Network on Environments, Services and Technologies for Maximizing Independence
NEST - An ASA Constituent Group

• Risk is not a material or actuarial fact. Rather, it is socially perceived, replete with symbolic meanings and interpretations.
• The importance of specific meanings of risk is open to debate between older people, their families and healthcare providers.
• Points of view on what is safe differ widely. Elders, their families and healthcare professionals may have very different ideas of the best strategies for ameliorating risk.
• Each assessment of safe or unsafe leads to acceptance or rejection of certain activities, ideas or problem-solving strategies.

In general, older adults worry more about being hurt outside their homes than inside. To be sure, muggings, pedestrian injuries and the like do happen to older people on the street -- and these often receive coverage by the news media. But far more serious falls and injuries happen at home when elders have accidents such as slipping in the bathroom or missing their footing on stairs.

Facts about home injuries are usually revealed only in statistical reports inaccessible to the general public, and they do not convey the emotions or carry the immediacy of news reports. Thus, it is hard to convince older adults that their homes -- where they spend a lot of time and thus experience most exposure to hazards -- are far less safe than they believe.

An Appearance of Safety

Elders do recognize that some hazardous situations exist in their homes, and many make adjustments to create a sense of safety. However, the emphasis in such cases is on providing an appearance of safety more than on properly remediating hazards. For example, some older adults recognize the potential for slipping in the bathroom and so deliberately position towel racks to act as grab bars -- not realizing how flimsy the racks can be.

Similarly, elders often presented draping a telephone cord across the floor to make the phone more convenient to reach from a favorite chair as reducing a hazard rather than increasing the risk of tripping. Another accommodation often made by older people is restricting the space they use in their homes, avoiding steep, narrow stairs or places without much light.

The results of our study indicate that elders want to postpone as long as possible any potential stigma they might engender as a consequence of modifying their homes. Study participants talked about waiting to address hazards until they became -- in their words -- "really old" or "frail and decrepit." The visibility of the suggested modification was important here.

Installing grab bars in the bathroom -- a private space -- was often acceptable to elders, for example, whereas removing throw rugs from the front room generally was not. Rug removal would signal to visitors that the older adult was vulnerable, triggering undesirable scrutiny from those individuals. Most elders do not wish to be constantly monitored as if they were no longer capable or independent.

Health educators and professional assessors of home safety tend to emphasize the risks they discover in a home, but elders attend to both the risks and the aesthetics reflected by the evaluator's recommendation -- and tend to downplay possible risks to maintain the look they desire for their home. For example, older adults -- especially those who become easily fatigued while doing housework, who have few financial resources, or who lack able-bodied or willing kin or neighbors to assist in cleaning floors -- may resist taking up area rugs that hide stains or prevent damage to floors.

Reasons for Resistance

Many elders refuse to make home modifications because the memories associated with certain parts of the house -- for example, a husband's handiwork -- would be affected by the changes. In addition, it's easy for older adults to forget that their physical capabilities have changed since they first moved into their house, especially if they have lived in the same place for decades. "But I've always had that lamp in that corner of the room and I just stretch out here to reach the on-off switch," protested one 78-year-old woman, quite overlooking the fact that her balance is not nearly as good as it was 30 years ago.

Similarly, people usually agree that smoke alarms are good, even useful, safety devices but will nonetheless disable them by removing the batteries or not replacing depleted batteries. Smoke detectors are usually installed on a ceiling or high on a wall, out of reach without a ladder or another person to assist with maintenance. Older adults not only view climbing a ladder as a risky venture but also intensely dislike having to disarm the smoke alarm whenever they accidentally burn the toast.

The customary habits of decades are difficult to change, especially if the meaning given to the change is decline, vulnerability, increasing frailty or lessening independence. Elders are more likely to adopt recommended changes for improving home safety if the emphasis is on increasing convenience, comfort or pleasure for everyone, including visitors and family, not just on reducing risk for the older occupant.

As a qualitative researcher for the University of California, San Francisco, Judith C. Barker has focused on studying the social organization of healthcare and the ways in which older people manage chronic illnesses on a day-to-day basis. Contact her at barkerj@dahsm.ucsf.edu.