DISABILITY AND REHABILITATION,

2002;

VOL.

24, NO. 1/2/3 , 59 71

Evaluating home environments of persons with

dementia: interrater reliability and validity of the
Home Environmental Assessment Protocol
(HEAP)
L. N. GITLIN{*, S. SCHINFELD{, L. WINTER{, M. CORCORAN{,
A. A. BOYCE} and W. HAUCK}
{ Community and Homecare Research Division, College of Health Professions, Thomas
Jefferson University, Philadelphia PA, USA
{ Department of Health Care Sciences, School of Medicine and Health Science, George
Washington University, USA
} Community and Homecare Research Division, Cornell University, USA
} Clinical Pharmacology, Division of Biostatistics, Thomas Jefferson University, USA
Abstract
Purpose: This article reports on an interrater reliability and
preliminary validity study of an investigator-developed tool,
the Home Environmental Assessment Protocol (HEAP) for
use in homes of persons with dementia.
Method: The HEAP consists of 192 items that are summed
into separate indices representing the number of hazards,
adaptations, and level of clutter and comfort in eight areas of
the home. Interrater reliability was examined among four
raters, two environmental experts and two non-experts, who
observed 22 dementia households.
Results: The Kappa statistic was used to evaluate agreement level for each measured item and found that
agreement ranged from slight to almost perfect. Intraclass
correlations (ICCs), were used to evaluate agreement level
for indices. The hazard index in each room ranged from
fair (0.36) to moderate (0.66) for all raters. For the
adaptation, clutter and comfort indices in each room, ICCs
ranged from 0.51 to 0.90 for all raters. Agreement level
between expert and non-expert raters differed minimally for
all indices. Adaptations to dining rooms (r=70.080,
p=0.001), kitchens (r=70.52, p=0.02) and bedrooms
(r=70.76, p=0.001) were associated with patient deficits
such that more adaptations were made in homes of
dependent persons. Low Mini-Mental Status Examination
scores were associated with fewer hazards, more adaptations, and less clutter.

*Author for correspondence;

e-mail: Laura.Gitlin@mail.tju.edu

Conclusion: Findings show that both experts and non-expert

raters use the HEAP consistently. Also, measured attributes
are related to cognitive and functional status in the expected
direction.

Introduction
Most persons with dementia live at home and are
cared for by family members.1 As the disease progresses
however, physical features of the home environment
may present as a safety hazard or barrier to performing
daily activities of living, particularly at the moderate
stage of the disease process. Recommending environmental modications to enhance safe functioning at
home has become a routine part of clinical practice in
home care and rehabilitation. Nonetheless, there is not
a reliable and valid tool to systematically evaluate home
environments of dementia patients and derive recommendations for its redesign. The lack of a psychometrically sound tool has also limited the ability to study the
relationship of home environmental conditions to
dementia-related behaviours and the role of the home
in supporting caregiver eVorts to provide daily care.
Moreover, the extreme variation in living conditions,
and the tendency of individuals to underreport detrimental home conditions2 highlight the need for a standard metric for use in research and clinical practice.
Measures with adequate psychometric properties have
been developed to evaluate dementia patients in residen-

D isability an d R ehabilitation ISSN 09638288 print/ISSN 14645165/online # 2002 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080 /0963828011006632 5

L. N. Gitlin et al.
tial environments.3 These tools evaluate a range of
domains of the physical environment such as its support
of safety, orientation or way-nding, overall functioning, comfort and person-hood. For home environments
however, only a few environmental assessments have
been developed and the primary reference group has
been physically frail elders.4 , 5 In most of these assessments, home safety has been the main environmental
dimension measured and for which psychometric
adequacy has been evaluated.6, 7 Results of these studies
show that consistency in ratings vary by the type of
hazardous condition observed. For example, Clemson
and colleagues8 report excellent agreement among raters
for items such as oor coverings, lighting by beds, tub
bars and shower rails, and low levels of agreement for
oor surfaces, presence of pets, external and internal
rails, and ramps. Sattin and colleagues9 also report
inconsistency in raters for observations of grab bars in
bathrooms.
While environmental assessments developed for
physically frail elders contain items of relevance to all
populations, there are specic properties of home environments that may diVerentially impact persons with
dementia that are not examined. For example, there
are certain home safety concerns that are specic to
persons with dementia such as injury from ingestion of
dangerous substances, exiting home and getting lost,
injury to self or others from sharp objects, risk of re
or burns from or inappropriate use of appliances.10
Moreover, certain home adaptations are designed to
address limitations imposed by a cognitive impairment.
Removing unnecessary objects or clutter, labelling
common household items or using other visual cues
are designed to facilitate way-nding, orientation and
awareness. An evaluation tool that is specic to dementia is important in order to identify the particular environmental dimensions that contribute to overall wellbeing and support or hinder the ability of this population to remain at home.
To examine dimensions of the physical environment
of homes of persons with dementia, the Home Environment Assessment Protocol (HEAP) was developed. The
purpose of this paper is to examine the interrater reliability of the HEAP, the feasibility of its use by expert
(occupational therapists) and non-expert (research interviewers) raters, and its convergent validity. In this study
interrater agreement were compared among four raters.
Two raters were occupational therapists and considered
in this study as environmental experts. The other two
raters were social science interviewers and considered
in this study as non-environmental experts. Occupational therapists are professionally trained to examine
60

environmental features, evaluate homes for patient

safety and provide home modications. While occupational therapists by virtue of their professional background may be more reliable raters in comparison to
non-experts, it is believed that with su cient training
and fully developed written guidelines consistent ratings
would be obtained on the HEAP for both groups. Also,
since the HEAP is designed as an objective evaluative
tool, it does not require professional decision-making
as to how a persons capabilities match or t with the
environmental conditions of the home. By testing the
interrater reliability of the HEAP with expert and nonexpert raters, the possibility of its application by users
from various backgrounds is increased.
Preliminary convergent validity of the HEAP is also
explored by examining its relationship to standard
measures of cognitive status and ADL dependence of
persons with dementia. Previous research has shown
that caregivers implement environmental modications
in response to progressive declines associated with the
disease process.11 , 12 The study examined whether the
HEAP shows a similar relationship with indicators of
decline. Our working hypothesis was that families caring
for persons with functional dependency and low MiniMental Status Examination (MMSE) scores would
implement more modications and remove home safety
hazards in comparison to households in which persons
were more independent and had higher MMSE scores.
In households of mildly impaired persons, such modications would not be necessary.

