Home Modifications for People With Alzheimer’s

Disease: A Scoping Review

Linda R. Struckmeyer, Noralyn Davel Pickens

MeSH TERMS OBJECTIVE. The purpose of this review was twofold: (1) to gain insight into what is known from the
 Alzheimer disease literature about home modifications for people with Alzheimer’s disease (AD) and (2) to identify gaps in
the literature that could lead to opportunities for research.
 architectural accessibility
 caregivers
METHOD. A systematic scoping review of peer-reviewed articles published from 1994 through 2014 ex-
plored home modifications and AD.
 environment design
RESULTS. Seventeen articles met the inclusion criteria. The three major findings pertain to (1) the care-
 patient-centered care
giver role and caregiver training, (2) a client-centered collaborative approach to assessment and intervention,
 self-help devices and (3) modifications for safety and function. Home modifications involved the physical and social envi-
 social environment ronments as well as cognitive strategies at the task level.
CONCLUSION. Opportunities exist for the development of assessment procedures, the exploration of
home modifications in the later stages of AD, and the study of home modification needs of people with
dementia who live alone.

Struckmeyer, L. R., & Pickens, N. D. (2016). Home modifications for people with Alzheimer’s disease: A scoping review.
American Journal of Occupational Therapy, 70, 7001270020. http://dx.doi.org/10.5014/ajot.2015.016089

Linda R. Struckmeyer, MA, OTR/L, ATP, is Clinical

Lecturer, Department of Occupational Therapy, University
of Florida, and Doctoral Student, Texas Woman’s
A lzheimer’s disease (AD) is the most common type of dementia and ac-
counts for 60%–80% of all dementias (Alzheimer’s Association, 2014).
The Alzheimer’s Association (2014) has estimated that 5.2 million Americans
University, Dallas; [email protected]
have been diagnosed with AD; that figure is expected to triple by 2050. Of the
Noralyn Davel Pickens, PhD, OT, is Associate 5.2 million people with AD, 5 million are age 65 yr and older (Alzheimer’s
Professor and Associate Director, School of Occupational
Therapy, Texas Woman’s University, Dallas.
Association, 2014). A recent study by AARP (2014) found that more than 87%
of adults older than age 65 want to stay in their home as they age and that most
people with AD living at home had a caregiver living in the same home.
However, it has been estimated that 15% of people with AD live alone
(Alzheimer’s Association, 2012). One means of aging in place, whether alone
or with a caregiver, is to modify the home environment for safety and par-
ticipation. Home modifications have been shown to facilitate performance
and decrease caregiver stress, both of which support aging in place for people
with dementia (Gitlin, Hauck, Dennis, & Winter, 2005).
Gitlin (1998, p. 190) defined home environmental modifications as “a vast
array of strategies” that include structural renovation, assistive devices, place-
ment of visual cues and memory aids, and rearrangement or removal of fur-
niture and dangerous household items as well as the simplification of tasks. The
Occupational Therapy Practice Guidelines for Home Modifications (Siebert,
Smallfield, & Stark, 2014) defined home modifications as adaptations to envi-
ronments that are intended to increase use, safety, security, and independence.
Home modification is a process that includes evaluation, identification and im-
plementation of solutions, training, and outcomes assessment. For people with
AD and their caregivers, home modification is an ongoing process because of the

