School of Occupational Therapy Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET

Focused Question:
What is the effectiveness of home modification interventions to improve performance for older
adults with functional difficulties?

Prepared By:
Johnny Rider, OTS & Gary Pearson, OTS
School of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89014

Date Review Completed:
10/2/2014

Clinical Scenario:
You are working with an older couple experiencing difficulties completing activities of daily
living (ADLs) in their home. While obtaining an occupational profile you find out their main
goal is to stay in their home as long as possible. They are concerned about losing independence
and do not have financial resources to pay for extra help. They are also concerned about safety in
their home. You wonder if home modification interventions would be an effective intervention to
improve functional performance and abilities to complete ADLs and allow the couple to continue
living in their home independently.

Functional disability and difficulty is a major adverse outcome of age related chronic and
debilitating conditions that are common in older people. Difficulties performing instrumental
activities of daily living (IADLs) or ADLs represent pivotal events that may trigger the need for
personal assistance, relocation to a family members home or residential facility, thus increasing
financial burden and further limiting occupational engagement. Additionally, functional
disabilities are associated with a diminished quality of life, poor self-efficacy, shorter life-span,
high healthcare costs, and service utilization (Gitlin, 2006). Functional disabilities left
unaddressed lead to secondary complications that result in social isolation, anxiety, depression,
falls, and further functional decline (Gitlin, 2006).

Older adults experiencing functional limitations completing daily activities often have
environmental barriers in the home that compound minor limitations, due to various client
factors, into major limitations. Home modifications are a treatment strategy that can eliminate or
reduce environmental barriers to improve functional performance within the home, increase
safety, reduce the personal support needed to complete daily activities, and prevent further
decline in overall health and wellness. Home modifications include a wide array of strategies
requiring thorough evaluations of the client and the home environment. Therapists must utilize
clinical reasoning when recommending home modification interventions such as providing
durable medical equipment (e.g., shower chairs, tub transfer bench, grab bars), universally
designed equipment (e.g., large handle designed utensils), architectural modifications (e.g., a
ramp), major home renovations (e.g., removing a wall, changing light switch placement),
modifying floor plans (e.g., rearranging furniture), assistive technology (e.g., dressing or hygiene
tools), or learning a strategy to use the environment in a different way (e.g., turning on the light
before walking down the stairs). Home modifications cannot be categorized easily. They include
all of the interventions listed above and more.

Modifying the environment has become an important intervention strategy used by occupational
therapists to help manage chronic health conditions, maintain or improve functioning, increase
independence, reduce barriers, ensure safety, reduce the need to relocate to institutional facilities,
reduce the need for additional support services, and reduce costs associated with medical needs
and further functional decline. Environmental modifications may forestall the need for more
costly traditional medical services (Stearns et al., 2000). Additionally, a lack of environmental
support is attributed to poorer functional outcomes (Taylor & Hoenig, 2004).

This critically appraised topic paper is a review of the current research literature and provides
evidence on the effectiveness of home modifications used as an intervention to improve
performance in older adults with functional decline wanting to continue aging independently in
their home.

Summary of Key Findings:
Summary of Levels I, II and III:
-Addressing environmental barriers using the Canadian Occupational Performance
Measure (COPM) and providing home modifications improved client satisfaction in
occupational performance (Stark, 2004; Petersson, Lilja, Hammel, & Kottorp, 2008)

-Home modifications were effective in reducing difficulty in performing daily life tasks
after installation (Peterson et al., 2008; Petersson, Kottorp, Bergstrom, & Lilja, 2009)

-Home modifications need to be installed as soon as possible after the needs have been
identified to prevent further functional decline (Wilson, Mitchell, Kemp, Adkins, &
Mann, 2009)

-Perception of housing environment to support daily activities improved after home
modifications were installed (Fange & Iwarsson, 2005)

-Identifying meaningful activities that older adults have given up and providing home
modifications to address this specific participant activities improved client satisfaction
with performance (Stark, Landsbaum, Palmer, Somerville, & Morris, 2009)

-Home modifications may add years to the lives of older adults living in their homes
(Gitlin, Hauck, Dennis, Winger, Hodgson, & Schinfeld, 2009)

-Areas of the home that clients reported had the most environmental barriers for daily
activities were the bedroom, bathroom, and entrances (Szanton, Thorpe, Boyd, Tanner,
Leff, Agree, & Gitlin, 2011; Petersson et al., 2008; Gitlin, Winter, Dennis, Corcoran,
Schinfeld, & Hauck, 2006)

Summary of Level IV and V:
There are no Level IV or V articles included in this review.

Contributions of Qualitative Studies:
There are no qualitative studies included in this review.

Bottom Line for Occupational Therapy Practice:
The clinical and community-based practice of occupational therapy:
Home modifications are effective in improving occupational performance in ADLs, increasing
safety, and improving survivorship for older adults aging in place with functional difficulties.
Home modifications should be client-centered and installed as soon as environmental barriers are
identified to prevent further functional decline and safety concerns. Occupational therapists
should implement a multicomponent home modification intervention with emphasis on
bathrooms, bedrooms, entrances, stairways, and doorways.