Methods
SAMPLE

A convenience sample of 22 family caregivers was

recruited from two sources; Family Caregiver Support
Program of the Philadelphia Corporation for Aging
(PCA), an area agency on ageing, and the Philadelphia
REACH study, a multi-site caregiver intervention study
funded by the National Institute on Aging.1 3 To participate in the study, caregivers had to live with a person
(e.g. share cooking facilities) who had a diagnosis of
Alzheimers disease or a related disorder, provide four
or more hours of supervision or direct care each day,
and allow four raters to observe the home. Caregivers
were excluded if the persons they cared for were bedbound and used only one room in the home, or were
blind or deaf. These criteria were designed to maximize
participation of households in which care was provided
to ambulatory patients for whom a modication to the
physical environment might be helpful. Given the

Home Environmental Assessment Protocol

purpose of the study, to rate observations of a wide
range of environmental conditions including adaptations, it was important to enroll families most likely to
have altered their homes in response to caregiving.
The majority of caregivers were female (63%),
spouses (59%) and white (73%). Their average age
was 63 years (range 44 90) and they had an average
of 11 years of education. Dementia patients had an average age of 77 years, were primarily female (63%) and
white (73%). The average MMSE score was 14
(SD=8.57, range=0 25). Also, caregivers reported
on average a moderate level of dependency in basic
activities of daily living (mean=2.07, SD=0.67,
range=1 3) suggesting that patients were at the moderate stage of dementia.
RATERS

Four raters participated in this study. The two expert

raters were occupational therapists, each with over 10
years experience in home care and home modication
with dementia patients. The two non-expert raters were
trained research interviewers with social science backgrounds.
PROCEDURE

Eligible caregivers underwent a 15 minute telephone

interview to ascertain demographic characteristics and
level of dependency in basic activities of daily living.
At the conclusion of the telephone interview, a home
visit was scheduled. The home visit entailed a
45 minute walk-through of up to eight areas of the
home by the four raters who made their observations
at the same time. One rater was randomly assigned to
serve as the spokesperson in each household. The
spokesperson explained the study procedures, obtained
informed consent from the caregiver prior to raters
making observations of the home, and asked clarifying
questions of the caregiver during the home tour. The
other three raters remained silent during the tour
and made their observational recordings independent
of each other. At the conclusion of the tour, each
rater had an opportunity to privately ask the caregiver
clarifying questions about the observations if necessary. A review of these questions following completion
of the assessments indicated that most raters sought
clarication about particular adaptations and the
number of bathroom s and entrances used by the
person with dementia. Raters were instructed to not
discuss the households, their clarifying questions, or
their ratings with each other.

These procedures were designed to minimize caregiver inconvenience as well as replicate a one-on-one
observation of the home. It was not feasible for each
rater to observe the home on separate occasions. This
would have increased caregiver time and burden and
caregivers were unable to ensure their availability over
four separate occasions. Also, the authors were
concerned about the stability of the environment over
four separate occasions and that caregivers might
respond diVerently to each rater or experience instrument fatigue. By having all raters in the home at one
time, the confounding of ratings with variance in
naturally occurring environmental and caregiver characteristics were minimized.
At the conclusion of the home observation, one
designated rater remained in the home to administer
the MMSE with the dementia patient. Proxy consent
was obtained from the caregiver to administer the
MMSE. Caregivers were paid $15 for the home visit
and received referral information, educational materials, and a copy of the book, The Thirty-six Hour
Day.14
MEASURES

Functional dependence
Dependence in activities of daily living (ADL) was
assessed using the seven item measure of physical
activities of daily living from the Multilevel Assessment Instrument (MAI) developed by Lawton and
colleagues. 15 The need for assistance in the areas of
bathing, grooming, toileting, dressing upper and
lower body, eating, and transfer from bed, chair,
or wheelchair was measured using a three point
response format (1=cant do at all; 2=can do with
some help; and 3=can do without any help). A
summary score was computed by averaging the
ratings for all items. High scores reect greater independence.
Mini-mental State Examination (MMSE)
The MMSE was used to measure the severity of
cognitive impairment of the dementia patient.16 The
test consists of 17 items that assess orientation, attention, memory, ability to name, ability to follow
verbal and written commands, ability to write a
sentence spontaneously, and ability to copy a
complex polygon. The range of scores for this scale
is from 0 30 with a higher score indicating fewer
cognitive decits.
61

L. N. Gitlin et al.
Home Environmental Assessment Protocol (HEAP)
The HEAP is based in a competence-environmenta l
press framework17 and theories that articulate the
impact of the physical environment on patient functioning. 18 These conceptual frameworks suggest a relationship between daily competencies of dementia patients
and objective environmental conditions such that a poor
match may result in negative behavioural responses and
exacerbate functional limitations. For example,
common household items such as medications or cleaning uids that remain accessible may present as a hazard
as the disease progresses, particularly for the person at
the moderate stage. Likewise, visual and/or auditory
over-stimulation (a cluttered environment) may decrease
orientation and the persons ability to successfully interpret cues by which to navigate the home.
The pool of items, their denitions and the observational format for the HEAP were initially developed
from four sources: (1) available environmental assessments of homes and institutional settings including
home safety checklists used in research and clinical practice; (2) technical literature on the design of environments for dementia patients; (3) research and clinical
literature on the pathology and impairment of dementia;
and (4) direct observation of home modications implemented by 202 family caregivers in an intervention
study. 1 9 Based on these sources it was decided to develop
the HEAP as a measure of four dimensions that have
been identied as important aspects of the environment
that potentially contribute to wellbeing.2 3 These dimensions include safety or the lack of common home
hazards, the support of daily function or performance
of everyday tasks through physical adaptations, the
support of orientation through the use of visual cues,
and support of comfort through the presence of meaningful items to touch or observe. The HEAP was developed as an evaluative tool for use in research and
clinical practice. As an evaluative tool, the HEAP items
apply a standard approach to observing environmental
conditions such that ratings are made independent of
the particular characteristics of individuals in the household. This is in contrast to an assessment approach that
rates the environment in relation to particular capabilities of an individual.
The rst step in developing the HEAP was to establish
its content validity. This concerns the extent to which
items in a measure accurately reect the construct of
interest. To establish content validity, a panel of experts
composed of eight occupational therapists reviewed an
initial pool of items and their classication as supporting
safety hazards, function, orientation or comfort. The
62