The American Journal of Occupational Therapy 7001270020p1

progressive needs of the person with AD and resulting identify those articles that met criteria for further re-
needs of the caregiver (Olsen, Ehrenkrantz, & Hutchings, view. The authors met to debate and reach agreement
1996). on final article selection on the basis of the guiding
In an attempt to explore the impact of home environ- question “What is known from the existing literature
mental modifications for people with AD and their caregivers, about home modifications for people with AD living
we found there were no systematic reviews specific to home at home?” After final selection, both authors reviewed
modifications for people with AD. Evidence-based practice the articles in depth, creating a synthesis table as rec-
is strengthened by systematic reviews of the literature ommended by Aveyard (2010) to identify main ideas
(Arbesman & Lieberman, 2011). More evidence is needed and determine where gaps exist. Figure 1 illustrates the
specific to home modifications for successful aging in place decision-making process.
of people with AD.
The purpose of this scoping review was to gain in-
Results
creased insight about home modifications for people with
AD and to identify gaps that could lead to further research. The search strategy resulted in a total of 513 articles, of
Through this scoping review, we sought to answer the which 43 met the criteria for full article review. Appli-
question “What is known from the existing literature cation of the inclusion and exclusion criteria resulted in 17
about home modifications for people with AD living at articles on home modifications for people with AD living
home?” at home. The design of studies varied; 6 were randomized
controlled trials (Chee, Gitlin, Dennis, & Hauck, 2007;
Gitlin & Chee, 2006; Gitlin, Corcoran, Winter, Boyce,
Method & Hauck, 2001; Gitlin et al., 2005; Horvath et al., 2013;
A scoping review is a structured method for gathering Tchalla et al., 2013); 1 was a single-group study com-
background information useful in identifying gaps in the paring standard and user-centered intervention conditions
literature; summarizing findings (Armstrong, Hall, Doyle,
& Waters, 2011); and exploring the extent, range, and
Search terms:
nature of the research activity (Levac, Colquhoun, & Alzheimer’s disease [MeSH]
Home modifications
O’Brien, 2010). A scoping review was chosen over a sys- Housing for the elderly [MeSH]
tematic review because the purpose was to gain knowledge, Architectural accessibility
[MeSH]
not to evaluate the quality of the studies. Environment design [MeSH]
Aging in place
We worked with a research librarian to obtain guidance Assistive technology
Adaptive equipment
on scoping reviews, database choices, and development of
search strings. Databases searched for this study were Electronic sources:
Cochrane Review: 0
Excluded articles by title,
PubMed, CINAHL, PsycINFO, and Google Scholar. PubMed: 109
abstract, keywords: long
CINAHL (EBSCO): 120
RefWorks bibliographic software provided the platform PsycINFO (EBSCO): 4
term care, nursing home,
assisted living facilities,
Google Scholar: 280
for data storage and review. The combination of key words medications, animal
research, diagnosis other
and MeSH terms identified for the search were as follows: than Alzheimer’s and other
nonrelated dementias, and
Alzheimer’s disease, home modifications, housing for the el- secondary reviews
derly, architectural accessibility, environment design, aging PubMed, n = 96
CINAHL, n = 106
in place, assistive technology, and adaptive equipment. In- PsycINFO, n = 1
Articles for further review Google Scholar, n = 267
clusion criteria were peer-reviewed, English-language (n = 43)
PubMed, n = 13
scientific literature published between January 1994 and CINAHL, n = 14
PsycINFO, n = 3
July 2014, specific to people with AD, and specific to the Google Scholar, n = 13 Excluded articles after full
home environment. Articles were excluded if they were review that were methods or
model development,
pharmacological intervention or animal studies or involved residential settings,
dementias that can be definitively diagnosed, such as Lewy secondary reviews, diagnosis
other than Alzheimer’s and
body dementia, frontal lobe dementia, Parkinson’s de- Articles selected (n = 17) other nonrelated dementias
PubMed, n = 5 or not research study
mentia, and vascular dementia. Although we searched CINAHL, n = 6 PubMed, n = 8
PsycINFO, n = 1 CINAHL, n = 8
specifically for Alzheimer’s disease, some articles used the Google Scholar, n = 5 PsycINFO, n = 2
term dementia interchangeably with Alzheimer’s disease. Google Scholar, n = 8

Both authors independently reviewed all titles, ab- Figure 1. Decision-making process for inclusion of articles in the
stracts, and key words of articles from the search results to study.

