Home Safety: Alzheimer’s Disease and Dementia

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Introduction   

Alzheimer’s Disease and Dementia affect many millions of people throughout the world. In the United States, 2020 numbers estimate that 6.9 million adults have Alzheimer’s Disease and dementia. Cognitive decline of any type affects 1 in 10 people aged 45 years and older. The cognitive effects of Alzheimer’s and dementia cause over 40% of sufferers to have to give up their usual daily activities. One in three people report that their cognitive decline caused them to miss work, volunteering, or social activities. It is estimated that 35% of individuals with cognitive decline require help with household tasks [1].  

These challenges contribute to patients and caregivers deciding how care should proceed while balancing the patient’s wishes, needs, and safety. Many people choose to remain in their homes as they experience dementia and Alzheimer’s Disease. Nurses can contribute to supporting patients and their caregivers by assessing, educating, and advocating for a safe home environment for individuals experiencing Alzheimer’s Disease and Dementia.  

Alzheimer’s Disease and Dementia: A Review 

This course will focus on home safety for patients with Alzheimer’s Disease and Dementia. While we will not explore these diagnoses in-depth, we will review the basics.  

Dementia is a condition that impacts an individual’s ability to remember, think, and make informed decisions. While memory problems commonly occur with aging, dementia is not a normal part of the aging process. Forgetting knowledge, personal experiences, old memories, and language indicate that memory problems are more significant than age-related memory difficulties. Dementia can also affect communication, reasoning, judgment, and visual processing [2].  

There are four common types of dementia: 

• Lewy Body Dementia is caused by abnormal deposits of a particular protein, called Lewy bodies, that interfere with the brain’s chemical messages. It typically occurs in patients older than 50 and is characterized by attention difficulties, disordered thinking, muscle rigidity, coordination problems, reduced affect, insomnia, fatigue, and visual hallucinations [3].  

• Frontotemporal Dementia occurs when abnormal amounts of proteins accumulate in the neurons of the frontal and temporal lobes. This decline generally occurs between ages 45 and 65. It is categorized as having difficulty with planning and organizing, impulsiveness, increased or decreased expression of emotions, shaky hands, problems with balance and walking, and challenges with expressive and receptive speech [3].  

• Vascular Dementia is caused by decreased circulation to the brain, usually due to blood clots. It typically occurs in patients older than 65. These patients often experience forgetfulness of both current and past events, difficulty retaining new information, difficulty following instructions, hallucinations, delusions, and poor judgment [3].  

• Alzheimer’s Disease: Abnormal amounts and forms of proteins that are supposed to stabilize neuron structures form plaques and protein tangles throughout the brain. It usually occurs in patients older than 60 but has been observed in some individuals in their 30s. Patients with this type of dementia experience varying levels of cognitive decline, from repeating questions frequently to total loss of communication abilities [3]. 

Alzheimer’s Disease is the most common form of dementia. A healthy lifestyle, including regular exercise, can help lower the risk of memory loss or slow disease progression. Treatments vary and work to maintain cognitive status, manage symptoms, and delay disease. These treatments are most successful when initiated in the early phases of the disease [2].   

Caregivers 

Individuals with Alzheimer’s disease and other types of dementia need varying, though typically progressive, levels of caregiver support. This can be from family and/or friends, and over 11 million adults in the United States provide care for someone with dementia in a non-professional capacity. Most caregivers of an individual with dementia provide care for four years or more. Caregivers play an incredibly significant role in the life of their loved one experiencing any type of dementia.  

Nurses are essential to come alongside these caregivers to provide guidance and encouragement and enhance safety for the caregiver and patient [2] When caregivers feel confident in their ability to provide a safe home environment for their loved one, their ability to succeed increases [4].  

Home Safety 

Risk Factors 

Approximately 80% of patients with Alzheimer’s disease and other types of dementia receive care at home [2]. While an individual’s home may usually be safe, the experience of dementia creates safety hazards that would otherwise likely not exist. Dementia can affect judgment, orientation to time and place, behavior, balance, and how the senses perceive input, which can all cause unintentional injury. Household cleaners, tools, and chemicals stored in the basement, garage, or workshops can present particularly harmful risks. There are many potential safety issues in the kitchen, including injury from garbage disposals and sharp utensils and fire risks from ovens, stoves, and microwaves. Even sugar substitutes, cooking seasonings, plants, vitamins, medications, and home décor can present safety problems [5].  

Judgment problems may cause someone to give money to door-to-door solicitors, dress inappropriately for the weather, or take too much of their medication. Problems with orientation to time and place can confuse them when they see their reflection in a mirror. Behavior changes may make a usually docile person aggressive or prone to wander. A decreased ability to balance can increase the risk of falls, which is already typically increased for older people. An unreliable sensory system may contribute to unintentional burns, failure to respond to an emergency, or accidentally ingesting spoiled foods [6].  

Understanding these potential safety hazards can help nurses and caregivers address each problem to create a safe environment for the patient [4].  