panel was asked to evaluate item clarity and whether

items represented the full range of conditions related
to these four domains. Based on the panels review,
specic items and guidelines for their observation were
modied. Also, based on the panels review, it was
evident that there was overlap among the four environmental dimensions suggesting that they are only relatively orthogonal. For example, items for safety (e.g.
presence of a handrail) may also enhance daily functioning. Similarly, items we include as indicators of functional support (e.g. removal of excess items,
rearrangement of furniture) may also support orientation and comfort. Thus, any one condition of the environment may reect multiple dimensions. Agreement was
obtained however as to the primary classication of a
particular environmental condition as either a safety
hazard, an adaptation to support function, or an adaptation to support orientation or comfort.
The HEAP involves rating 192 items in up to eight
areas of the home (entrance, living room/den, dining
room, kitchen, bedroom, bathroom, hallway and stairs)
that are used by the person with dementia (see Appendix
A for an example of items and observational format for
the living room). Three approaches are used to derive
ratings. First, the study relies on caregiver self-report
to identify the presence of two types of adaptations in
each room (`Have you removed any items from this
room to make caregiving easier or in response to the
dementia patients needs? and `Have you added, modied or rearranged any furniture or objects in response to
the dementia patients problems or to make caregiving
easier for you?) These two items are not amenable to
direct observation. Therefore, for these two items, the
methodology of reliably recording a caregivers verbal
responses is tested. Secondly, for select items direct
observation is used by the rater combined with a probing question to the caregiver to clarify the observation
(e.g. probe to determine if photos observed in bedroom
were purposely placed there for comfort; clarify
presence of cushion as a seating device). Third, for most
items direct observation is used by the rater (e.g. inadequate illumination; presence of grab bars, labels) to
derive a score.
A safety hazard is dened on the HEAP as the
presence of three types of conditions: tripping and falling hazards (e.g. glare, torn carpets, objects in pathway);
electrical problems (e.g. cords draped over oven or
water; frayed cords or overloaded or obsolete electrical
service); and access to dangerous items (e.g. medications, sharp objects). These conditions are observed in
each area of the home and are rated as either present
(1) or not present (0). For functionality, items are

Home Environmental Assessment Protocol

observed that reect four types of adaptations that have
the potential to support a persons engagement in daily
routines: (1) xed or permanent structural renovations
(e.g. changes to wiring, plumbing or wall structure);
(2) home modications and adaptive equipment (e.g.
grab bars); (3) assistive devices (e.g. mobility aids, aids
for toileting, bathing, dressing); and (4) non-permanent
adaptations such as setting up a control centre, removing, modifying or rearranging furniture or household
objects. These items are observed in each area of the
home and are also rated as either present (1) or not
present (0).
For orientation, the level of clutter that may impact
a persons ability to successfully navigate the home
and the use of visual cues to help identify common
objects used in daily activities is examined. Level of
clutter is dened as the presence of an excessive
number of objects in a living space that increase its
complexity. Raters provide an overall rating in rooms
(1=not at all cluttered to 3=very cluttered) and also
estimate the extent to which designated surfaces (e.g.
kitchen countertops) are covered with objects using a
four category response set (1=525% to 4=475%
of surface covered with objects). Four diVerent types
of visual cues are observed (See Appendix A, part
III); use of labels, pictures, short instruction lists, or
the use of contrasting colors to highlight objects
(e.g. red placemat and white dinner plate). These items
are rated either present (1) or not present (0). Finally,
for comfort, the purposeful placement and availability
of objects of interest, symbolic meaning or items that
had ties to the past to the person with dementia are
considered. This single item was observed in the living
room. The availability of meaningful objects to be
touched and/or manipulated, and the level of noise
and privacy in the bedroom was also considered.
These items are rated as either present (1) or not
present (0).
Indices can be created for the number of hazards
(safety), adaptations (function) , level of orientation
(clutter and visual cue use) and comfort in each room
or area of the home for which such observations are
made by summing the relevant items. For hazards, the
composite score reects the total number of unsafe
conditions in each room. For adaptations, the composite score reects the total number of adjustments made
in each room. For orientation only the clutter was examined, because, for this study sample visual cues were not
used. A high score indicates more clutter, or a greater
number of excessive items or surface coverage. For
comfort, a high score represents the presence of more
comfort in the bedroom.

Raters participated in three hours of training that

involved a slide show illustrating measured items. Each
rater then observed two homes with a member of the
research team to practice using the tool and the coding
procedures. Finally, all four raters simultaneously
observed two homes to practice general procedures
and the role of the spokesperson. Additionally, each
rater received an instructional manual and codebook
that reinforced the procedures and observational guidelines provided in training. Table 1 identies each item
and their specic denition that guided the observations
and ratings.
Statistical analysis
The kappa coe cient was used to evaluate interrater agreement of ratings by the four raters for individual HEAP items that were dichotomous (presence or
absence of a condition).20 It was not possible to
calculate a kappa coe cient for items in which
90% or more of the responses were identical across
all raters and households together. Items for which
this occurred were thus not included in the development of the indices and were also necessarily
excluded in the intraclass correlation analyses. This
primarily aVected the evaluation of interrater reliability for the visual cue items and the development of
an orientation index. Visual cues were not observed
for this study sample and thus were not included in
the item analyses, and index formation. Thus, individual items and total scores for clutter only were
reported. Since the dementia patients in this sample
were at the moderate to severe stage, visual cueing
such as the use of instructional lists or labels may
not have been a modication used by this sample
of caregivers.
Intraclass correlation coe cients (ICCs) were
calculated for the HEAP indices that were continuous variables across all four raters and then for
expert and non-expert raters.20 2 2 Qualitative evaluation of Kappas and ICCS used the terminology of
Landis and Koch (0.81 1.00=almost perfect;
0.61 0.80=substantial ; 0.41 0.60=moderate; 0.210.40=fair; 0.00 0.20=slight; 50.00=poor). 23 To
examine convergent validity, the Pearson correlation
analysis was used. The association between HEAP
index scores and cognitive and physical function
scores of the dementia patient were examined to
evaluate the extent to which the measure correlates
with related behaviours. Data analyses were
conducted using SAS 6.12 and SPSS for the PC
version 10.
63

