Elderly people and their accident experiences: Implication for the design of safer and easier-to-use dwellings
Report of the CIB Expert Seminar on Building Non-Handicapping Environments, Budapest 1991
Capability of daily living of old persons and their accident experiences:
Implication for the design of safer and easier-to-use dwellings
Satoshi Kose, Building Design and Use Division, Building Research Institute, Tsukuba, Japan
Introduction
Within thirty years, Japan will experience an increase in the elderly population unprecedented in the world. Recently, the ratio occupied by the 65-years-and-over age group to Japan's total population has been rapidly increasing. Furthermore, the aging of the population is progressing faster than the estimate published by the Institute on Population Problems of the Ministry of Health and Welfare in 1986. According to a population estimate made in September 1990, old persons constitute 12 per cent of the present population. Three years ago, the author remarked on the influence of aging on buildings, but present and future conditions will likely be more serious than predicted at that time. A pessimistic view of the future is counterproductive, this paper will consider the problem more positively with a focus on the housing issue.
When we consider future-oriented measures to cope with the problems encountered by old persons, the first problem that arises is what should be taken into account when designing their dwellings, which are the practical centers of their lives? It is important to determine the range of the perceptions, judgements, and behavior of old persons whom we were dealing with. How well can an old person who has become frail or incapacitated can reside in a dwelling will largely depend on its setup. In industrially advanced countries, many feel it is desirable for old persons to reside in their own homes as long as possible. In Japan too, this has become generally accepted. To realize it, dwellings must be made to accommodate the declining capability of aging people.
A rare but satisfying alternative would be to design a dwelling for a particular resident and thus incorporating his/her terms and conditions. This would indicate that the elderly population was taken good care of. Unfortunately, such personal treatment is impossible. Accordingly, many people will require dwellings with better standard design than before to allow them to be conveniently used without major modification.
However, conventional design guidelines for specialized dwellings have been established particularly for disabled residents rather than the needs of old persons. Information has been scarce concerning what is indispensable to elderly people with no particular disabilities (i.e., who simply are aging slowly). As a result, it is generally thought that even when old persons grow frail and become incapacitated as they age, they will be able to freely operate manual wheelchairs. It is unrealistic, however, to expect their arm capability to be sufficient for managing a manual wheelchair when leg capability declines considerably. Personally, I have seen no elderly person who handles such a heavy wheelchair by himself, and the number of those who can do so will not increase substantially. It is also unthinkable for an elderly person to get in and out of a wheelchair frequently (e.g. for such activities as using a toilet) with only upper-body strength. Except when going out, old persons are more likely to live inside a dwelling using handrails for support as much as possible. I do not agree with the idea of cutting back on fundamental dwelling furnishings with the expectation that help and care will be provided (especially by family members). This paper also opposes the belief that all dwellings should be constructed so that a large outdoor wheelchairs could be accommodated. Presently, various reasons make it difficult to obtain social support for the latter, and I am critical of the present large wheelchairs as the standard to be used both outdoors and indoors by old persons as they are designed for outdoor use under less favorable conditions. If use of a wheelchair is limited to indoors, it would be possible to make ones that are more convenient to handle. Those who are involved with rehabilitation understand this well, but many building researchers and designers lack the perspective. It is at least inappropriate to place old persons and people with disabilities (particularly those who use wheelchairs) in the same category for discussion. To give an example, ramps designed for a wheelchair can be dangerous (especially when descending) for elderly people with declining walking capability who rely on handrails or walking sticks. Until recently, it has been difficult to agree with concrete evidence exactly what the words 'the elderly' meant.
During the discussion of "Development of Technology to Improve Residential Environments in an Aging Society", the comprehensive technological development project of the Ministry of Construction, several kinds of research revealed data that provide clues to solutions. I would like to discuss the desirable dwelling design based on convenience and safety of residents through examination of those data.
Elderly people are quite varied
For many people, the most familiar elderly are their own parents. Because these elderly are familiar, the younger generation may consider them the general standard - which may be a greatly distorted view. What's more, the fact that these elderly people are family members can be an obstacle to objectivity. Also, because the mass media tend to focus on extreme cases, people often respond with excessive fear that the same will occur within their own home. This is why the distorted concept that most elderly people will become senile or bed-ridden is most influential.
