An elderly gentleman looks anxiously out the window of his rehabilitation hospital room, quietly anticipating the arrival of his daughter who is coming to pick him up. Sitting alone, he can hear the nurses shuffling their med cart down the hall and a physical therapist trying to convince his neighbor to get out of bed for a walk. Just two weeks ago he was playing baseball with his grandson. Now he needs assistance to walk to the bathroom; a sudden stroke has left him with weakness in one leg and with faltering balance. His daughter will take him home to live with her.

As a hospital-based physical therapist, I have witnessed this scene hundreds of times. Concerned and confused patients, deemed ready for discharge in the physical sense, must face the reality that they can no longer safely do all the things they once could do to care for themselves. Often the decision to accept help in the face of declining mental or physical health is made for them. Doctors or family members simply decide that Mom or Dad can no longer continue to live alone.

Of all the options, bringing a previously independent, elderly loved one to live with the family is often the most difficult. The daughter mentioned above will be taking on an enormous responsibility, almost as great as the time she brought her own children home from the hospital. She had 9 months to prepare for the arrival of her newborn but only two weeks to prepare for this newest addition to her family. In addition to preparing for the medical and emotional needs of an elderly family member, preparation must also include consideration of such issues such as home safety, mobility and independence.

What Can I Do to Make My Home Safe?

Safety is the first consideration in planning for the arrival of an older person to your home. Even the healthiest, most independent older person is at risk of falling, and the consequences of a fall can be devastating. Hip fractures, vertebral fractures and head injuries can result from even minor falls. Many medical conditions increase the risk of falls. Weakness or unsteadiness of the legs can result from stroke or other neurological problems. Many medications, including some of the most commonly used blood pressure drugs, can cause dizziness or balance problems. Vision problems, from simple cataracts to partial blindness, can make navigating an unfamiliar home difficult.

Simple solutions
Your loved one's doctor should address these issues, but there are simple things you can do yourself to minimize the risk of falls. Picking up slippery throw rugs is mandatory. Grab bars or handrails, available at most large home improvement stores and some medical supply companies, can be installed in the bedroom near the bed and in the bathroom by the toilet or in the bathtub. A shower or tub chair will prevent a weak or unsteady person from having to stand in the shower, or get up from a sitting position in the tub.

Making stairs safe
Another important safety measure is the installation of additional railings in stairwells so that there is a railing on each side of the stairs. This allows someone who is unsteady to hold on with both hands, and someone with one weak arm to hold on with their strong arm as they go up and down the stairs.

What if climbing stairs isn't an option?
Having a loved one's entire living space on a single floor is ideal for people unable to climb or descend stairs safely. For homes in which this is not possible, a stairglide might be an option. A stairglide, or stair-lift, is a motorized chair that rides up and down a rail attached to the stairwell. Some are designed to negotiate stairwells with turns or corners, and all models leave the stairway open for others to use when the chair is not in operation. The chairs have their own safety features, including safety belts, seats that swivel, and back-up power.

Wheelchairs
For the wheelchair bound, the average home can seem like an obstacle course or a prison. Doorways must be wide enough to fit the chair. Barriers should be placed at the top of stairwells to prevent accidental falls. Outside ramps with rails for access to the house are essential. Consult local building codes or a contractor for help in understanding the building requirements of making your home wheelchair-accessible.

What Can a Physical Therapist or Occupational Therapist Do to Help?

Physical therapy
Doctors will often refer patients to a physical therapist such as myself, to work with on building or maintaining strength and fitness, and to help select appropriate activities and exercises. I most often work with people on an outpatient basis, but there are inpatient services available as well. Ask your doctor to refer you to a physical therapist for an evaluation. With a doctor's guidance, a therapist can initiate supervised physical activity, and can train the patient or his or her family members to do these exercises independently at home.

In an initial assessment of an older patient, I evaluate their walking ability, assess the ease with which they can get in and out of bed, and do a general evaluation of their strength and balance. With this information, I can determine what kind of ambulatory aid they will need and what type of exercises will improve their function. I can also order all necessary aids and equipment.

A home visit from a physical therapist can be extremely helpful. A physical therapist can evaluate your living space and make recommendations for how you might make it safer and easier for an older person to negotiate. When I do home therapy prescribed by a doctor, I usually schedule visits 2 to 3 times a week to do strengthening exercises, practice transfers in and out of bed, and exercise to improve balance and coordination.