L. N. Gitlin et al.
Table 1

Item, denition, and area of home observed

Hazard items

Denitions

E xternal steps
H andrail

U neven, steep ( over 10 in ), loose, cracked, sloping

Not securely attached;
does not cover all steps
G lare, shadows, broken lamp, no shades or broken bulbs
A bsence of on interior door
41 inch
Slippery, carpet frayed, torn; folds, tile broken, throw rugs not
secured
O bjects on oor in pathways
O n oor in pathways
Cords, switches, outlets in poor repair, fuses or circuit breakers blow
R ocking chair, plastic folding chair, broken legs

X
X

Lighting
Lock or dead bolt*
D oor threshold
Floor conditions
Pathways
E lectrical/phone cords
E lectrical problems
Stability of chair used
by CR
Cords, switches, outlets
Medications
D angerous items

X
X
X

DR

Stair

BD

Bath

X
X

X
X

X
X

X
X

X
X

X
X

X
X
X
X

X
X
X
X

X
X
X
X

X
X

X
X

X
X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

LR

Kit

DR

BD

Bath

Changes to oors, walls, ceiling, wiring and/or plumbing

D oor removed, locks or chains installed, doorway widened,
pressure gate or barrier
Such as throw rugs, replace equipment, matches etc.
Large print books, remote controls for TV, etc.

X
X

X
X

X
X

X
X

X
X

X
X

X
X

Special pillows, plastic covers, pads, etc.

Intercoms, wandering devices
Commode, incontinence pads
A dapted utensils, special placemats, microwave etc.

X
X
X

X
X

X
X

Frayed, blow fuses or circuit breakers, insuf cient outlets

E asily accessible
E asy access to scissors, knives, sharp objects
Denitions

Modi cation to
entrance
Structural renovations
D oor modi cations

Presence of stairglide, elevator or ramp

Safety latch on cabinet

door/drawer
A daptations to oven
U se of personal space
Steps outlined*
Pressure gates on stairs*
Mirror present*
G rab bars
R aised toilet seat
Bathmat
H ot water adjusted

Kit

Adaptation items

O bjects removed
D evices/special
equipment for leisure
Seating devices
Monitoring device s
Toileting devices
D evices for feeding/
meal prep
D ressing devices
A dapted grooming
devices
O ther device s
O bjects added, modi ed,
or rearranged
Control centre

LR

Stair

X
X
X

Stocking donner, reacher, etc.

Built-up toothbrush, hair brush, razor, etc.

X
X

O xygen , feeding tubes, Hospital bed, etc.

Bed rails, adapted chairs, removal of furniture to create pathway

O bjects for more than one task kept together to assist CR to function
in room
Childproof locks, latches

R emoval of knobs, cover stovetop, disable oven

Place at table, labeled chair
Tape or color used to highlight stairs
Secure gates at top or bottom of staircase to prevent access
A ccessible mirror in room
G rab bars by toilet sink or tub/shower
R aised or adjusted toilet

X
X
X

X
X

X
X
X
X
X
X
X

Lowered water temperature

Visual cue items

Denitions

Labelled objects*
D irections to bathroom*
Instruction list*
Colour contrast*
O bjects kept together*

Common household items labelled by print or pictures

U se of a picture, label or arrow pointing to bathroom
Short instruction list for living room tasks or daily schedule
U se of colours to highlight an object
Items purposely grouped on a shelf, in container, or section of room
for caregiving tasks

LR

Kit

DR

X
X
X
X
X

X
X
X
X
X

X
X
X
X

H
X
X

Stair

BD

Bath

X
X
X
X
X

X
X
X
X
X

Continued

64

Home Environmental Assessment Protocol

Table 1 Continued
Comfort items

Denitions

Presence of meaningful
items
Privacy
Noise level

Photos, stuffed animals, other objects of personal meaning

LR

Kit

DR

Stair

BD

Bath

A bility to have privacy, dressing, sleeping

Noise from radio, TV, construction

X
X

*90% or more of responses were identical. Kappas could not be calculated and items not included in index development

Table 2 Characteristics of the home environments (N=22)

Results
CHARACTERISTICS OF OBSERVED HOMES

Homes were observed in areas that were used by

dementia patients and for which caregivers agreed to
have observed. The 22 homes varied in the number of
living areas that were available for observation with 22
entrances, 21 living rooms, 16 dining rooms, 21 kitchens,
19 bedrooms, 21 bathrooms, 16 hallways and 15 stairs
actually observed. Reasons for not observing a room
or area included the following: the dementia patient
never entered the area, the area did not exist in the
home, or the caregiver requested that the area not be
observed (e.g. dementia patient asleep in bedroom).
Most caregivers lived in row homes (73%) and had
made at least one adaptation to a room or area of the
home (96%). Most adaptations were made in the bathroom and bedroom with the least number of adaptations being made in the kitchen. The level of clutter in
homes was moderate to high across areas observed.
An average of 12 hazards was found throughout homes
with the greatest number occurring in bathroom s and
bedrooms (table 2).

