, or deconditioning, and also multiple medical problems could lead to falls. In terms of wander risk, it's very important to assess for the severity and our psychiatric symptoms of the patient. Also history of wandering, getting lost, how the home is secured and set up, and how the locks of the entrances and exits are handled. And, also lack of supervision during the day and at night when the person could be alone and at risk for wandering. In terms of self-neglect, you can assess for how the person appears, whether they are keeping with their hygiene, whether their appearance is unkempt, whether they look malnourished, soiled furniture, bedding, unpleasant odors, both on the person and also in their home, and also in the refrigerator you can look for out of date or rotting food. In terms of driving, a very simple way to access for potential safety issues is to ask the family if they feel comfortable about allowing a young child to ride with the person. Often, that will give you a good glimpse into whether they should still be driving. Checking also the car for evidence of accidents or places where they have run into things, that's another good indication. History of becoming lost while driving in familiar areas, and also driving errors, and accidents, and citations are good indicators. In terms of risky behavior such as including fraud, abuse and exploitation. There could be history of cooking errors where they have left things on the stove and started small kitchen fires. Also evidence that they've been allowing strangers into their home. Or giving away money to people who they would not normally be giving money to. In terms of managing finances, they could, indicators could be bouncing checks, paying bills multiple times or not paying. And also, you should assess for evidence of verbal or physical abuse and also ask about their neighborhood environment and whether or not it's high crime Which would put them at risk for some of these exploitations or abuse. In terms of medications, which is a very common risk area, evidence of them not taking medicines So, screening them on whether or not how they are swallowing their medicine, how they are getting their medicine, are they having to go to multiple prescribing providers to get their medicine, are they having to go to multiple pharmacies. Checking the medicines doing perhaps a brown bag review, to see if they are taking out of date medicine. Are other effective ways of assessing for potential problems. Other risk areas include guns and dangerous objects, emergency planning, environmental danger, having a daily schedule for their daily activities, spiritual support, and social isolation. In terms of guns and dangerous objects, it's wise to find out if they're unsecured guns or ammunition in the home. Knives that are in places that they could access, swords, power tools, other dangerous objects. Also harmful chemicals, that they could potentially ingest because they smell Like shampoo because they smell so wonderful. And also assess the person for delusion and neuropsychiatric symptoms that may lead to use of or access in dangerous objects. And in terms of emergency planning, asking whether or not the family has a plan for emergencies such as hurricanes or other disasters. Asking if they have a list of medical contacts for their providers and a list of the current medications that they're taking. Also asking whether or not they have food and water storage in the home that could be used in case of electrical outages in other situations like that. In terms of environmental dangers, it really refers to how the maintenance and the upkeep of their living environment is. Are there broken steps? Is there poor lighting? Are there steep steps? Are the smoke and carbon monoxide detectors operable? Do they have infestation such as bedbugs? Also, chemicals that could cause harm. Daily life schedule is very important for their quality of life and also for engaging them in stimulating and meaningful activities. To assess for that you could ask what is their daily routine like on a typical Difficult day, are there activities planned that are interesting to the person, and that they engage in. Spiritual support is another risk area, and you could assess for that using, finding out first of all if they're spiritual and if their spiritual needs are being met, and then whether or not they have access to go and be involved in those spiritual activities. Social isolation is another concern in terms of loss of social network, the availability of the informal caregiving network. And also how close their families are to their resident. To give Hypothetical examples to illustrate some of this risk areas. This is the case of 88 year old retired school teacher, with early dementia living at home with her husband. She had significant memory impairment, but was not yet diagnosed or treated for the dementia. She suffered also from peripheral neuropathy and vision problems due to diabetes. She also had a recent unexplained weight loss. So in this picture, things to consider given her situation would be the fall risk In terms of the clutter that you can see stacked up along the walls. Making sure that people have clear unobstructed pathways reduces fall risk. And also you can see the pet on the top of the chair. In some cases pets may actually become a fall risk if they're around the person's feet. And they don't see them, or they're not able to move around them. And this particular cases refrigerator, what you can see here is a kind of messy- A collection of food that some of which looks like it's been in there for a while. So this would be one case where it would be great to be able to get into the home and assess what she's eating and how her nutritional needs are being met. For this case because She has dementia She show the primary person He prepares the meal,in this situation is very common for people to begin have cooking areas where they turn on the stove and leave the food on and they burns and. And can either cause a lot of smoke or also small fires, or big fires. [LAUGH] In this case, you can see that the smoke detector was actually disengaged by taking the battery Because it had been going off so many times. So checking whether or not smoke detectors are working and also possibly putting in safety mechanisms for the stove are excellent ideas. And things to assess for. In terms of medication errors she has memory impairment, she also has poor vision. And as you can see on the bottom picture the medication is, the medications are not kept in a. Orderly fashion. The medication pill bottles that are turned upside down are actually ones that still need to be refilled. You can see clearly that it would be very easy to lose medications on top of the table. So visually checking how people are storing their medications can be very helpful. In another example, we have a 96-year-old retired dentist with mild to moderate Dementia, who is living at home with his wife who is also his caregiver. He has gait and steadiness and syncope. He also has persistent paranoid delusion that his wife is having other men In her room at night, he also has a tendency to kind of escape out the back door unattended and unnoticed by the family members. In his case. It would be very important to consider forest management which would include things like making sure that there's grab bars in place and that they're fastened in the right location and securely fastened. Also providing shower benches Are a shower bench and a shower wand may be things to assess for. And also scatter rugs either having assessing whether the scatter rugs pose a fall risk and having them removed or either having them taped or tacked down to the floor. Other structural fall hazards might be things like door sills. In this case, in the bottom picture you can see that this is a raised door sill that you could actually possibly put some colored tape on to increase the visibility of it. In his case also he suffers from delusions and paranoia that his wife is having an affair,. Here in his room where he actually sleeps you can see large, a large sword on the wall and also a dagger on the wall. >> This will be a good case where you would want to ask the family if there is access to any dangerous weapons or guns or tools or knives, in case that, he were to act on his delusion and cause harm to other people. Another thing to consider in this case is his proclivity to wonder away unattended. One thing to access for would be the security of the doors. In this case, in this picture you can actually see a door chime alarm system that has been put into place that actually notifies the family members when doors are opened and gives them audio of which door was opened. So that increases this, decreases the risk that he could leave without anyone knowing. So in summary these have just been a few examples of potential risk areas that you would want to assess that are related to the home and community. These are very important to consider in supporting the patients and families over the course of the illness. Proactive assessment may help prevent accidents, emergencies, and harm to the patient, and also to others. Ongoing assessments of these types of supports and risk areas are needed as the needs change with the progression of the illness. Risk screening tools are available online and also in books as well as professional home safety evaluations.