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(Giovannetti et al., 2007); 1 was a single-group study with design of a house being built specifically for a person with
five intervention sessions over 3 mo (Gitlin, Corcoran, AD. An example was the incorporation of an open floor
Winter, Boyce, & Marcus, 1999); and 1 study measured plan in which both the caregiver and the person with
the use of assistive technology and home modifications dementia could see each other from almost all positions in
over 1 yr (Mann, Hurren, Charvat, & Tomita, 1996). the home.
The remaining 8 studies were qualitative and descriptive The physical health of the caregiver was also associated
in design (Table 1). All the studies were limited to a small with adherence to home modification strategies. Researchers
geographic region. found that caregivers in poorer health may not benefit from
The number of study participants ranged from 2 environmental skills training, meaning that they are less likely
(Sheldon & Teaford, 2002) to 171 (Gitlin et al., 2001). to implement or follow through with recommendations
One study included only people with dementia as par- (Chee et al., 2007). Other barriers to implementation of
ticipants (Giovannetti et al., 2007), whereas all the other home modifications were linked to caregivers’ lack of
studies included caregivers of people with AD as partic- knowledge about the disease process and available re-
ipants. Thirteen studies focused on the family or personal sources (Gitlin et al., 1999). Gitlin and Chee (2006) and
caregiver of the person with dementia. One study involved Horvath et al. (2013) attempted to overcome these barriers
professional caregivers, such as occupational therapists and by providing caregiver training and adaptive equipment to
nurses (Horvath et al., 2005). Two of the qualitative focus their participants. After addressing these barriers, Horvath
group studies involved environmental designers and people et al. reported small but significant positive changes in
with knowledge of home modifications for AD (van Hoof, caregiver efficacy and reduced strain.
Blom, Post, & Bastein, 2013; van Hoof, Kort, van Waarde, Improvement in caregiver self-efficacy was a frequent
& Blom, 2010). outcome of training (Chee et al., 2007; Gitlin et al.,
We identified three major findings pertaining to home 2001, 2005; Horvath et al., 2013; Lach & Chang, 2007;
modifications for people with AD: (1) the importance of Sheldon & Teaford, 2002). Ten months after training,
the caregiver role and caregiver training; (2) the impor- caregivers reported that 73% of the home modifications
tance of a client-centered collaborative approach to as- were still in use (Gitlin & Chee, 2006). Gitlin and
sessment and intervention; and (3) the importance of a Chee (2006) attributed this finding to the importance
variety of environmental modifications, including physi- of ongoing education and collaboration that fine-tuned
cal, cognitive, and social modifications, to improve safety modifications.
or function. The physical modifications often included the Caregivers had a broad range of needs that included
use of adaptive equipment and assistive technology. The training and collaboration with professionals (Smith,
cognitive modifications were strategies that occurred at the Lauret, Peery, & Mueller, 2001) and wanted resources
task level and involved simplification or cueing. The social and knowledge of home modifications and of the disease
modifications included supervision and cueing. To a lesser process (Chee et al., 2007; Horvath et al., 2013; Smith
extent, the literature discussed the number of home en- et al., 2001). Caregiver training included activities such as
vironmental modifications recommended, the need for education on potential hazards, provision of resources for
follow-up intervention visits to ensure implementation and implementation of modifications, and role-playing and
adherence to recommendations, and the reported under- resulted in modification of the social environment as the
utilization of adaptive devices and home safety modifications. caregiver learned and implemented new skills (Chee
et al., 2007; Gitlin & Chee, 2006; Gitlin et al., 2005;
Caregiver Role and Caregiver Training Horvath et al., 2005). None of the articles included a
The importance of the caregiver’s role in the home en- description of the role-playing or training methods in
vironmental modifications process was a common theme enough detail to replicate them in research or clinical
throughout the literature. The caregiver was part of the practice. However, the importance of the caregiver’s role
social environment and in this role took on more re- in implementing and adhering to home modifications was
sponsibility as the care recipient’s cognitive status declined. clearly demonstrated.
The caregiver was the one who implemented home envi-
ronmental modifications and strategies (Chee et al., 2007; Client-Centered Approach
Mann et al., 1996; Olsen et al., 1996; Sheldon & Teaford, The second major finding in the literature was the im-
2002; Tchalla et al., 2013; van Hoof et al., 2010). Van portance of identifying the individualized needs of the
Hoof et al. (2013) considered the caregiver in the initial person with AD and caregiver. Client-centered care is a