Variable
Adaptations
Living room
Kitchen
D ining room
Bathroom
Bedroom
Clutter
Living room
Kitchen
D ining room
Bathroom
Bedroom
Hazards
E ntrance
Living room
D ining room
Kitchen
Bedroom
Bathroom
H allway
Stairs

Mean (SD)

Range

1.1 ( 1.59 )
0.57 ( 1.03 )
0.93 ( 1.07 )
3.24 ( 1.51 )
2.11 ( 1.62 )

0 10
0 10
0 10
0 9
0 10

2.00 ( 0.63 )
6.62 ( 2.65 )
4.64 ( 1.74 )
6.10 ( 2.43 )
5.16 ( 1.64 )

1 3
1 11
2 7
3 10
1 7

2.14 ( 0.88 )
1.9 ( 1.37 )
2.2 ( 1.25 )
1.6 ( 1.06 )
2.4 ( 1.57 )
2.5 ( 1.17 )
0.81 ( 0.66 )
1.3 ( 1.54 )

1 4
0 5
0 4
0 4
0 5
1 6
0 2
0 5

item and room such that for certain items and rooms
experts had moderate to almost perfect agreement levels
in comparison to non-experts, and for other items and
rooms the opposite was true.

KAPPA COEFFICIENTS FOR HEAP ITEMS

First, the kappa coe cients were calculated for individual HEAP items for all four raters. Given the vast
number of items for which kappa was calculated, great
variability in levels of agreement across items was
expected. Levels of agreement ranged from slight
(0.01) to almost perfect (0.95) (table 3). Also, for any
one item, the level of agreement varied from room to
room. For example, while the kappa coe cient for
adequacy of lighting in the entrance was 0.95, it was
0.25 in the hall.
Although not shown in table 3, expert and non-expert
ratings were compared for each individual item. Given
the large number of individual items, once again great
variability was expected and found in the level of consistency between the two types of raters. There was no
consistent pattern. The level of consistency varied by

INTRACLASS COEFFICIENTS (ICCS) FOR HEAP INDICES

Next, ICCs were calculated for HEAP subindices in

each room or area of the home. Scores ranged from
slight (0.09) to almost perfect (0.93) for all four raters
(table 4). For eight hazard indices, the strength of agreement was slight for the entrance, fair for kitchen, bathroom and hall, moderate for dining room, bedroom and
stairs and substantial for living room. For ve adaptation indices, the strength of agreement was primarily
substantial to almost perfect for all rooms and areas.
For the one comfort index, a moderate level of agreement was achieved. For the six clutter indices, the
strength of agreement ranged from moderate to almost
perfect.
Next, expert and non-expert ratings were compared
on the index scores. Whereas at the individual item
65

L. N. Gitlin et al.
Table 3

Kappa coe cient for observed items by room

Variable
I. Hazards
E xternal step or oor ( Step ) conditions
H andrail
D oor threshold
O bjects in pathway
Cords in pathway
Stability of furniture
Lighting adequate
Nighlight
Lit path to bathrm
E lectrical problems
D angerous objects
Medications exposed
II. Adaptations
D ressing devices
Feeding devices
Toileting devices
Monitoring device s
Seating devices
O ther device s
G rab bar
In tub/shower
A t sink
A t toilet
Tub bench
Bathmat
H ot water temp. adjusted
O bjects removed
O bjects added
Control centre {
Structural renovation
O ven adaptations
D oor modi cations

Entrance

LR

DR

Kitchen

Bedrm

Bathrm

Hall

Stair

0.34
0.19
0.16

0.95

0.59

0.39
0.38
0.66
0.13

0.39

70.26
0.19
0.24
*
*

0.49

*
0.37
0.20
0.81
*

0.43
0.30

0.63

0.24

0.53
0.26
0.93

*
*
0.73

0.41

70.01
0.07
*

*
0.75

0.02
0.64
0.61

0.31

*
0.44
0.84

0.25

0.40
0.66
0.73

0.52

*
0.32
0.35
0.73
*
0.52
0.48
0.13
0.41
0.50

*
0.90
0.75
0.42

*
0.64
0.49

0.84

*
0.73
*

0.82
*
0.50
0.55

0.94

0.82
*

0.52

0.87

0.85
0.83
0.77
*

0.77
0.91
0.61
0.77

0.76
0.93
0.41
*
*
0.52

0.84
0.88
0.34
0.80

0.87

0.95
*
0.71
0.86
0.54
0.95
0.91{
*
0.33
0.67

0.73

III. Comfort
Sense of privacy
Comforting items
Bedroom quiet

0.81

*
*

0.33
0.77
*

IV. Clutter
O verall room clutter
Counter/sink clutter
O ther surfaces

0.71

0.67
0.58

0.50
0.49
0.64

0.82
0.55

0.71
0.53
0.83

Key: item not observed in room;

*90% or more of responses were identical and Kappa not calculated
{
Control centre or objects kept together for use by dementia patient
{
Objects removed in bathroom refers to removal of receptacles (e.g. wastebasket)
LR=living room; DR=dining room; Bedrm=Bedroom; Bathrm=Bathroom
Bold items reect substantial to almost perfect levels of agreement according to Landis and Koch2 1

level there were diVerences between experts and nonexperts, there were less diVerences at the score level.
Expert raters obtained a moderate to almost perfect
level of agreement for 16 of the 20 indices shown on
table 4. Non-expert raters obtained a moderate to
almost perfect level of agreement for 15 of the 20
indices.
66

RELATIONSHIP OF HEAP TO ILLNESS CHARACTERISTICS

Convergent validity is typically established by examining the correlation of scores to criterion which are
assessed simultaneously.24 , 25 To initiate the validation
process, the relationship between HEAP subindices
and characteristics of the dementia patient were exam-

