available on home and its correlation to well-being demonstrates the complexity of the situation but does lean toward positive results. Research has found that the built environment plays a role in maintaining the physical functioning of older adults. The structure of the outside community can impact the ability of an older adult to perform basic ADLs; people who reside in communities with more resources are more independent than those who live in more isolated communities (Clarke & George, 2005). Even the ability to ambulate in the community relates to greater independence in their daily lives by preventing lower extremity weakness. Oddly enough, this study did find that the absence of full bathrooms or complete plumbing actually increased independence in bathing. It is hypothesized that this less-than-ideal housing structure forced older adults to perform less demanding sponge baths rather than full showers. It does, however, show the importance of home design features in impacting performance of ADLs and increased independence. There is some connection between aging in place at home and a sense of well-being. The sense of well-being comes from a sense of connection more to the community and space than to the home itself (Gilleard, Hyde, & Higgs, 2007).
However, that connection can be attributed to the memories created that attach people to the place and create meaning. Regardless, older adults tend to have an emotional connection to their community and home. The strength of that connection contributes to their overall sense of well-being. Older adults are at risk for depression and loneliness; those with an increased sense of well-being are at a lesser risk of these serious mental health issues. Therefore, aging in place is important for the psychosocial maintenance of older adults. It is important to recognize the impact of home modifications on older adults’ perceptions of their home. Maintaining space for family and pets can be a top priority. Older adults also will have emotions tied to the aesthetics of the home as a representation of themselves. However, when modifications increase the safety and comfort of the home or increase their independence in tasks, older adults can be more receptive and be accepting of the modification (Tanner et al., 2008). At the same time, they appreciate when the design/modification is not advertised or addressed in a way that represents a disability or negative connotation. Being part of the decision-making process during home modifications can assist with increasing the satisfaction of older adults with their homes. performance; they reach the “just right challenge.” Home modifications should bring people into the zone of maximum comfort, where the difficulties imposed upon the older adult by the environment are lessened to meet his or her level of competence. An example of this would be someone faced with a bathtub that is too high. The environmental press is strong, and the person may have low to moderate competence in terms of balance, safety awareness, and ability to step over the bathtub edge. The installation of a grab bar would reduce the environmental press enough to allow the person to move from either maladaptive or marginal zones into the zone of maximum comfort. Then the person could perform a tub transfer safely and independently. Figure 3: Lawton’s Theory of Environmental Press
Contexts and their impact on activities of daily living performance Physical therapists are well aware of the role contexts and environments play in maintaining people’s independence, health, and well-being. As people age, they do become more sensitive to changes in their environment. Anyone who has worked with someone with dementia knows that changes in the environment can impact cognition and cause increased confusion, because the environment provides an organizing structure to his or her day. This is just one example of how the environment can impact the daily life of an older adult.
Theory supports the implementation of home modifications in allowing older adults independence in their daily occupations. Lawton’s Theory of Environmental Press informs several theories, such as Person-Environment-Occupation, Ecology of Human Performance, and Model of Human Occupation. All these theories share a common thread: the environment is an integral component of the ability of people to perform their occupations and can serve as either a barrier or support to successful activity completion. Lawton’s Theory of Environmental Press and the Environmental Docility Hypothesis function on the idea that as people’s abilities decrease, their sensitivity to the environment increases (Lawton, 1990). The Environmental Docility Hypothesis also discusses the idea of “control centers,” which are self- structured environmental features in a home that allow someone to concentrate needed items in a specific area to maximize independence in an area of activity. An example of this would be placing a preferred chair in a location that allows for proper surveillance of the home for safety, but is also in proximity to the bathroom and has space for needed objects such as remotes, mobility devices, and a table for water and food. Environmental density has increased and lessened the effect of the overall physical context on the person. In this situation, moving items into other locations or even changing the orientation of the chair would greatly reduce the ability of the person to monitor the home and reach needed areas quickly. Also, moving items could cause confusion; the person may not be able to find objects, such as the television remote or telephone, which could cause agitation and anxiety. Ideally, home modifications match the person’s ability to complete ADLs and maintain an appropriate level of environmental press, or demands, to allow someone to reside in either the zone of maximum comfort or the zone of maximum performance potential (see Figure 3). In the zone of maximum comfort, people are supported in their abilities by the environment. In the zone of maximum performance potential, people are challenged by the environment to improve their skills to achieve occupational
Strong
Too much press
Marginal
Stimulation
Negative affect and maladaptive behavior
Positive affect and adaptive behavior
Maximum comfort
Environmental Press
Support
Maximum performance potential
Marginal
Negative affect and maladaptive behavior
Too little press
Weak
Low
High
Competence
Note. From Western Schools, © 2018.
EliteLearning.com/Physical-Therapy
Book Code: PTNY3622B
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