Occupational therapy
An occupational therapist can also work with an older person in the hospital or in the home. Occupational therapists evaluate how well people manage everyday activities, like getting dressed, bathing, grooming, and preparing meals. They also work on fine motor skills that most of us take for granted, like buttoning clothing or tying shoelaces. All of these activities can become difficult for older persons with a variety of medical problems. Imagine, for example, how you would put on your socks if arthritis in your back made it impossible for you bend over to reach your feet. Occupational therapists are trained in helping to find alternative ways to do these everyday things, often using simple assist devices. A long-handled grasper, for example, can be used to pull on socks that one can't reach. Occupational therapists are also experts on home safety, and can often make important recommendations about how to make the home a safer place.

Staying Active and Healthy

Staying active, in whatever capacity, is an important part of staying healthy. Even older persons with significant physical limitations, including those confined to bed, can benefit from some degree of physical activity. Safety, however, is critical. Many older persons move in with younger family members after an illness or a decline in their mental or physical health. It is essential that their doctor be involved in helping to determine safe and reasonable forms of activity for them.

Exercise for mobile patients
For mobile patients, even simple activities can be great sources of exercise. Whenever possible, I recommend walking to my patients. The benefits are substantial; walking is an excellent way to increase circulation, improve cardiovascular health and maintain bone strength. One of my patients, living with his daughter after breaking a hip, told me that he made it a point every day to get up and go outside with the aid of his walker, and walk down his daughter's 300-foot driveway to get the mail. I knew that the path was flat and obstacle-free, and that he was steady enough with his walker to make this trip safely. For him, this simple task gave him both a daily dose of exercise and a sense of accomplishment.

Walking Made Simple

As I noted above, multiple medical and physical problems can make walking difficult, and various devices are available to make walking safer, easier or less painful. Your family member's doctor or therapist can recommend an appropriate device.

Walkers
A walker is usually necessary for severe balance problems and also can be useful if bearing weight on one leg is painful. If a stroke has left a patient with one hand weak, a platform (arm-rest on side of walker) can be ordered for the walker or a one-handed hemi-walker (smaller walker with four legs to use with strong hand) can be ordered. If your loved one has difficulty walking long distances even with a walker, you may want to consider getting a wheelchair for excursions outside your home.

Canes
Quad canes are canes with four feet, which provide more stability and support for an unsteady person than a regular, single point cane. Single point canes are helpful for those who have slight balance difficulties or need mild support for a painful leg. Both types of canes have handles that come in a variety of shapes and forms. A special handle, called Ortho-Ease, molds to a person's grip; this can be especially useful for those with arthritis in the hands which can cause difficulty with holding or gripping a cane.

Where do I find these devices?
Medical supply stores and some large pharmacies will have many of these items on display. Special adaptations and sizes are available from medical supply catalogs. If prescribed by a doctor, most walking aids are covered at least in part by Medicare and supplemental insurance.

Staying Healthy in Bed

If a loved one is temporarily or permanently bed-bound as a result of injury or illness, other concerns exist. Most people who are unable to get out of bed have difficulty moving around in the bed as well. Changing positions can be difficult, and lying in one position for too long can lead to pressure sores and ulcers. Turning them or helping them turn onto their back or side every two hours can help prevent pressure-related problems

Exercise in bed
Exercise is important for bed-bound persons as well. Range of motion exercises, in which a limb is gently moved through its normal movements (bending and straightening the arm at the elbow, for example), can help prevent muscles from becoming tight and joints from becoming stiff. A typical, full body range of motion regimen starts with the shoulders and works toward the feet, moving each joint in turn. Although these exercises should be done only with the initial guidance of a trained therapist, nurse or doctor, any caregiver can be trained to do them easily. The key is to perform the exercises slowly and to listen and watch for reactions signaling discomfort – no exercise should be continued if it causes significant pain.

Who Can I Turn to For Support?

You should not feel alone when it comes to thinking about what's best for your loved one. Whether you have a question about where to install a grab bar, what kind of exercise is safe, or which kind of walking aid is appropriate for a given disability, there are people who can help. If your family member's doctor does not have experience with the special needs of older persons, ask for a referral to a local geriatrician or gerontologist. These doctors have special training and interest in the medical, physical and emotional needs of older persons. Also ask for a referral to the local or state home health service. If your family member is coming to live with you after a hospitalization, speak to the hospital social worker about visiting nurses and home care services. Although services vary greatly from region to region, many are able to provide home nursing, in-home attendants and home physical therapy. A good social worker will work with the visiting nurse service to determine the amount of help you need based on the physical limitations or medical needs of your loved one.

Conclusion

If you decide to bring an elderly family member into your home, remember that they are losing some of their independence in return for your care and support. It is important to keep them safe, and equally important to ensure that they stay as active and vital as possible. If they feel strong and independent, you will both have happier and healthier home lives.