Safety Interventions 

Safety modifications made in the home should be considered using the Person-Environment-Occupation (PEO) model. This model focuses on the interactions between the patient, their setting, and the tasks they need to complete safely. Changes in any of these areas will alter how the person functions in their home. The interdisciplinary team, especially occupational therapy, can be a valuable asset when determining what changes should be made to allow the patient and caregiver to continue pursuing their preferred activities [4].  

Providing a safe home environment for people with Alzheimer’s and dementia can help them to remain at home with family/caregivers. A safe environment can also decrease stress for caregivers. The first step in creating a safe home environment is to assess the home. Each room should be evaluated for potential safety concerns. Any immediate dangers, like loose railings, tripping hazards, and poor lighting, should be addressed first. Many interventions can contribute to a safer environment. As the nurse and caregiver evaluate each room, they can also create a list of changes that can be made.  

General 

• Label rooms with brightly colored signs 

• Limit mirrors in the home to prevent confusion 

• Pad sharp corners on furniture 

• Place decals on sliding glass doors or furniture with glass panels to help identify the glass plane 

• Place and frequently check smoke and carbon monoxide detectors 

• Install nightlights throughout the home 

• List emergency numbers near each phone 

• Remove poisonous plants from the home 

• Secure or remove firearms 

• Remove portable space heaters 

• Store all medications, vitamins, and supplements out of sight 

• Use medication organizers to help patients keep track of if/when they took medications 

• Learn basic first aid and CPR 

• Consider using outlet covers and cabinet locks 

• Install a notification system to alert caregivers when power is lost in the home 

• Remove locks on interior doors and keep an extra set of house keys 

• Secure large furniture 

Fall Safety 

• Remove tripping hazards, such as curled or thick area rugs and clutter 

• Place brightly colored tape on the edges of the steps 

• Paint walls a bright, light color to contrast with darker floors 

• Ensure all stairs have at least one handrail and that it is not loose 

• Evaluate for electrical cords that could cause someone to trip 

Kitchen 

• Place signs near the oven and stove that say things such as “HOT!” or “DO NOT TOUCH” 

• Check the refrigerator, cabinets, and pantry often for foods that may be expired or spoiled 

• Consider disconnecting the garbage disposal or blocking access to the switch that controls it 

• Add safety knobs, automatic shut-off mechanisms, or child-proofing products to stove and oven controls 

• Remove alcohol from the home 

• Remove/secure knives and other sharp items 

• Place large print instructions next to appliances that must be used, like the toaster, microwave, or coffee pot 

Bedroom 

• Use a monitor that can alert the caregiver to a fall in the night 

• Use caution with electric blankets and heating pads 

• Install bed rails  

• Provide mobility aids within reach of the bed 

• Provide seating near the dresser/closet to help with dressing 

• Rotate clothing with the seasons to assist with weather-appropriate attire 

Bathroom 

• Remove small appliances from the bathroom 

• Put hygiene items, such as toothpaste and perfume, out of sight, as these could be confused for foods 

• Install grab bars for the shower and toilet 

• Use a raised toilet seat 

• Place non-skid strips in the bathtub and on hard floor surfaces in the bathroom 

• Install rubber faucet covers  

• Consider installing a walk-in shower 

Garage/Basement/Laundry/Utility Room 

• Remove flammable items, such as gasoline and matches 

• Enhance lighting 

• Remove/secure tools 

• Store vehicle keys in an inaccessible location 

• Adjust the water heater so that water is not heated above 120 degrees Fahrenheit, which can cause burns 

• Place safety mechanisms on the thermostat  

• Store laundry detergent/pods out of sight and in their original packaging 

• Clean out lint screens and dryer ducts regularly 

• Ensure toxic cleaning products are stored securely 

Outdoor Areas 

• Ensure proper lighting at entrances 

• Install a video doorbell and/or outdoor motion-sensing cameras to alert the caregiver if the individual wanders out of the home 

• Limit access to yard maintenance equipment 

• Consider alerting neighbors to the situation so they can notify the caregiver of any concerning observations 

[6] [7] [5] 

Technology and Home Safety 

Like other areas of healthcare, technology can enhance home safety for people with Alzheimer’s disease and dementia. Video sessions for medical appointments benefit patients and their caregivers as they do not have to greatly disrupt the patient’s routine, drive in inclement weather, deal with mobility challenges, or encounter ill people. Caregivers of those experiencing dementia have reported equivalent satisfaction with this type of appointment as in-person appointments.  

The recent development of telemedicine software has made this type of care more accessible [8]. Using telehealth technology to conduct virtual home assessments has been studied. Some results have shown that issues with technology troubleshooting and understanding how to use the technology have been challenges for some caregivers [9]. More studies are needed to develop evidence-based strategies for telehealth technology to provide PEO-focused home assessments [4].  

Role of Nurses 

As previously reviewed, nurses can have a meaningful impact on the lives of patients with Alzheimer’s disease and dementia. Nurses can assess the home environment for safety, provide patient and family education, and advocate for their patients. Caregivers may choose in-home care to prolong the time the individual can remain at home. This may require in-home care by nurses or certified nurse aides.  