Home Environmental Assessment Protocol

Table 4 ICC Scores for indices by room and type of rater
Room

Hazards
Total

OT

Non-OT

Adaptations
Total
OT

Non-OT

Comfort
Total

OT

Non-OT

Clutter
Total

OT

Non-OT

E ntrance
LR
DR
Kitchen
Bedrm
Bathrm
H all
Stair

0.09
0.66
0.53
0.36
0.50
0.30
0.36
0.41

0.20
0.62
0.59
0.57
0.49
0.17
0.42
0.24

70.19
0.57
0.28
0.55
0.64
0.33
0.09
0.30

0.90
0.89
0.87
0.84
0.82

0.87
0.87
0.85
0.86
0.95

0.58

0.44

0.65

0.83
0.65
0.71
0.63
0.79
0.93

0.74
0.77
0.74
0.51
0.92
0.88

0.73
0.59
0.74
0.89
0.90
0.86

0.91
0.84
0.86
0.84
0.75

Bold items reect substantial to almost perfect levels of agreement according to Landis and Koch2 1

ined that it was hypothesized would be related to environmental set-ups. It was anticipated that caregivers of
dementia patients with greater cognitive loss and ADL
decits would implement more adaptations and safety
proof the home. It was found that ADL decits were
associated with having a greater number of adaptations
in the entrance, dining room, kitchen, and bedroom,
and fewer hazards in the entrance. Also, low cognitive
status was associated with less clutter in the living room,
dining room and bathroom, more adaptations in all
rooms and fewer hazards in all areas except the entrance
(table 5).
Discussion
Modifying the environment for safe functioning of
patients with dementia living at home either alone or
with a family member is a clinical concern and of
research importance in rehabilitation and home care.
Nevertheless, a standard metric is lacking by which to
evaluate homes and determine the adequacy of environments to support dementia care. Moreover, a tool to
systematically evaluate home environments is important
in order to advance this area of research. To our knowledge, this is the rst study to report preliminary psychometric properties of a tool designed to assess basic
dimensions of the physical environment of households
of persons with dementia.
This interrater reliability study shows that the HEAP
provides a systematic and consistent approach to observing home environments on four key dimensions related
to the well-being of persons with dementia. Specically,
a slight to moderate strength of agreement for home
hazard indices was found and substantial to almost
perfect consistency for adaptation, clutter and comfort
indices. The ndings also show that an adequate level
of agreement was obtained with indices for both expert
and non-expert raters. This supports the use of the

Table 5 Pearson Correlation of HEAP indices and patient

characteristics

Hazard indice
E ntrance
LR
DR
Kitchen
Bedrm
Bathrm
Adaptatio n indices
LR
DR
Kitchen
Bedrm
Bathrm
Clutter indices
LR
DR
Kitchen
Bedrm
Bathrm
Comfort index
Bedrm

MMSE

ADL

70.26
0.39
0.37
0.17
0.09
0.10

70.53*
70.05
70.29
0.00
70.06
70.03

70.29
70.39
70.40
70.26
0.19

70.24
70.80**
70.52*
70.76**
0.01

0.52*
0.60*
70.04
0.14
0.43*

0.14
0.37
70.21
70.05
0.33

70.29

70.08

*p50.01; **p50.001

HEAP by raters of diVerent professional training and

extends its utility.
The convergent validity of the HEAP using correlational analysis was examined. It was found that HEAP
subindices were associated with functional and cognitive
status in the expected direction. That is, homes of
persons with more ADL decits and cognitive impairment had fewer hazards, less clutter and more adaptations, suggesting that the environment had been
modied in response to behavioural dysfunction. This
preliminary evidence suggests that the HEAP provides
ratings for dimensions of the environment that are
important in dementia care at home. Clearly, more
research is required to substantiate these relationships
and examine other predictive relationships.
67

L. N. Gitlin et al.
The other signicant nding of this study is that a
given measure of an environmental feature varies from
room to room. That is, any one item has diVerent levels
of consistency in ratings across areas of the home. Also,
there is a range of levels of agreement among items, with
hazard observations demonstrating less consistency in
ratings. This has important implications for training in
the use of this tool. An item may have a unique presentation in each room. Training must be room and item
specic such that the rules for observation are tailored
to the particular context in which the rating occurs.
It should also be noted that although an acceptable
level of agreement for most hazard indices was obtained,
there was more inconsistency among these items than
for adaptation, clutter and comfort items. The inconsistent ratings for hazard items and indices found in this
study is similar to that reported by other studies but is
di cult to explain.8 9 There may be several reasons for
inconsistencies among raters. One reason for inconsistent ratings may be the need for additional training of
raters and more rened denitions and decision rules
to avoid discrepancies in ratings. For instance, the slight
level of agreement for `door threshold too high in the
entrance may reect a coding inconsistency that was
identied through rater debriengs. Some raters coded
the condition in the living room whereas others coded
the threshold as part of the interior of the entranceway.
Also, slight to fair agreement for presence of a handrail
of the exterior entrance appeared to reect confusion as
to whether handrails were both securely attached and
covered all steps. Raters found it di cult to judge
whether the rail covered all steps adequately to assure
the safety of persons in the household.
Another reason for inconsistent hazard ratings may
be due to the confusion as to whether characteristics
of persons in the household should be considered in a
response. For example, raters were instructed to record
the presence of knives in open areas or on countertops in
kitchens as a hazard. However, in some households,
caregivers reported that the dementia patient was
unaware of the placement of knives or other potentially
dangerous objects or were unable to reach the items due
to a mobility limitation. Raters reported confusion as to
how to record these conditions. According to our denition, these items were accessible to the dementia patient
and thus, should be coded as a hazard. However, that
rating may not reect the real-life context of the household. Raters were aware that the HEAP was not
designed to provide an assessment of how specic
persons t within particular environmental set-ups.
However, in its administration, raters were confronted
with the practical issue and wisdom of removing person
68

