CAREGIVER ADAPTATIONS TO REDUCE ENVIRONMENTAL STRESS:

THE ROLE OF HOME MODIFICATIONS

Julie Overton, MSG, MHA

National Resource Center on Supportive Housing and Home Modification
University of Southern California Andrus Gerontology Center
Los Angeles, California

According to the most recent National Long Term Care Survey, more than seven

million persons are informal caregivers – providing unpaid help to older persons who

live in home environments and have at least one limitation on their activities of daily

living (Administration on Aging, 2002). Although often overlooked in discussions of

caregiver support, the home environment is a critical component significantly affecting

the capacities of caregivers and service agencies to provide assistance. The home,

whether of the care recipient or the caregiver, functions as a service delivery site.

Adequate space and features within the home environment are essential tools for

caregiving by caregivers (Pynoos & Sanford, 2001).

Home modifications (e.g., portable ramps for access, roll-in showers to assist

with bathing, widened doorways for inside transport) and assistive devices (e.g., raised

toilet seats to assist with toilet transferring, hand held showers for bathing) help address

the physical demands faced by caregivers. Caring for an impaired older person often

requires tasks (e.g., heavy lifting and turning, helping a person transfer on and off the

bed) that physically strain caregivers (many of whom are also older persons) and can

compound existing health problems (Administration on Aging, 2000). Home

modifications and assistive devices can provide immediate relief and allow caregivers to

provide assistance more easily and safely (Gitlin et al., 2001) and with less stress.
They also can reduce home care costs for frail elders and help to delay

institutionalization (Mann et al., 1999).

“Caregiver Adaptations to Reduce Environmental Stress” or CARES, a project

funded by the Administration on Aging, has taken several steps to assess caregiver

awareness and need for home modifications, ascertain the environmental coping

strategies used by caregivers in their own homes or in the homes of care recipients, and

evaluate the extent to which caregivers use home modification and AAA providers and

professionals. CARES convened four focus groups of caregivers, two consisting of

minorities. Characteristics of the approximately 40 caregivers included: 1) nearly 50%

were spousal caregivers; 30% were adult children; 2) over three-quarters were over age

70; and 3) 75% lived with their care recipient.

Initial focus group findings include:

1) Lifting, transferring, and bathing are the top three physical burdens faced by

caregivers;

2) Most caregivers do not know how to locate home modification products or

professionals. They told CARES they are desperate for a single, comprehensive

information source and they expressed a strong preference that the source be “a human

being they could talk to” as opposed to a booklet or a videotape. None of them were

aware of “Area Agencies on Aging.” Joyce said, “I’ve spent hours on the phone…you

don’t know where to start. Caregivers are so overwhelmed by what’s happening. How

do you learn what’s available?”

3) The most common home modification used to help with caregiving is grab bars,

however, many home modifications were not specially designed products but are
homemade by caregivers often inventing their own solution (for example, plastic chairs

in showers, using an empty detergent bottle as a urinal, removing the knobs of the

stove).

4) Caregivers perceived the bathroom to be the most problematic room in the house.

Many caregivers mentioned that they were afraid of the hard, wet surfaces and were

particularly worried about slips and falls in the bathroom.

5) A supportive home environment must be accompanied by the ability to get in and out

of the home and to transfer the care recipient into a car or taxi. The majority of CGs

reported extreme difficultly transporting the care recipient in a car or taxi.

6) Caregivers do not use home modifications primarily due to expense and lack of

understanding of the benefits.

7) Caregivers believe they would receive more financial support if they placed their

loved one in a facility. Jerry told us, “Financially I’m being ruined by stupid legislation. If

I put my wife in a nursing home I would get financial assistance… keeping her at home I

get zilch.” However, caregivers also believe that the care they provide at home is

superior to that of a facility. Patrice told us: “No one will love my mother like I do.”

Despite the benefits of environmental coping strategies for supporting caregivers,

several barriers prevent their use: 1) policymakers and programs lack awareness of

unmet needs and the benefits of environmental coping strategies; 2) caregivers lack

understanding of environmental coping strategies benefits; 3) a lack of research on

environmental coping strategies needs of different types of caregivers (e.g., spouses,

adult children); and 4) service provider difficulties in reaching and assessing caregivers

for environmental coping strategies.

 To improve the capacity of caregivers to provide daily assistance, several

recommendations are suggested. First, home modification informational resources for

caregivers need to be significantly improved (a future outcome of the CARES project).

Second, local lead agencies need to be more effective in advertising their services.

Third, caregivers need information about government and other funding for home

modifications to reduce their financial burden and increase the likelihood that they will

make environmental changes. Fourth, since caregivers respect the knowledge and

experience of their peers in implementing home modifications, a structure or process

should be put in place to inventory their collective knowledge beyond support groups.

Fifth, because caregivers are often wary of the help available, standardized training and

quality assurance of in home care personnel would allay these fears. Sixth, further

attention is needed with respect to problems associated with transporting care

recipients. Lastly, given that many caregivers reported relying almost exclusively on

retail stores such as Lowe’s and Home Depot, it may be worthwhile for local social

service and AAAs to explore partnerships with these stores (e.g., train employees

regarding home modifications, set up in-store displays, have onsite and contact

information available).

We cannot ignore the physical stresses placed on caregivers who provide daily

assistance to their care recipients. Home modifications can help care for the caregiver

by making caregiving activities less stressful, more convenient, and easier. Additionally,

home modifications for the caregivers’ homes can support their ability to maximize and

maintain their own health. As put by focus group participant, Patrice, “I’m sacrificing

career, I’m sacrificing financial stability by caring for my mother…it is a very

depressing situation …I need some care too.” The ability of caregivers to continue

to provide care hinges on their physical and emotional health. Home modifications and

assistive devices to reduce physical burden and strain must be addressed by programs,

professionals and policies responding to the needs of caregivers. CARES’ next project

will address this recommendation by training and providing technical assistance to

aging network agencies on strategies to improve environmental coping strategies for

caregivers.

References

Administration on Aging (2002). Family Caregiving. Washington, DC: Administration on

Aging.

Administration on Aging (2000). America’s Families Care: A Report on the Needs of

America’s Family Caregivers. Washington, D.C.: Administration on Aging.

Gitlin, L., Corcoran, M., Winter, L., Boyce, A., & Hauck, W. (2001). A randomized
controlled trial of a home environmental intervention: Effect on efficacy and upset in
caregivers and on a daily function of persons with dementia. Gerontologist 41(1), 4-14.

Mann, W.C., Ottenbacher, K.J., Fraas, L., Tomita, M., & Granger, C.V. (1999).
Effectiveness of assistive technology and environmental interventions in maintaining
independence and reducing home care costs for the frail elderly. Archives of Family
Medicine 8, 210-217.

Pynoos, J. (2001) Home Modifications. In G. Maddox (Ed.), The Encyclopedia of Aging

(3rd ed). New York: Springer.

Acknowledgements
Funding for CARES is provided by the Administration on Aging, U.S. Department of
Health and Human Services. For more information on CARES, contact the National
Resource Center on Supportive Housing and Home Modification, USC Andrus
Gerontology Center, 3715 McClintock Avenue, Los Angeles, California 90089-0191.
(213) 740-1364, homemods@usc.edu, or www.homemods.org