Unless this bias is removed, reasonable discussion, including concrete dwelling design, will not evolve. Thus, we conducted two kinds of surveys and tried to clarify characteristics of the elderly using basic capabilities of daily living. We also conducted a survey to unearth the problems of present dwellings to grasp their connection to capability of daily living under the assumption that such work would clarify the fundamental issues that should be considered when designing a dwelling.
For this purpose, we conducted a survey on the extended families living in the Tokyo area, mostly in detached houses. We also surveyed residents living in such dwellings specially designed for old persons as "Silver Housing", the supply of which has recently increased. Our goal was to comparatively examine the actual effectiveness of dwellings specially designed for old persons.
Survey No. 1. Elderly living as an extended family in detached houses
Survey method
The questionnaire-answering populace accessed by Urban Life Institute of Tokyo Gas Co., Ltd. (TULIP) was comprised of Tokyo Gas customers who were randomly selected, asked to participate/cooperate in the survey, and who expressed consent.
For this questionnaire, the subjects were elderly people living with "under 65" family members. We aimed to collect about 1,000 respondents. The survey included questions on physical characteristics of the houses, such as detailed design and dimensions of dwellings, to clarify the difference in evaluating physical conditions by old persons (65 years and over) and non-elderly (under 65 years), thereby checking the requirements specially designed for old persons. In addition, considering the survey of stairs inside a dwelling, we surveyed basically detached houses. Items included in the questionnaire were as follows.
- Self-evaluation of capability of daily living and sensory characteristics, made by old persons themselves,
- description of dwelling characteristics (answered by a resident under 65 years),
- evaluation of dwelling characteristics (answered by all residents age 65 and over and one resident under 65),
- desires to modify dwelling characteristics (answered by the same as above),
- whether building-related domestic accidents occurred or not during the past year (answered by the same as above).
Walking capability was selected as the index of basic capability of daily living. Behavior capabilities of old persons were then evaluated along this axis. If capabilities of old persons in daily life can be relatively clearly classified along this axis for subjective and objective understanding, it will greatly contribute to design and other issues related to old persons.
To survey building-related domestic accidents, a questionnaire was prepared following the survey formerly used in Hyogo Prefecture so that results could be compared if necessary.
Survey results
The effective answer rate was considerably low, owing to the number of the questionnaire items and the fact that we could not analyze and evaluate the results when either data from old persons or from the non-elderly were not available. In terms of composition by sex, male respondents 65 years and over constituted a relatively high ratio - nearly half - compared to female respondents. One reason for this was that many households answering the survey were a combination of an elderly husband and a non-elderly wife. Nearly 70 per cent of those surveyed answered "None" when asked about job occupation. Therefore the ratio of "Stay at home nearly all the time" was fairly high (65 per cent).
In terms of houses, most were wooden, two-story homes. Age of the houses was comparatively long, as can be expected with wooden buildings. Total floor areas were relatively large, as multiple households were living together in detached houses.
Evaluating capability of daily living of old persons
According to self-evaluation of walking capability made by old persons covered by this survey, 31 per cent of 888 elderly people to whom data analysis was applied answered that they could run. This segment (classified as type I) is far from the image of the frail elderly person. 51 per cent answered that they were not confident about running, but could walk completely unassisted (type II-1). Around 15 per cent needed some assistance, such as a walking stick, a handrail, or a personal assistant (type II-2). Those who moved about by crawling or who could not move without a wheelchair (type III) and those who were persons who spend most of the time lying down (type IV) constituted just 2 per cent.
As walking capability differs with the individual, it is difficult to make sweeping statements. However, approximately half of the 65-69 age group were type I and most of the rest were type II-1. In the 85 and over age group, type II-1 was slightly less than half and type II-2 nearly half; as expected, almost no one was type I in this age group.
Elderly people who were hospitalized at the time of survey were naturally excluded from the subject pool. However, the hospitalization rate was not extremely high for the age group. Taking this point into account, capability of daily living was considerably high on the whole, and old persons were not as frail as was generally imagined. (Heavy care was usually unnecessary.) This finding also correlates with the general trend in survey results in Sweden.