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Table 1. Summary of Main Ideas About Home Modifications for People With Alzheimer’s Disease
Main Ideas
Caregiver Client Environmental
Author/Date Design/Sample Study Aim Involvement Centered Modifications Comment
Chee, Gitlin, RCT; intervention To identify predictors of caregiver X X Caregiver: training,
Dennis, & adherence to strategies implementation, adherence,
N 5 105 caregivers of
Hauck (2007) and efficacy
people with AD. Physical and task level
Giovannetti et al. Crossover design To examine and characterize the X X Cognitive cueing improved
(2007) effect of environmental performance
N 5 46 people with
adaptations on everyday
AD. action in AD
Gitlin & Chee RCT; intervention To describe the low-cost X X X Caregiver training, decision
(2006) technology and the reasons making, and follow-up
N 5 121 families of
why caregivers did not use Client needs change over time
people with AD. prescribed equipment Modifications for safety and
comfort
Gitlin, Corcoran, RCT; intervention To determine the effects of a home X X Ongoing training
Winter, Boyce, & environmental intervention on Physical, social, and cognitive
Hauck (2001) N 5 171 family self-efficacy and upset in modifications
caregivers. caregivers and daily function
of patients with dementia
Gitlin, Corcoran, Feasibility study; To investigate how caregiver X X X Caregiver training improved
Winter, Boyce, & intervention characteristics relate to efficacy
Marcus (1999) the delivery of a home Physical and social
N 5 100 family modifications intervention modifications
caregivers.
Gitlin, Hauck, RCT; maintenance To report the 12-mo maintenance X X Caregiver adherence to
Dennis, & Winter effect at 12 mo effects of the Home intervention and caregiver
(2005) Environmental Skill-Building as client
N 5 127 family Program Simplification at task level
caregivers.
Horvath et al. Qualitative descriptive, To understand caregiver X X X Caregiver training and
(2005) exploratory design competence in everyday collaboration with
life related to environmental professionals for confidence
N 5 17 interdisciplinary
safety in AD and self-efficacy
professionals. Client-centered care difficult
when unsafe
Physical and cognitive
modifications for safety
and behavior techniques
Horvath et al. RCT; intervention To test an intervention to improve X X X Caregiver training and
(2013) caregiver competence in resources reduced strain
N 5 108 patient– creating a safer home and improved self-efficacy
caregiver dyads. environment Collaboration with client
Modifications for safety
devices provided
Lach & Chang Qualitative; group To explore caregivers’ perceptions X X Considered caregiver
(2007) design of safety problems and identify motivation
how they manage safety and efficacy
N 5 39 caregivers of
Physical modifications for
people with AD. safety; cognitive
modifications
for task demands and driving
Lach, Reed, Smith, Qualitative; phone To determine which safety X X Caregiver training
& Carr (1995) interviews problems were most common Physical modifications for
safety, cognitive
N 5 35 caregivers of
management
people with AD. strategies and changed task
demands; included driving
Mann, Hurren, Quantitative; interviews To examine satisfaction rate of X X Caregiver needs changed as
Charvat, & at 1-yr follow-up assistive devices used and AD progressed
Tomita (1996) home modifications Assistive technology for
N 5 19 people with AD implemented during 1-yr study physical and cognitive
and caregivers.
limitations; initially for
restricting behaviors
(Continued)

