Editor’s note: The first part of this article, focusing on medications, mobility, assistive devices, and protective equipment, appeared in the June 2007 issue of ECPN and is available at www.extendedcarenews.com/article/7222.

T

he aim of environmental modification is to identify and eliminate hazardous conditions related to falls. While environmental hazards by themselves can increase fall risk, their relationship to the likelihood of falling is more accurately reflected by the effects on mobility and the ability of the resident with Alzheimer’s disease (AD) to ambulate and transfer independently and safely in his or her environment. Consequently, the fundamental question to ask when assessing the environment of a resident with AD is how the person’s living environment affects (helps or hinders) mobility. The answer is best determined by observing the resident’s functional ability and whether a particular environmental area or furnishing is safe or hazardous. Ask the resident to walk about his or her bedroom, bathroom, and other facility locations; transfer on and off the bed, chairs, and the toilet; get in and out of bathtubs and shower stalls; and reach up to obtain objects from closet shelves. By noting which environmental features interfere with safe mobility, targeted environmental modifications can be designed. Observing the residents’ mobility can also help determine their cognitive skills (ie, comprehension, judgment, etc.) and spatial orientation. The following aspects of the facility environment frequently contribute to unsafe mobility in residents with AD and call for specific modifications.
       Circulation paths. When walking from one location to another, residents with poor gait and balance often place their hands on furnishings (eg, chairs, tables, dressers) and walls for support. As an alternative, a cane or walker may be provided. However, residents with AD may have difficulty learning a new activity or using a walking aid safely. In this case, furnishings used for stability should be stable enough to support the resident, and hallway walls should be accessible and free of clutter.
       During ambulation, some residents with AD keep their heads and eyes focused straight ahead, and they often collide with low objects in their path. Visual field restrictions contribute to this problem. For this reason, pathways should be unobstructed, absent of decorations. Since residents commonly get up during the night to urinate, the path from the bed to the bathroom should be clear of objects and well illuminated. Nightlights can be used to provide sufficient lighting. Be aware, however, that nightlights can cast shadows and images that lead to hallucinations and paranoia in some residents with AD.
       Lighting. Residents with AD may have difficulty adjusting to stark changes in illumination. Moving from bright to dark areas (decreased dark adaptation) and visa versa (sensitivity to bright lights) can lead to a temporary loss of vision and promote confusion. Therefore, it is important to maintain uniform lighting levels. This can be achieved with three-way bulbs and wall dimmer switches that allow caregivers to vary light levels.
       Glare from sunlight shining through windows or unshielded light bulbs reflecting on polished floors may impair vision. Direct window glare can be dispersed with sheer shades or tinted glass. Light-bulb glare is reduced with frosted bulbs or translucent lighting shades. Floor glare can be controlled with carpets or low-luster polishes that diffuse light.
       Floor surfaces. Carpets, rugs, and tiled floors that are patterned (ie, checkered or floral designs) should be avoided. These coverings interfere with depth perception and balance. Floor coverings should be solid in color. Sliding throw rugs should be replaced. As an alternative, non-slip backing can be placed under rugs to prevent sliding.
       Beds. Elevated bed heights and soft mattress surfaces promote balance loss during resident transfers. Appropriate bed heights can be achieved by replacing thick mattresses with those thinner in width. Mattresses should be firm enough to support balance when residents get out of bed. The floor surface along the bed should be slip-resistant to support safe transfers. If floor surfaces are slippery, have the resident wear traction-soled socks or slippers. Beds that slide away during transfers can be placed against the wall for support if feasible.
       Chairs. All chairs used by residents with AD should have arm rests, which provide leverage and balance support during transfers. Arm rests can also compensate for low seat heights. For those residents who continue to experience problems, a cushion can be added to increase the height of low-seated chairs. The stability of chairs is crucial for safety. A good test of chair stability is to grasp and lean into a chair and slide and tilt it forward, backward, and sideways during sitting and rising.
       Bathrooms. The addition of toilet grab bars (either wall- or toilet-attached) or elevated toilet seats can compensate for low toilet seats. Bedside commodes are beneficial if toilets are inaccessible or difficult for the patient to use.
       Towel bars used for balance support should be replaced with wall-mounted bars. Wall- and bath-mounted grab bars in the bathtub provide support during tub transfers. All grab bars should be slip-resistant, color-contrasted from the wall for visibility, and securely fixed to the studs of the wall for adequate support. Non-slip adhesive strips can be placed on the top of sink edges to guard against hand slippage if these surfaces are used for balance support.
       Rubber mats or non-slip adhesive strips applied to the bathtub floor surface provide stable footing and visual cuing. Residents with AD with decreased depth perception often view tub surfaces as bottomless pits and become fearful when entering. Also, tub benches and extended shower hoses can serve as useful devices to assure safe bathing.

Environmental Modifications

       In adapting the environment, it is important to remember that changes can be disruptive for residents with AD and may produce anxiety that can intensify cognitive deficits. Therefore, it is advisable to modify only those features of the environment that clearly benefit the resident’s mobility and decrease the risk of falls. As a rule of thumb, try to keep modifications to a minimum—the key is simplicity. If several changes are needed, introduce them one at a time. Because of intellectual impairment, residents may be unable to learn new tasks (eg, using toilet or tub grab bars), and they may become frightened of new gadgets. Therefore, after implementing modifications, always test to ensure that the alteration is safe and beneficial. Also, as mobility changes over time, reassess resident mobility and the need for new modifications or changes with existing modifications periodically.

Behavioral Strategies

       A number of behavioral problems are associated with fall risk, including agitation and anger, wandering, and catastrophic reactions. The “ABC” method (ie, the antecedent or what came before, the behavior itself, and the consequences of the behavior) is a good strategy for managing the behavior of a resident with AD. The idea is to observe what is going on (ie, the antecedent) shortly before the behavior to determine possible causes. For example, agitation or wandering might be caused by too much excitement, stress, or activity in the environment. Altering the environment (ie, decreasing stimulation and simplifying activities) may reduce the behavior. Also, observe what happens after a particular behavior occurs. Consequences sometimes act as reinforcement for problem behaviors. If the resident with AD gains something (eg, he or she receives more attention or avoids a specific activity) from a particular behavior, the likelihood of that behavior occurring again is increased.
       Lastly, the antecedent of certain behaviors (eg, agitation or sleep disturbances) can be due to underlying physical illness (eg, pain, urinary tract infection, constipation). Identifying and treating the underlying problem will often eliminate the behavioral problem. Medication management should only be considered if behavioral interventions prove ineffective, there is significant safety risk to the resident or others, or the resident is very distressed. Any medication used to control troubling behaviors should be maintained at the lowest possible dose and discontinued when no longer effective or needed.

Conclusion

       Falls are common in residents with AD. For the most part, they have been attributed solely to cognitive deficits. However, experience in caring for residents with AD indicates otherwise. Falls in AD may be regarded as a sentinel event indicating the presence of chronic conditions, adverse medication affects, and hazardous environmental conditions affecting mobility. By addressing these risk factors, long-term care facilities can greatly reduce falls in residents with AD.