Collected data on other capabilities of daily living and sensory characteristics related to walking capability indicate that leg force - including that used to ascend and descend stairs - correlates closely with walking capability. On the other hand, factors concerning eyesight, coordination, and practice were not directly connected. Answers of "can do" and "cannot do" varied greatly, depending on what the required basic capability was.
Looking at the answers as a whole, "can do"/"cannot do" clearly changed in connection with the level of walking capability. For example, a positive answer to the question, "Can you take a shower in a standing position in the bathroom?" was obtained from 80 per cent of the type I group, 60 per cent of the type II-1, and 20 per cent of the type II-2. On the other hand, to the question "Can you dial the telephone?" slightly under 30 per cent of those in the type II-2 group answered negatively. Thus, it was not possible to establish criteria to measure the degree of decline in capability through this issue. Capability of conducting delicate tasks was closely connected with experience; in this case, the unfamiliar push-button phone was not favored. Sensory characteristics are closely linked to age.
Differences in evaluating physical conditions of dwellings
According to survey results on evaluation of physical design and dimensions of the house they currently live in (in terms of fear of accidents, inconvenience, etc.; see Figure 3), the burden or recognition of danger by old persons was remarkably high on such issues as step differences at the entrance rail, entrance door, bathroom doorway, toilet doorway, and level differences between Japanese and Western rooms. Also, old persons evaluated the handrail more highly than the non-elderly. The elderly considered above-mentioned design features to be serious problems.
In terms of convenience to use, many items were not highly evaluated by old persons; in fact, their evaluation was similar to that made by the non-elderly. For example, there was little difference in terms of faucet operation and hot water temperature adjustment. It seems that they do not give great consideration to replacing present furnishings with more convenient ones unless the need is urgent.
As to flights of stairs, there was little difference in subjective evaluation made by old persons and the non-elderly, which seemed strange at first glance. This unexpected result can be explained through other questions asked on frequency of stair use. Use of stairs by those 65 and over was rare. Not only the type II-2 group but also one third of the type II-1 group never or seldom use the stairs during the course of a day. Even in the type I group, one fourth of the elderly seldom used stairs. Nearly 40 per cent of the non-elderly use stairs frequently, and only about 10 per cent of them seldom do. Compared with the case of old persons, there was a great difference here. In short, old persons do not feel the trouble, because they do not use the stairs. What should be noted here is that private rooms for old persons are recommended to be placed on the lower floor when funds are financed by the Housing Loan Corporation. However, this unfairly narrows the possible living space for old persons.
Moreover, in the future, even three-story wooden dwellings will be introduced in the quest for maximal environment conditions on limited plottage. Thus, the concept of placing old persons on the ground floor will not, in more and more cases, be reasonable as a long-term solution. Accordingly, stairs will become more significant. In this sense, the specification of the maximum allowable slope of 6/7 in the requirements for higher standard housing is considered a milestone. Also, old persons surveyed did not express strong desires to make safety- and convenience-related modifications, except in urgent cases.
Problems in relation to capability and desire to introduce more needs-oriented housing for the elderly
We examined problem areas and analyzed residents' desire for modification for daily living capability based on walking capacity. The study revealed that the two are closely related. Using the trouble spots and desires for modification/introduction of the non-elderly as a reference, types I, II-1, and II-2 elderly were compared. Type I elderly seems more energetic than the non-elderly, and the type II-1 elderly show a similar tendency. However, the type II-2 elderly feel seriously troubled in some areas. Entering and leaving the bathroom, laying out and putting away futon bedding, and managing stairs are the conspicuous troubles. Other problems are characterized by level differences.
Most modification requests center on handrails at the entrance, in the toilet, bathroom, and on the stairs and a bench in the dressing room. These features were pointed out by the type II-1 elderly and were particularly conspicuous among the type II-2. The only reason why the request for handrails by stairways was not so striking is that many elderly do not use the stairs. Accordingly, problems related to troubles and improvement requests for old persons begin to emerge with type II-1 and first become conspicuous with type II-2.