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Table 1. Summary of Main Ideas About Home Modifications for People With Alzheimer’s Disease (cont. )
Main Ideas
Caregiver Client Environmental
Author/Date Design/Sample Study Aim Involvement Centered Modifications Comment
Olsen, Ehrenkrantz, Qualitative; interviews To determine how environmental X X X Caregivers designed and
& Hutchings supports can be achieved most implemented many
(1996) N 5 90 long-term effectively by investigating the modifications
caregivers of people relationship between home and Client-centered needs changed
with AD.
AD as AD progressed
Physical and cognitive
modifications for safety
and support, home design,
and devices
Sheldon & Teaford Multiple case study To identify information that would X X X Caregiver implemented
(2002) be helpful in determining what recommendations, wanted
N 5 2 primary
home environment intervention more information, improved
caregivers of people strategies should be proposed self-efficacy after OT
with AD. Rapport with client was
important
Physical modifications for
safety and support; devices,
cueing
Smith, Lauret, Qualitative; interviews To identify the needs and concerns X X Caregivers identified needing
Peery, & Mueller of caregivers through their training and collaboration
(2001) N 5 45 primary experiences Used a biopsychosocial–
caregivers of people spiritual approach to tap into
with AD.
caregiver strengths
Tchalla et al. (2013) RCT; experimental To evaluate the effectiveness and X X Caregiver implemented and
prospective study acceptance of a teleassistance monitored use of technology
service with a nightlight path for fall prevention
N 5 96 people with AD
and electronic bracelet
who had fall history
and caregiver to
record data.
van Hoof, Blom, Qualitative; focus To design a home for people with X X Caregiver considered in design
Post, & Bastein groups dementia to support aging in of home
(2013) place Architectural and technology
N 5 18 experts in care
focus for physical
of aging adults and modifications
home modifications
van Hoof, Kort, van Qualitative focus To connect the needs of people X X X Caregiver considered in design
Waarde, & Blom groups (4) with dementia and their of home
(2010) caregivers to specific design Housing design, assistive
N not provided;
solutions devices, and task
professionals simplification
familiar
with home
modifications
Note. AD 5 Alzheimer’s disease; OT 5 occupational therapy; RCT 5 randomized controlled trial.

core concept in the occupational therapy process (AOTA, This client-centered approach with the caregiver,
2014) and refers to putting the goals of the client at the person with AD, and health care provider demonstrated
forefront of evaluation and intervention. Sheldon and improved caregiver efficacy (Gitlin et al., 2001; Horvath
Teaford (2002) identified the importance of developing et al., 2013) and adherence to recommendations (Chee
rapport with the client (caregiver and person with AD) et al., 2007; Gitlin et al., 1999). Olsen et al. (1996) ac-
for successful home modification intervention. The 1 knowledged the importance of an ongoing client-centered
study that included only people with dementia reported approach as the home modification needs of the person
on the importance of a client-centered approach to in- with dementia changed as the disease progressed. Con-
tervention (Giovannetti et al., 2007). Giovannetti et al. sistent with these findings was that resistance to modifi-
(2007) used client-centered training with environmental cations by the person with AD was reported as a barrier
adaptations to improve task performance in people with to implementation (Gitlin & Chee, 2006; Lach, Reed,
AD. The other studies included both the person with AD Smith, & Carr, 1995). Horvath et al. (2005) noted the
and the caregiver as the client when discussing individualized challenge of being client centered when safety issues were
client-centered home environmental modifications. identified, yet the choices made by clients were unsafe.