When providing care in the home, nurses contribute to safety by practicing evidenced-based nursing care and communicating effectively with caregivers and members of the healthcare team. A Registered Nurse must also supervise CNAs working with patients in the home. The nurse is responsible for developing the care plan for the CNA, assessing the patient and environment, delegating tasks, and providing ongoing supervisory visits.  

Nurses may also work in outpatient clinics or inpatient settings. Both settings provide opportunities to assess, educate, and advocate.  Home safety checklists and diagnosis-related education can be given to patients and their caregivers. Nurses can listen to evaluate concerns and help find resources to meet specific needs. Nurses in the outpatient setting may become familiar with patients and can help identify changes in the patient’s cognition, which could affect judgment and safety. Nurses in the inpatient setting are vital in ensuring that the discharge plan is safe for the patient and that they can follow discharge instructions. Communication with the caregiver in each setting is an essential way nurses contribute to home safety.  

Assessment 

Assessing the home environment can be overwhelming for a caregiver. The nurse can help identify and prioritize changes that need to be made. In some cases, caregivers may not have considered some of the safety concerns the nurse may identify. The physical and cognitive assessment of the patient can also aid in identifying needs or changes in needs. Home modifications should be patient-centered, using the PEO model, and tailored to the patient’s progressive cognitive and occupational decline [4]. 

Patient and Family Education 

Safety priorities for home care patients can vary, but most caregivers and healthcare providers agree that mobility-related issues concerning falls and wandering are a top priority. Even a frequently lucid patient may experience confusion, which could contribute to a fall. Factors that disrupt the patient’s usual routine and care most contribute to adverse events [10]. Fall education for caregivers is essential.  

Web-based caregiver education programs are being trialed to assess for effectiveness. The requirement for personalized education that includes information relevant to the patient and caregiver’s unique needs is suggested as implementation, and favorable outcomes may be more likely. In a small study conducted to assess the implementation of an online caregiver education platform, 84.4% of caregivers reported using skills they learned during the training. Researchers concluded that an online platform for dementia education may be effective for some caregivers, but others may not embrace the use of technology as well.  

Home safety education can be conducted virtually, but nurses should evaluate the caregiver, patient, and needs to determine if this type of virtual learning is appropriate [11].  

Regardless of the type of dementia a patient is experiencing, nurses are essential in advocating for the best interests of their patients. Nurses can advocate by bridging perspectives. Sometimes, the medical treatment recommended may conflict with the caregiver’s views. Nurses can help facilitate the conversation to uncover the concerns and find the best solutions for the patient. Nurses can advocate for their patients by embracing a shared humanity. They can recognize that the patient is an individual with a history, family, interests, and ideals, but they need professional help to navigate this stage in their life.  

Nurses can affirm belongingness. Patients still belong to their families even when a nurse is supervising care. In the home, it is essential that the nurse advocates for a patient-centered approach for safety but also recognizes that the individual is part of a family in their home, and those relationships are also vital. Even if the family caregiver has chosen to have home health nurses or aids assist in caring for their loved one at home, the caregiver is still an integral part of the care team. They should be kept informed of any changes and involved in decision-making. 

Nurses can also advocate for their patients by empowering voices for change. The economy, new medical advances, changes in health insurance coverage, and health policy all affect how patients receive care and what care they have access to. Nurses can be the voice from the frontline advocating for patients and caregivers by having conversations with policymakers about the needs of patients with Alzheimer’s Disease and dementia and the challenges they face while being cared for at home [12].  

Caregiver Self-Care 

A caregiver’s understanding of home safety is essential for a person experiencing Alzheimer’s Disease or dementia to remain safe in their home. Injuries can be prevented by nurses guiding caregivers regarding safety interventions and supervision of their loved ones [13]. When the caregiver at home feels confident and supported, the patient can stay in their home for a longer period and receive a higher quality of care.  

It is important to educate the caregiver not only on home safety strategies but also on the importance of self-care. Nurses should emphasize to the caregiver that by caring for themselves, they are improving the safety of their loved ones. Some recommendations for caregiver self-care include asking for help when needed, eating a nutritious diet, joining an online or in-person support group, taking breaks each day, spending time with friends, continuing hobbies, exercising, meditation, and seeking help from a professional counselor when needed [7].  

Conclusion

Dementia and Alzheimer’s Disease affect a significant portion of the population, either as a patient or a caregiver to a loved one. When the patient and caregivers desire their family member to remain at home as long as possible, nurses can help facilitate this wish by contributing to home safety. Home safety must focus on physical interventions but also consider cognitive changes and how they may affect how the patient interacts with their environment.  

Nurses working with this population should educate themselves on various types of dementia and safety concerns associated with different diagnoses. Being aware of different safety issues and prevention strategies can help the nurse inform their patient care plan. Through assessment, education, and advocacy, the support nurses give patients and caregivers can prolong the time patients can safely remain at home.  

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