Occurrence of accidents in daily living activities and injuries inside the dwellings
Regarding domestic accidents experienced in the past year, 13 per cent of old persons and 8.6 per cent of the non-elderly answered that they had had accidents. Classified by walking capability, only 6.5 per cent of the type I elderly answered that they had had accidents - a figure which was lower than among the non-elderly. From type II-1 on, occurrence was more frequent. Type II-2 elderly had had 2.5 times as many accidents as non-elderly. Accidents causing injury shifted, with decline in walking capability, from stair-related accidents to other falls, such as slipping and stumbling on the floor. Of the total accidents, 16 per cent of old persons suffered broken bones. The more walking capability declines, the higher this ratio is. In addition, the ratio of going to the hospital (for treatment) and being hospitalized also rises, which may be related to it.
It has been pointed out that bones do age in elderly people and that the incidence of breaking bones also increases. Moreover, these broken bones result from light falls in almost all cases. The data we obtained proved similar.
Survey No. 2. Residents of special housing for old persons
The supply of special housing for old persons has been rapidly increasing, spurred on by the Silver Housing Plan. However, this plan basically stresses software, and examination of dwelling design - the hardware - was insufficient. Accordingly, individual designers were left to determine what should be included in an elderly specific dwellings in their plans, resulting in a lack of uniformity in design details.
In addition, design detail effectiveness has not normally been pursued after completion, and the post-occupancy evaluation (POE) in the buildings did not effectively function. Under these circumstances, the same design failures will naturally occur many times.
We therefore tried to examine and evaluate the details of specific dwellings built on the Silver-pia Plan of the City of Tokyo how they were evaluated by the residents in terms of their capabilities of daily living.
As the subject of the survey was basically identical housing design for each building, it was expected that the interrelationship between design and capability of old persons would be clarified, thereby proving useful in establishing distinct guidelines for design details. This was the main purpose of the survey.
Outline of the survey
We selected Shinju-en (Setagaya Ward) and Tokumaru Keyaki-en (Itabashi Ward) as the survey targets. (There were about 40 residents in each house). We asked residents to evaluate the design of their dwellings. To make the survey as effective as possible, we prepared color photographs of details shot at relevant angles (for example, differences in level, handrails) and attached them next to the questions. We also asked about physical condition and capability of daily living of the residents using the same basic process as for Survey No. 1.
Next, we selected several similar houses in the Kanto and Koshin-etsu districts for subjects and conducted surveys in basically the same way. When photographs of the details were not available, illustrations were used.
Shinju-en was surveyed in late April, 1990, and Tokumaru Keyaki-en in late August. The remaining houses were surveyed from late September through October. At the time this paper was written, data had yet to be completed. Thus, herein, only the results of Shinju-en and Tokumaru Keyaki-en have been summarized.
Survey results
Shinju-en
Of the 40 residents of Shinju-en, two were hospitalized at the time the survey was made so answers were obtained from 38 residents. Average age: 77 years. Results on the question concerning walking capability indicative of their capacity showed that 6 people were type I, 23 type II-1, and 9 type II-2. As the admission qualifications specify that a resident must be independent, there were no type III elderly, even though some time had passed since admission.
Residents tended to grip something when stepping up at entrances and when standing at the toilet. Although the type II-1 elderly, according to walking capability, were not supposed to be using handrails, 5 out of 23 of them reported of gripping something when moving vertically in both of the preceding cases. As this shows, it is clear that the decline in capability appears sooner in actions involving vertical rather than horizontal weight movement, and support was thus sought for that reason (Table 3).
To the question of how often they went to the toilet at night, many of old persons answered one or more times. Thus, attention should be paid to the relative positions of the bedroom and toilet and also to heating the toilet at night during the winter.
Looking at the answers reveals that their former residences were often old apartment houses without baths and, in many cases, with public lavatories. Cooking was generally done over a gas range, and the residents do not normally recognize the danger of a fire occurring. At Shinju-en, electric cooking ranges were furnished. Only 4 of the type II-1 residents preferred gas cooking. This dwelling was basically for single people, thus the expectations for the cooking facilities were not great.
Evaluation of the details of a new residential environment indicates that handrails inside elevators and along corridors were not as necessary as assumed. In contrast, handrails along stairs and in toilets are well accepted in accordance with the decline in capability. At the same time, questions were asked concerning evaluation of height of handrail installation at these places. Few opinions were expressed on what height would be most convenient; they seem to be satisfied with the very existence of handrails. This result also indicates that their former housing environments were quite below standard. Also, it may be connected to present housing conditions for old persons, making the residents feel thankful simply of the fact that they were admitted to this dwelling.