characteristics when rating whether a condition reected

a hazard.
As discussed earlier, the HEAP follows the tradition of
tools developed in residential settings such that the
HEAP applies a standard set of criteria as to what constitutes a hazard. This approach imposes a gold standard
based on conventional wisdom and empirical evidence
as to what constitutes a safety concern. The HEAP
presupposes that certain conditions reect a hazard
regardless of a persons physical or cognitive capabilities.
HEAP scores provide a description of particular aspects
of physical dimensions of home environments but do not
provide ratings as to an individuals specic functional t
within that context. This may be a limitation of the
HEAP. Future research is warranted to determine the
relative gains and feasibility of an assessment approach
versus the evaluative strategy used here.
A related point is that it is not known whether
observed hazards represent the same levels of risk to individuals, whether some environmental conditions present
a greater risk depending on a persons level of competency, or whether identied hazards are actually associated with fall or injury events. For example, it is not
known if a high door threshold places an older person
at higher risk than inadequate illumination or glare.
One condition may be inherently more hazardous than
the other for older people and level of risk may vary
based on health status. The HEAP was not designed to
evaluate these issues. However, these issues warrant careful examination and further study to understand the role
of physical dimensions of home environments in dementia care. Such research would also provide the foundation from which to rene a tool such as the HEAP.
There are several important strengths of the HEAP.
First, the HEAP includes items that are most pertinent
to dementia patients. An optimal environment for a
person with dementia, particularly at the moderate stage
consists of highly familiar objects and surroundings and
removal of items of potential danger. Also, simplifying
the home by removing unnecessary objects or using
visual cues provides information that increases orientation and the ability to navigate the environment. The
HEAP includes items that reect these particular
supportive features of the environment. Another important strength of the HEAP is that it involves a tour of
each room and area of the home and includes both
direct observation and probes of the family caregiver.
Previous research has shown that the sole reliance on
self-report may yield inaccurate and inconsistent ratings
of the home environment.3 However, direct observation
only may also yield an incomplete understanding of
home environments. The presence of an observer may

Home Environmental Assessment Protocol

trigger behaviours that alter the true environmental
conditions of a home. The use of both observation, clarifying probes, and self-report is therefore a necessary
combination of methodologies in order to discern modications that may be questionable or not perceptible.
For example, removal of dangerous objects, eVorts to
remove clutter, or purposeful placement of household
items may not be perceptible to a rater through direct
observation alone.
Conclusions
Evaluating the physical environment of homes as a
basis from which to enhance its t with a persons
competencies is an important aspect of clinical practice
and research with dementia patients living at home.
Our purpose was to examine the interrater reliability
of environmental experts and non-experts using a new
assessment tool of the home environment. The HEAP
overcomes some of the weaknesses of previous assessment tools. It relies on both structured observation
and self-report from family members to derive ratings
and raters are provided denitions and guidelines for
each observation. Also, the HEAP is grounded in a
theoretical perspective and specic dimensions of the
physical environment are evaluated that have been
shown to support persons with dementia.
The ndings of this study suggest that it is feasible to
make reliable observation s of physical dimensions of
home environments of persons with dementia. Both
environmental experts, such as occupational therapists
as well as social scientists who receive training in the
tool can use the HEAP. The dimensions of the HEAP
also appear to be related to illness characteristics of
dementia patients such that households caring for
persons with reduced competencies have more adaptations in place and fewer observed home hazards. Future
research should test the validity of this tool in more
depth, begin to determine its use as an outcome measure
in intervention research, and resolve ways of integrating
person capabilities in environmental ratings.

Acknowledgements
The authors gratefully acknowledge the contributions of raters, Jean
Machemer, MGS, Amelia Henning, MA, Stephen Kern, OTR/L and
Geri Shaw, OTR/L. Appreciation is also extended to the caregivers
who allowed their homes to be observed. The study was supported by
the National Institute on Ageing (Grant # R03-AG15517 and Grant #
U01-AG13265) . A version of this paper was presented at the
Gerontological Society of America Meetings, 18 November, 2000,
Washington DC, USA.

References
1 Haley WE, Bailey S. Research on family caregiving in Alzheimers
disease: implications for practice and policy. In: B Vellas, JL Fitten
(eds). Research and Practice in Alzheimers Disease, volume 2.
Paris: Serdi Publisher, 1999; 321 332.
2 Gitlin LN. Testing home modication interventions: issues of
theory, measurement, design, and implementation. In: R Schulz,
MP Lawton, G Maddox (eds) Annual Review of Gerontology and
Geriatrics. Intervention Research with Older Adults. New York:
Springer Publishing Company, 1998; 190 246.
3 Norrris-Baker C, Weisman GD, Lawton MP, Sloane P, Kaup M.
Assessing special care units for dementia: the professional
Environmental Assessment Protocol. In: E Steinfeld, GS Danford
(eds). Enabling Environments: Measuring the Impact of Environment
on Disability and Rehabilitation. New York: Plenum Publishers,
1999; 16 182.
4 Letts L, Law M, Rigby P, Cooper B, Stewart D, Strong, S. Personenvironmental competence amongst independent elderly households. American Journa l of Occupational Therapy 1994; 48: 608
618.
5 Tideiksaar R. Preventing falls: home hazard checklists to help older
patients protect themselves. Geriatrics 1986; 41: 26 28.
6 Oliver R, Blathwayt J, Brackley C, Tamaki T. Development of the
Safety Assessment of Function and the Environment for Rehabilitation (SAFER) tool. Canadian Journa l of Occupational Therapy
1993; 60: 78 82.
7 Mann WC, Hurren D, Tomita M, Bengali M, Steinfeld E.
Environmental problems in homes of elders with disabilities.
Occupational Therapy Journa l of Research 1994; 14: 191 211.
8 Clemson L, Roland M, Cumming RG. Types of hazards in the
homes of elderly people. Occupational Therapy Journa l of Research
1997; 17: 200 213.
9 Sattin RW, Rodriquez JG, DeVito CA, Wingo PA. Home
environmental hazards and the risk of fall injury events among
community-dwelling older persons. Journa l of the American
Geriatric Society 1998; 46: 669 676.
10 Gitlin LN, Corcoran M. Making homes safer: environmental
adaptations for people with dementia. Alzheimers Care Quarterly
Winter 2000, vol 1: 50 58.
11 Pynoos J, Ohta RJ. In-home interventions for person with
Alzheimers disease and their caregivers. Occupational Therapy
and Physical Therapy in Geriatrics 1991; 9: 83 92.
12 Gitlin LN, Corcoran M. Expanding caregiver ability to use environmental solutions for problems of bathing and incontinence in the
elderly with dementia. Technology and Disability 1993; 2: 12 21.
13 Coon DW, Schulz R, Ory MG, REACH Study Group. Innovative
intervention approaches with Alzheimers caregivers. In: D Biegel,
A Blum (eds) Innovation s in Practice and Service and Delivery
across the Lifespan. New York: Oxford University Press, 1999:
295 325.
14 Mace NL, Rabbins PV. The Thirty-Six Hour Day: A Family Guide
to Caring for Persons with Alzheimers Disease, Related Dementing
Illnesses, and Memory Loss in Later Life. Baltimore: John Hopkins
University Press, 1981.
15 Lawton MP, Moss M, Fulcomer M, Kleban MH. A research and
service oriented multilevel assessment instrument. Journal of
Gerontology 1982; 37: 91 99.
16 Folstein MF, Folstein SE, McHugh RR. Mini-mental state: a
practical method for grading the cognitive state of patients for the
clinician. Journal of Psychiatric Research 1975; 12: 189 198.
17 Lawton MP, Nahemow LE. Ecology and the ageing process. In: C
Eisdorfer, MP Lawton (eds). The Psychology of Adult Development
and Ageing. Washington, DC: American Psychological Association, 1973; 619 674.
18 Gitlin LN, Corcoran M. Managing dementia at home: the role of
home environmental modications. Top Geriatr Rehabil 1996; 12:
28 39.