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When working with the person with AD, the practitioner tations) by the person with AD; however, use of assistive
needs to recognize both the person and the caregiver as technology by the caregiver increased.
clients or care partners as they work together and with the Assistive technology was used as a home modification
practitioner to collaborate on home modifications that to improve safety and function and to assist the caregiver.
will promote participation and safety. Two studies reported on advanced (high-tech) technology.
Tchalla et al. (2013) used an automatic night light path
Modifications for Safety and Function that activates when the person’s foot touches the floor.
The third major finding was the importance of a range of This system reduced the incidence of indoor falls that
environmental modifications, including modifications ad- required intervention. Van Hoof et al. (2013) identified
dressing physical, cognitive, and social needs, to improve 54 technological focus points in a design of a home for
safety or function. people with AD and their caregiver. Many of these points
Physical. The physical environmental problems were were built-in items such as lighting, hearing systems, and
specifically related to safety. Lach and Chang (2007) adjustable-height fixtures. Low-tech assistive technology
identified that 94.9% of caregivers had concerns about the was also included, such as a towel warmer and a memory
safety of the person with AD. Lach et al. (1995) reported board for daily scheduling. Two studies were forward
that 71% of caregivers identified unsafe behaviors, and of thinking in that the design of the home was developed
those caregivers only 24% reported taking precautions. before the person with AD and the caregiver took up
Safety concerns related to home modifications included residence (van Hoof et al., 2010, 2013).
wandering, falls, inattention, poor judgment, medication Cognitive and Social. Home modifications designed to
management, adaptations for temperature, cooking, use of compensate for the progressive cognitive decline associated
appliances, and use of sharp objects (Lach et al., 1995). with AD appeared to be implemented at the task level.
To promote implementation of modifications, Horvath These modifications were made in combination through
et al. (2013) developed a home safety tool kit of adaptive both the physical environment and the social environment.
equipment and a resource booklet for caregivers to make An example was simplifying the task (Chee et al., 2007).
the home modifications needed for improved home safety. Cognitive strategies that included setup of task supplies
The physical home modifications most frequently were shown to improve performance in simple cooking
identified were removal of throw rugs, removal of access activities of toast and coffee making (Giovannetti et al.,
to kitchen items such as stove knobs and sharps, and the 2007). Training caregivers in simplification of tasks and
addition of door locks and lighting and bathroom safety setup were other cognitive home modifications that re-
equipment such as grab bars, handheld spray hoses, nonslip sulted in caregiver self-efficacy (Gitlin et al., 1999, 2005;
mats, raised commode seats, and shower seats (Gitlin & Sheldon & Teaford, 2002). Creating routines and engag-
Chee, 2006; Gitlin et al., 1999, 2005; Horvath et al., 2005; ing the person with dementia in activities provided yet
Lach & Chang, 2007; Lach et al., 1995; Mann et al., 1996; more cognitive modifications that appeared to reduce
Olsen et al., 1996; Sheldon & Teaford, 2002; Smith et al., caregiver upset and improved safety (Gitlin et al., 2005;
2001; van Hoof et al., 2010). Lowering the hot water Sheldon & Teaford, 2002). Sheldon and Teaford (2002)
temperature was another frequently identified home mod- provided an example in a case study in which the caregiver
ification (Lach & Chang, 2007; Lach et al., 1995; Mann engaged her mother (with AD) in a gardening activity that
et al., 1996; Olsen et al., 1996). was incorporated into their routine and accommodated her
Olsen et al. (1996) divided the home modifications mother’s need for constant supervision.
by stages of AD. In the early stages of AD, home mod- The increased need for supervision of the person with AD
ifications were adaptations, such as grab bars, that pro- was also identified as a modification by Horvath et al. (2005)
moted safety and independence. In the middle stages of and Lach and Chang (2007). On the basis of the Occupa-
AD, home modifications were more restrictive, such as tional Therapy Practice Framework: Domain and Process (3rd
gates, locks, and closed-in yards. In the later stages of AD, ed.; AOTA, 2014), it would be considered a modification to
home modifications such as ramps and lifts tended to the social environment. Other social environmental modifi-
support the caregiver (Olsen et al., 1996). Van Hoof et al. cations included use of additional social support networks
(2010) also identified that home modifications in the (Smith et al., 2001), use of verbal cueing, and use of com-
early stages of dementia may be different and, at that munication strategies (Gitlin et al., 1999). Lach and Chang
stage, support performance deficits. Mann et al. (1996) reported that caregivers discussed the need to modify their
reported that decline in cognitive function resulted in a social activities because of safety concerns that affected ac-
parallel decline in the use of assistive technology (adap- tivities in the home as well as in the larger community.