Elimination of the height difference between Japanese-style rooms and rooms with wooden floors was relatively well accepted, with no one answering that they hoped this difference would be restored. Many of those answering that there was no need to eliminate the height difference were the type I elderly, whereas the type II elderly greatly appreciated it - likely because they have an acquaintance who suffered a serious injury by misjudging the slight height difference or have heard a similar story. The emergency buzzer and life rhythm sensor were also well approved (25 of 31 and 25 of 28 effective answers, respectively, claimed these devices brought about a sense of security).
Old persons are most concerned with emergencies. In various surveys, the function of communication and information systems was rated the highest. An inquiry on actual usage revealed, however, that these systems were seldom used. Their biggest effect seems to be providing psychological security. In essence, it would be better to use them regularly, for example, to use the lines to converse, partly to prevent mistakes from being made during an emergency. Unfortunately, present conditions show that there are few examples of such usage in any facility, including Shinju-en.
In contrast, the hatch opening in the veranda for emergency use, which was installed to secure safe egress, was not well evaluated. (Only 5 of 20 effective answers claim they were assured by it.) The flexible board used as a balcony partition, which can be broken in an emergency, and the hatch for emergency use were standard equipment for securing an escape route to a neighbor's quarters. Both were poorly evaluated, not only by residents but those concerned with the facility. Thus, it can be said they are basically useless for the elderly. Such equipment should be reconsidered by returning to the basic principle of ensuring safety during a fire. They should be replaced with more active measures, such as small sprinklers.
Tokumaru Keyaki-en
We received answers from 32 of the 40 Tokumaru Keyaki-en residents (2 of the 8 not answering were hospitalized at the time). Average age: 72 years. Classified by walking capability, 6 were type I, 20 type II-1, and 5 type II-2.
Overall trends among the residents were similar to those in Shinju-en, with subjective evaluation of physical conditions mostly resembling one another. However, the ratio of those holding onto a handrail or something like it when stepping up to an entrance or standing at the toilet was lower than in Shinju-en. No type II-1 resident claimed to use the handrail at the toilet. The frequency of night-time visits to the toilet was as high as at Shinju-en. Regarding the effectiveness of such details as handrails, the residents did not evaluate height or convenience, possibly because they were relatively healthy, as just described. Most answered that the handrails were appropriate. This result was because the residents have no basis for comparison. However, the very existence of such details seems to be highly appreciated.
In clear contrast to the handrails, many complaints were expressed on the height of the (high) suspended closet and clothesline pole, which have been long and frequently used. The type II-1 elderly proposed that height differences in the kitchen, dressing room, and toilet be eliminated. Three type II-1 residents pointed out that the height difference between Japanese-style rooms and rooms with wooden floors was a problem.
The emergency buzzer near the toilet and in the Japanese-style room and the rhythm sensor near the toilet were generally accepted. Many answers indicated that residents do not know how to use the escape ladder and escape passage or were doubtful that they can use them - similar to Shinju-en.
Examination of survey results
The following items were clarified after examining survey results.
The capability of daily living of old persons was relatively higher than generally thought for both old persons living with their families and those living alone. Consciousness to elderly specific design was revealed by the type II-2 elderly, who began to suffer a particular decline in capability. Height differences of various places was indicated as a trouble to old persons. The active requests made by the type II-2 elderly for improvements in detached houses surpassed those made by the non-elderly when old persons and non-elderly are compared. Specifically, handrail installation (and others) were requested.
However, data on building related domestic accidents revealed that with the type II-1 elderly, a conspicuous pattern of accidents befalling old persons emerged (frequent falls on floors resulting from slips and stumbles). Thus, differences in floor height should be eliminated for the type II-1 elderly, who precede the type II-2 elderly. This has already been done in elderly specific dwellings. The opinion that height differences should be maintained was seldom expressed, even by the type I elderly.
Residents do not seem to have any practical basis of objections (in contrast to the assumption of the designers) against lack of level differences. Eliminating the height difference was appreciated not only by the type II-2 elderly, who are actually inconvenienced by it, but also by the type II-1 elderly, who are still active. In fact, eliminating such differences would be no easy thing, owing to the difficulty in changing traditional way of construction; designers often try to avoid the issue, by arguing for the importance of maintaining traditional Japanese culture.