Program development:
All healthcare professionals entering the home of clients should assess environmental barriers,
functional difficulties, and utilize ecological theories. Studies have demonstrated how grants can
be used effectively to create home modification programs to help older adults prevent functional
decline and improve functional difficulties with ADLs and IADLs. Programs need to develop
efficient strategies for evaluating housing adaptations within occupational therapy and emphasize
home modifications in areas of the most need such as the bathroom and bedroom.

Societal needs:
The surge in the aging population is beginning to tax healthcare services. Home modifications
are an effective solution to deal with the functional losses associated with aging. Lack of self-
efficacy is noted in the aging population and cites the need for home modifications to improve
independence, occupational performance, and the goal of older adults to age in place.

Healthcare delivery and policy:
Multicomponent home modification interventions utilizing expertise from interdisciplinary teams
should be delivered in the home of older adults with functional difficulties. Home modifications
may prevent development of health problems, healthcare needs, and functional dependency due
to their effect at reducing disability in everyday activities and therefore reduce healthcare costs.
Factors other than medical conditions should be considered when referring clients for home
evaluations. Participation in meaningful occupations, ADLs, and IADLs must be considered and
assessed by an occupational therapist for older adults with perceived functional limitations.

Education and training of occupational therapy students:
All students should be taught a variety of home modifications and assistive technology to benefit
older adults with diverse disabilities, client-centered outcome measures such as the COPM, and
how to identify environmental barriers within a clients home. Students should practice teaching
modified approaches and safe usability of home modifications/adapted equipment to participate
in meaningful activities for older adults. Students should be well versed in ecological models of
practice and appropriate home assessments.

Refinement, revision, and advancement of factual knowledge or theory:
Although the evidence is clear that home modifications are effective at improving occupational
performance of older adults with functional difficulties, more research is needed in diverse
populations with larger sample sizes to ensure generalizability to the aging populations in the
United States. Further research in cost-effectiveness, objective functional performance measures,
how much training is necessary on home modifications and usability of the modifications is also
necessary.

Review Process:
-Review authors critically appraised articles selected for inclusion using the McMaster Critical
Review Form

-Authors reviewed the McMaster Critical Review Form for each study selected for accuracy

-Authors constructed an evidence table that included ten articles for review and critically
analyzed each studys results, limitations, and implications for occupational therapy practice

Procedures for the Selection and Appraisal of Articles:
Inclusion Criteria:
-Peer-reviewed scientific literature published in English with full-text, abstract, and references
available

-Published since 2004

-Intervention in studies focused on home or home environment modifications

-Intervention is within the scope of practice of occupational therapy, although it did not have to
be administered by an occupational therapist

-Any study meeting the criteria represented in the focused question

-Participants in the studies were older adults (age 55 or older) experiencing functional
difficulties/limitations completing activities/instrumental activities of daily living in the home

-Level I, II, and III evidence
Exclusion Criteria:
-Published prior to 2004

-Non-peer reviewed research literature

-Presentations, conference proceedings, dissertations, theses

-Studies with outcomes not reported

-Studies with participants that did not have documented functional limitations

-Studies focused on safety and fall prevention

-Studies that did not examine and apply interventions focused on home/home environment
modifications

-Studies with participants younger than 55 years of age

-Level IV and V evidence

-Qualitative studies

Search Strategies:
Categories Key Search Terms
Patient/Client Population Older adults, seniors, physical disabilities, disability,
functional decline, functional difficulties
Intervention Home modification(s), home adaptation(s), housing
adaptation(s), home modification interventions, environmental
modification(s), environmental adaptation(s), occupational
therapy, assistive technology, environmental barriers,
residential modification(s)/adaptation(s)
Outcomes Functional improvement, function, activities of daily living,
instrumental activities of daily living, participation, activity
participation, independence, performance

Databases and Sites Searched
CINAHL, PubMed, OT Seeker, OT Search, SAGE Premier, Medline, Google Scholar, Cochrane
Database of Systematic Reviews

Quality Control/Peer Review Process:
-To ensure relevance and appropriateness of the focused question, the instructor of record
analyzed and approved focused question prior to beginning an exhaustive search of the literature

-Search terms were developed by review authors and instructor of record

-Articles selected were reviewed by review authors for inclusion or exclusion.

-The instructor of record reviewed critical appraisal forms, evidence table, and associated articles
for relevance and appropriateness for review

-Review authors developed CAT, which was reviewed by instructor of record

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
Study Design/Methodology of Selected Articles Number of Articles
Selected
I Systematic reviews, meta-analysis, randomized
controlled trials
4
II Two groups, nonrandomized studies (e.g., cohort,
case-control)
3
III One group, nonrandomized (e.g., before and after,
pretest and posttest)
3
IV Descriptive studies that include analysis of outcomes
(single-subject design, case series)
0
V Case reports and expert opinion, which include
narrative literature reviews and consensus statements
0
Other Qualitative Studies 0
TOTAL: 10
Limitations of the Studies Appraised:
Levels I, II, and III
-Findings may not be generalizable due to voluntary participants demonstrating
motivation for intervention (Gitlin, Winter, Denis, Corcoran, Schinfeld, & Hauck, 2006;
Petersson, Lilja, Hammel, & Kottorp, 2008)