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Discussion Research challenges exist in studying home modifi-
cations because of the vast amount of modifications and
In this scoping review, we found two significant gaps in the
variations on modifications (van Hoof et al., 2010). Re-
literature. The first is the minimal use of standardized as-
search with people with AD is further challenged by the
sessment tools to determine intervention needs or outcomes.
high attrition rate of participants as the disease progresses
Only two home modification assessments were identified
(Mann et al., 1996). In addition to these challenges, the
in this scoping review. The first one, the Home Safety
home modification needs of the person with AD and the
Checklist, has preliminary psychometric properties
(Horvath et al., 2013). The other one, a Home Safety caregiver change throughout the disease process (Olsen
Inventory, was developed for the study in which it was et al., 1996; van Hoof et al., 2010). The demands of
used and is not a measurement tool (Lach et al., 1995). caring for this population and their individualized needs
Neither assessment examines the full scope of the home challenges research in the home environment.
environment of people with AD. Researchers described Limitations
an assessment process that involved an interview with
structured and probing questions, observation, and a This study was limited by the number of databases searched
home tour (Chee et al., 2007; Gitlin & Chee, 2006; (four). Searching additional databases may have provided
Gitlin et al., 1999, 2001, 2005). The lack of standard- more articles for review. Including more reviewers in the
ized home modification assessment in these studies process may have added alternative perspectives that could
demonstrates the need for more research toward the have resulted in a different number of articles selected.
development of such a tool. Inclusion criteria did not require a review of levels of
The second gap identified in this scoping literature evidence; thus, we found a range of designs and rigor.
review is the lack of information on home modifications in
Future Research
the later stages of AD. A small group of researchers (Mann
et al., 1996; Olsen et al., 1996) discussed the changes in Areas of research that would strengthen the evidence for
modifications used as the stages of AD progress. This gap the home modification process for people with dementia
may be the result of the more intensive needs and cost of include identification of what environmental modifications
remaining at home during the later stages of the disease are used during the later stages of AD and exploration of
that often result in residential placement. Future research environmental supports for people with AD who live alone
could identify the progressive needs of the caregiver and in the community. Further research with higher level trials
how to implement environmental modifications during is needed to assess the efficacy and effectiveness of envi-
the later stages of AD. A special report by the Alzheimer’s ronmental modification for people with dementia. An
Association (2012) estimated that 800,000 (15% of 5.4 additional area to explore is translation of the research on
million) people in the United States who have AD live residential care settings to the home. Some environmental
alone in the community. No articles that met inclusion design elements incorporated into facilities may have
criteria discussed living alone with AD. Future research is benefit in the private home. Way-finding systems (Quayle,
needed to explore environmental supports for people 1997), lighting (Brawley, 2009), and safe outdoor spaces
with AD who live alone in the community. (Ruga, 1996) are just a few examples of design elements for
Strengths of the literature include intervention em- residential facilities that may have value in the private home.
phases on caregivers and client-centered care. The liter-
ature demonstrates that caregiver training improves not
only the home modifications process but also caregiver
Implications for Occupational
self-efficacy. Client-centered care partnerships with the Therapy Practice
person with dementia and caregivers, both personal and The results of this study have the following implications
professional, improved the implementation of home mod- for occupational therapy practice:
ifications and caregiver self-efficacy. In addition, client-centered • Because occupational therapy is an evidence-based,
environmental interventions improved task performance. science-driven profession, evaluators need instruments
Effective home modifications included a range of adap- with solid psychometric properties and clinical utility
tations that addressed the physical, cognitive, and social to inform practice in the area of home modifications
needs of the person with AD. Limitations of the literature for people with AD.
include lack of perspective of the person with dementia, • As occupational therapy moves toward more community-
lack of high-level evidence, and small sample sizes. based practice settings, and as the incidence of AD