It is said that old persons have special attachment to Japanese-style rooms and will not give up sleeping on futons in tatami rooms. However, there were many examples when they switched to beds when space became available through renovation, moving, or when old persons are given their own rooms. Survey results indicate that it was a very serious problem when they cannot use beds, because the narrow space in which they must store their futons and lay them out causes them a lot of trouble. However, their desire for tatami continues, as seen by the fact that when they can choose a dwelling unit, they prefer ones with tatami rooms to those with Western-style rooms alone. This seems to be a great gap between what is good for safety and comfort versus what is preferred, at least as long as the aged persons think they are capable of managing it.
Design requirements to keep pace with the growing aging population - What are indispensable elements?
The above survey clarified that a basic requirement of dwellings for a growing elderly population would allow old persons to live without much inconvenience. Simply, the minimum requirements based on the examinations made thus far, would be: 1) eliminating height differences; and 2) providing handrails. These are two requirements (basically necessary and sufficient ones) for designing a dwelling which will allow an elderly person to move freely, without any high risk of injury. The following five points are fundamental characteristics for a dwelling to be a supportive one.
- Safety: To what extent should safety be pursued?
- Health: How healthy an environment can a house be?
- Function: How convenient should a house be? (How does one distinguish convenience from laziness?)
- Comfort: How would a stimulus-free environment affect a human being?
- Economy: Who will eventually bear the cost?
Supposing that residents and those people on the waiting list are elderly, setting the level of each of the above factors would be a question of making hardware to cope with aging-related decline and changes in various capabilities. As everyone ages, however, such houses must provide for an increasing elderly population rather than for elderly people alone. In other words, dwellings must consider the aging not of individuals but of the society as a whole. We hope we have made this point clear, as it will be key to supplying dwelling units in which old persons can live by choice, rather than by force.
However, it is not yet clear what concrete measures should be taken in this direction as the related contents have not been fully clarified - nor has their expression. A rough classification of these contents is as follows.
- Requirements for which specifications can be established.
- Those for which performance requirements can be specified.
- Those for which the property requirement itself has no definite form and is restricted to conceptual descriptions.
- Those which depend on the actual situation and degree of freedom.
In order for the dwellings to be designed and built, specifications must be established. Presently, not enough requests are being transformed into practical requirements; many are conceptual requirements described only in performance terms. Also, as mentioned earlier, when specifications are established, they are often for people with disabilities or wheelchair users, and not old persons. The move must, however, be toward a broader, more universal direction.
As mentioned above, a Swedish long-term follow up study concluded that it is basically wrong to consider old persons just as frail, which would support our survey results of the real situation.
Conclusions
The design requirements for dwellings for an aging population mentioned thus far include eliminating the height difference and providing handrails. Most of the points described herein were specified in "Rehabilitation Manual of Dwellings for the Needs of the Aged", basic guidelines compiled by the Japan Housing Reform Center. It will be widely used in rehabilitation of existing dwellings for old persons.
Another is the "Design Specifications of the Publicly Operated Collective Rental Housing Construction", compiled and issued by the Ministry of Construction. It is now obligatory to comply with the specification in order to obtain central government subsidies for new construction by the local governments. It is also expected to be applied not only to the Housing and Urban Development Corporation Housing and Privately Supplied Housing Construction. Guidelines for detached dwelling design are also expected to be issued in the near future. It is expected that some financial incentives will accompany this.
Acknowledgements
The surveys cited here were conducted as a cooperative research between BRI, Asahi Chemical Co., Ltd. Housing Department, and Sekisui House Co., Tokyo Design Department. The author would like to express his sincere thanks to Mr. I. Kumano, Mr. K. Ebara, and Mr. D. Kimura of Asahi Chemical Co., Mr. I. Nitta of Tokyo Gas Co., Mr. A. Ohta and Mr. Y. Tanaka of Sekisui House Co., and Mrs. K. Watanabe of the Tokyo Metropolitan Government Housing Bureau. The previous Japanese version of this paper appeared in "Research on Disasters" published by the Association of Fire Insurance Rates Studies.
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