-Results cannot be generalized to all individuals aging with disabilities due to the variety
of disabilities, age of onset, functional limitations, and prior treatment (Wilson,
Mitchell, Kemp, Adkins, & Mann, 2009)

-Sample does not represent general population of older adults (Stark, 2004)

-Small sample size (Petersson et al., 2008; Stark, 2004; Fange & Iwarsson, 2005; Stark,
Landsbau, Palmer, Somerville, & Morris, 2009)

-Time lapse for implementing home modifications after baseline evaluations was up to
12 months (Stark, 2004)

-Variety of participant circumstances and client factors posed challenges and
methodological issues when analyzing data (Petersson et al., 2009)

-The control group received no equipment from the study but may have obtained
equipment from outside sources (Wilson et al., 2009; Fange & Iwarsson, 2005)

-Self-reports may be inconsistent with actual ability (Liu & Lapane, 2009)

-Time between baseline, intervention, and data collection may be too broad to capture
disability transitions that occurred between waves or too short to evaluate the impact of
physical function decline amenable by residential modifications (Liu & Lapane, 2009)

-Study design and size prohibited determination of the relative value of each individual
intervention component (Szanton, Thorpe, Boyd, Tanner, Leff, Agree, & Gitlin,
2011)

-Unable to control for clinical variables that are out of control of the intervention but
significantly impact health, function, and quality of life (Gitlin, Hauck, Dennis, Winter,
Hodgson, & Schinfeld, 2009)

Levels IV and V
There are no Level IV or V articles included in this review.

Other
N/A

Articles Selected for Appraisal:
Fange, A., & Iwarsson, S. (2005). Changes in ADL dependence and aspects of usability
following housing adaption - A longitudinal perspective. American Journal of Occupational
Therapy, 59(3), 296-304.

Gitlin, L., Hauck, W., Dennis, M., Winter, L., Hodgson, N., & Schinfeld, S. (2009). Long-term
effect on mortality of a home intervention that reduces functional difficulties in older adults:
Results from a randomized trial. Journal of the American Geriatrics Society, 57(3), 476-481.
doi:10.1111/j.1532-5415.2008.02147.x

Gitlin, L., Winter, L., Dennis, M., Corcoran, M., Schinfeld, S., & Hauck, W. (2006). A
randomized trial of a multicomponent home intervention to reduce functional difficulties in older
adults. Journal of The American Geriatrics Society, 54(5), 809-816. doi:10.1111/j.1532-
5415.2006.00703.x

Liu, S. Y., & Lapane, K. L. (2009). Residential modifications and decline in physical function
among community-dwelling older adults. The Gerontologist, 49(3), 344-354. doi:
10.1093/geront/gnp033

Petersson, I., Kottorp, A., Bergstrom, J., & Lilja, M. (2009). Longitudinal changes in everyday
life after home modifications for people aging with disabilities. Scandinavian Journal of
Occupational Therapy, 16(2), 78-87. doi:10.1080/11038120802409747

Petersson, I., Lilja, M., Hammel, J., & Kottorp, A. (2008). Impact of home modification services
on ability in everyday life for people ageing with disabilities. Journal of Rehabilitation
Medicine, 40(4), 253-260.

Stark, S. (2004). Removing environmental barriers in the homes of older adults with disabilities
improves occupational performance. OTJR: Occupation, Participation & Health, 24(1), 32-39.

Stark, S., Landsbaum, A., Palmer, J., Somerville, E. K., & Morris, J. C. (2009). Client-centered
home modifications improve daily activity performance of older adults. Canadian Journal of
Occupational Therapy. 76, 235.

Szanton, S. L., Thorpe, R. J., Boyd, C., Tanner, E. K., Leff, B., Agree, E., & Gitlin, L. N.
(2011). Community aging in place, advancing better living for elders: A biobehavioral-
environmental intervention to improve function and health-related quality of life in disabled
older adults. Journal of The American Geriatrics Society, 59(12), 2314-2320.
doi:10.1111/j.1532-5415.2011.03698.x

Wilson, D., Mitchell, J., Kemp, B., Adkins, R., & Mann, W. (2009). Effects of assistive
technology on functional decline in people aging with a disability. Assistive Technology, 21(4),
208-217. doi:10.1080/10400430903246068

Other References:
Stearns, S. C., Bernard, S. L, Fasick, S. B., Schwartz, R., Konrad, T. R., Ory, M. G., & DeFriese,
G. G. (2000). The economic implications of self-care: The effect of lifestyle, functional
adaptations, and medical self-care among a national sample of Medicare beneficiaries. American
Journal of Public Health, 90, 1608-1612.
Taylor, D. H., & Hoenig, H. (2004). The effect of equipment usage and residual task difficulty
on use of personal assistance, days in bed, and nursing home placement. Journal of The
American Geriatrics Society, 52, 72-79.







Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05