The American Journal of Occupational Therapy 7001270020p7

 continues to rise, evidence is needed to support home Alzheimer’s Association. (2014). 2014 Alzheimer’s disease
modifications for aging in place throughout all stages facts and figures. Alzheimer’s and Dementia, 10, e47–e92.
of the disease process. http://dx.doi.org/10.1016/j.jalz.2014.02.001
American Occupational Therapy Association. (2014). Occupa-
• Because occupational therapy practitioners provide ser-
tional therapy practice framework: Domain and pro-
vices to people with AD, including people with AD who cess (3rd ed.). American Journal of Occupational Therapy,
live alone, evidence is needed on how to best promote 68(Suppl. 1), S1–S48. http://dx.doi.org/10.5014/
safety and function while maintaining a client-centered ajot.2014.682006
approach. Arbesman, M., & Lieberman, D. (2011). Methodology for the
systematic reviews on occupational therapy for adults with
Alzheimer’s disease and related dementias. American Jour-
Conclusion nal of Occupational Therapy, 65, 490–496. http://dx.doi.
org/10.5014/ajot.2011.002576
The interventions delivered in these studies were not described Armstrong, R., Hall, B. J., Doyle, J., & Waters, E. (2011).
in enough detail to replicate them, in part because of the client “Scoping the scope” of a Cochrane Review. Journal of
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needed, the evidence gathered in this study indicates that home pubmed/fdr015
modifications for people with AD and related dementias Aveyard, H. (2010). Doing a literature review in health
should include the caregiver and be client centered. The and social care: A practical guide (2nd ed.). New York:
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majority of home modifications were related to the physical Brawley, E. C. (2009). Enriching lighting design. NeuroReha-
built environment, although the evidence for modifications bilitation, 25, 189–199. http://dx.doi.org/10.3233/NRE-
that incorporate virtual technology into physical home 2009-0515
modifications is growing. Evidence for home modifications is Chee, Y. K., Gitlin, L. N., Dennis, M. P., & Hauck, W. W.
emerging in the areas of cognitive and social modifications. (2007). Predictors of adherence to a skill-building inter-
The profession would benefit from more research tar- vention in dementia caregivers. Journals of Gerontology,
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geting home modifications for people with AD, specifically
673–678. http://dx.doi.org/10.1093/gerona/62.6.673
(1) what standardized evidence-based assessment procedures Giovannetti, T., Bettcher, B. M., Libon, D. J., Brennan, L.,
best determine what home modifications are indicated, (2) Sestito, N., & Kessler, R. K. (2007). Environmental adap-
what home modifications are needed in the later stages of tations improve everyday action performance in Alzheimer’s
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modifications are no longer sufficient to promote safety at
Gitlin, L. N. (1998). Testing home modification interventions:
home alone. The research in this area is further challenged by Issues of theory, measurement, design, and implementa-
the time, cost, and accessibility of studying participants in tion. Annual Review of Gerontology and Geriatrics, 18,
their private homes. As the population continues to age and 190–246.
the incidence of AD continues to rise, there is an increased Gitlin, L. N., & Chee, Y. K. (2006). Use of adaptive equipment
urgency to learn about home modifications for people with in caring for persons with dementia at home. Alzheimer’s
Care Today, 7, 32–40.
AD who want to age in place. s
Gitlin, L. N., Corcoran, M., Winter, L., Boyce, A., & Hauck,
W. W. (2001). A randomized, controlled trial of a home
Acknowledgment environmental intervention: Effect on efficacy and upset in
caregivers and on daily function of persons with dementia.
We acknowledge Elaine Cox, reference librarian, Texas Gerontologist, 41, 4–14. http://dx.doi.org/10.1093/geront/
Woman’s University, for her guidance throughout the 41.1.4
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