Select evidentiary support
Collaborative approach to identify an individual’s valued activities and specific performance challenges and explore environmental solutions. Individuals should be viewed as a partner who has valued information about his or her daily challenges and personal functional goals. Client preferences need to be identified and respected. Not every adaptation will be acceptable or perceived as useful to the client, so a range of adaptations should be offered and discussed, implementing only those that are acceptable
Toth-Cohen et al. (2001)
Cultural relevance and understanding
View of home as a microculture reflecting values, beliefs, and preferred approaches to carrying out daily activities of self-care. Therapist must identify and understand the specific cultural influences shaping daily participation choices and what changes in the environment would be acceptable
Brach and Fraser (2000)
Process of helping individuals identify performance difficulties and environmental barriers and explore potential environmental solutions. Also, serves as an approach to modeling for individuals to address environmental barriers to effective functioning
Tailoring of specific environmental strategies to match environmental specifications, person-identified concerns, capabilities, and culturally appropriate solutions
Richards et al. (2007)
Use of active strategies to instruct individuals in use of adaptations. Use of demonstration, role-play, and observed practices are effective
Chee et al. (2007)
Another core principle is that since adaptations occur in people’s private living space, sensitivity to the meaning of objects and environmental configurations is essential. Objects and environmental setups reflect cultural preferences, long-standing values, and hidden meanings (Oswald and Wahl 2005). What may appear as a simple alteration that may be helpful to an individual (such as rearranging furniture to enhance way-finding) may disrupt a person’s sense of normalcy and long-standing preferred environmental placements. Furthermore, the process of identifying environmental solutions involves problem solving with clients as to their performance difficulties and occupational goals, barriers and supports to performance, and potential environmental solutions. Yet another principle is tailoring. Solutions must be customized to the particular person–environment and cultural and occupational context, with the most effective training actively involving the client through use of demonstration and hands-on practice sessions. Each of these treatment principles is informed by evidence and reflects best practices.
The implementation of a particular environmental solution involves five basic considerations (Table 12.2). These include making small incremental changes to an environment so as not to overwhelm clients and facilitate their adaptation to the change, involving family members when appropriate to support new learning and sustained safe use of modifications, providing only those adaptations that are agreed upon, and providing education about resources for obtaining other adaptations that may be necessary in the future.
Key clinical considerations
Make small or incremental changes in the environment, particularly for individuals with cognitive impairments
Only make those changes acceptable to and agreed upon by the client and family members
Use catalogues, pictures, or sample devices as exemplars so that client has realistic understanding of the possibilities
Allow ample opportunities for practice and refinement of the adaptation if necessary
Include family members if so desired by the older person in the assessment, adaptation selection process, and training
Knowledge about the evidence of environmental adaptations is emerging. There are several different data sources that support this approach. First, large-scale epidemiologic research consistently shows a relationship between increasing frailty and use of adaptations, suggesting that this is one of the preferred and effective approaches for compensating for physical and possibly cognitive declines (Manton et al. 1997). Similarly, studies using population-based samples have shown that use of special equipment is associated with enhanced self-efficacy , whereas reliance on help is not (Verbrugge et al. 1997). Another source of supportive evidence for this approach is from randomized clinical trials with family caregivers and frail elders in which environmental supports are one of the treatment components. While there are few of these studies, they consistently show positive treatment outcomes including reduced falls in fall-risk elders (Cumming et al. 1999), enhanced functioning (Gitlin et al. 2006b; Mann et al. 1999; Szanton et al. 2011), reduced fear of falling, reduced risk of mortality (Gitlin et al. 2006a; Gitlin et al. 2009), and enhanced caregiver self-efficacy and the dementia patients’ quality of life (Gitlin et al. 2003). As environmental adaptations tend to be embedded in multicomponent interventions, it is difficult to tease out the specific effects of any one adaptation on a particular behavior or health outcome. Nevertheless, there is a growing consensus that environmental adaptations are an important component of multifactorial approaches to address the complex consequences of chronic illness and to prevent falls.
Environmental adaptations mitigate impairment and disability by reducing the press in the environment or demands that exceed a person’s capabilities. Of importance is that adaptations be designed to enable an individual to continue participation in valued occupations.
Existing environmental adaptation services have several limitations that must be noted. First, in many countries, and particularly the USA, there is a lack of funding and necessary supports for the delivery of this therapeutic approach. Existing community-based programs typically have restrictive eligibility requirements or programs are specific to a region, not widely available, or are limited in scope with monetary caps or restrictions on the types of environmental modifications that are available. Second, there is the lack of awareness among consumers and health professionals as to the importance of involving OTs in the assessment and training process for such adaptations. As a skilled intervention, OTs have the requisite knowledge and skill for matching persons and environments with adaptive strategies. Third, this approach requires not only an assessment by an OT but also follow-up training. Often, training and follow-up are not provided due to agency budgetary considerations. Fourth, limited research is available on environmental configurations and person–environment fit specifics that might be more amenable to one versus another environmental approach so that OTs must depend upon their own experiences and the collective wisdom of the field. Finally, the evidence is mixed as to whether environmental adaptations prevent falls in and of themselves, whereas there is stronger evidence of its benefits for reducing functional difficulties and enhancing the ability to engage in valued occupations (Mann et al. 1999; Wahl et al. 2009).