69

L. N. Gitlin et al.
19 Gitlin LN, Corcoran M, Winter L, Boyce A, Hauck W.
A randomized, controlled trial of a home environmental intervention to enhance self-e cacy and reduce upset in family caregivers
of persons with dementia. The Gerontologis t (2001) vol 41; 4 14.
20 Fleiss JL. The measurement of interrater agreement. In: JL Fleiss
(ed.) Statistical Methods for Rates and Proportion s. New York:
John Wiley and Sons, 1981; 212 236.
21 Donner A, Klar N. The statistical analysis of kappa statistics in
multiple samples. J Clin Epidemiol 1996; 49: 1053 1058.

22 Donner A, Koval JJ, Bull S. Testing the eVect of sex diVerences on

sib-sib correlations. Biometrics 1984; 40: 349 356.
23 Landis JR, Koch GG. The measurement of observer agreement for
categorical data. Biometrics 1997; 33: 159 174.
24 Nunally JC, Bernstein IH. Pyschometric Theory, third edition. New
York: McGraw Hill, 1994.
25 Switzer GE, Wisniewski SR, Belle SH, Dew MA, Schulz R.
Selecting, developing, and evaluating research instruments. Social
Psychiatry Epidemiology 1999; 34: 399 409.

Appendix Aliving room

PROBE: Do you keep scissors or other sharp objects

in this room?

I. POTENTIAL HAZARDS
A. Tripping/Falling
Yes No
1. Observe condition of oor
1
0
(a) If linoleum or tile, is oor slippery?
(b) If carpeting, is it frayed, torn, or are there folds?
(c) If tiled, is it broken?
(d) If throw rugs, not secured?

IF YES, Where do you keep them in this room?

9. Are medications accessible to CR?
1
D. Other Any other safety hazards? Specify
1

0
0

II. ADAPTATIONS
2. Is door threshold 41 inch?

3. Are objects on oor in pathways?

1. Are there any structural renovations?

4. Are electrical/phone cords on oor in

pathways?

5. Is furniture that CR uses stable?

PROBE: Where does CR usually sit? Does CR use

other furniture to get up and down from this chair/sofa?
If furniture unstable, then code=1 (no).
6. Is lighting adequate?
0
1
(e.g. if no lamp shades, glare, dimness, shadows,
broken light bulbs, code=1)
B. Electrical
0
7. Are cords, switches, outlets, in good repair?

PROBE: Do you frequently blow fuses or circuit

breakers (If this occurs, code=1) Are there enough
outlets to accommodate all appliances?
C. Accessible objects
8. Are dangerous objects accessible to CR? 1

70

PROBE: Have you made any major alterations or

renovations in this room to make things easier for yourself or CR? This includes any changes to oors (including removal of wall-to-wall rugs), walls, ceiling, wiring,
and/or plumbing.
2. Has any door leading to or in living room been
modied?
1
0
If no doors, code=72
PROBE: Have you done anything to doors in living
room?
(a) Has door been removed?
(b) Have locks or chains been installed, removed or
placed in unusual manner?
(c) Was doorway made wider?
(d) Is there a pressure gate or other barrier to room?
(e) Other
3. PROBE: Have you removed any items or objects in
response to CRs problems? (e.g. throw rugs, plants, replace equipment, framed pictures, magazine holders,
matches, etc.)
1
0
Specify:__________________________/_____/_____/

Home Environmental Assessment Protocol

4. PROBE: Are there devices or special equipment in
this room that CR uses or you use to help CR for:
Yes

No

1
1

0
0

1
1
1

0
0
0

(a) leisure activities? Specify__________ _

(b) seating? Specify__________ _
(c) monitoring or communicating?
Specify____________
(d) toileting Specify____________ _
(e) other (Specify)?

5. Have any other objects or furniture (not coded in

q. 4) been added, modied or rearranged?
1
0
PROBE: Have you added, modied or rearranged
any furniture or objects in response to CRs problems
or to make caregiving easier for you? Specify:
6. Is there a control centre set-up for CRs use?
1
0
III. VISUAL CUES

Yes No
2. Is there a picture, label or arrow pointing to bathroom?
1
0
3. Is there a drawing, picture or short instruction list
for living room tasks or daily schedule?
1
0
4. Is there use of colours or colour contrast to highlight an object?
1
0
5. Are objects kept together or in containers by task
for caregiving activities?
1
0
6. Any other visual cues or adaptations? (specify)________
1
0
IV. COMFORT
1. Are objects available to touch or look at that are
meaningful to CR?
1
0
V. OBSERVATION ONLYCLUTTER
Very cluttered
3

Somewhat cluttered
2

Not cluttered
1

1. How would you rate the level of clutter in the living

room?

1. Are any objects labelled (television, knitting) with

drawings, signs, or written information?
1
0

71

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