Home Modifications for Older Adults: A Systematic Review

Abstract

While ≧10,000 Americans turn 65 years old every day, only 10% of American homes are “aging ready.” Unsafe homes can exacerbate disability, lead to falls, and increase the likelihood of hospitalization. With increased investments in home and community-based services, public health stakeholders are considering home modifications to promote successful aging. While several home modification models exist, there is significant heterogeneity between models and no consensus on critical features. PubMed, EMBASE, and Web of Science were reviewed and twelve randomized controlled trials of home modifications for older adults were identified and evaluated for model structure, reported outcomes, and risk of bias. Overall, occupational therapist-driven home modifications supplemented with clinical, physical activity, and/or behavioral components saw the greatest success. This systematic review discusses the components of these models, highlights particularly effective and frequently used features, and the practice and research needed to create effective next-generation home modification models which promote healthy longevity.

Keywords

home modifications older adults aging in place

What this paper adds

• Systematically categorizes home modification models evaluated in randomized controlled trials based on intervention design and characteristics.

• Demonstrates multicomponent home modification interventions which strengthen the housing of older adults as well as clinical, physical activity, and/or behavioral domains as most effective in achieving outcomes, compared to just home modifications.

• Reinforces the importance of features that enhance patient-centeredness, such as shared-decision making, in promoting adherence to home modification interventions and recommendations.

Applications of study findings

• Highlights commonly used and particularly effective features of home modification models, serving as a resource for policymakers, payors, and public health stakeholders considering home modifications.

• Identifies opportunities to improve home modifications for older adults, such as facilitating broadband internet access, enrollment into public service programs like SNAP, and advance care planning.

Introduction

More than 10,000 Americans turn 65 years old every day (Vespa et al., 2018). In the year 2034, for the first time in United States history, the number of adults aged 65 years or older will surpass the number of children aged 18 years or younger (Roberts et al., 2018; Vespa et al., 2018). For older adults, maintaining safety and independence is a primary health goal. In 2011, the American Association of Retired Persons (AARP) reported that nearly 90% of older individuals wished to stay in their own homes as they age (Farber et al., 2011). However, data from the U.S. Census Bureau indicates that only 10% of American homes are “aging-ready,” (Vespa et al., 2020) signifying that the home environment is an obstacle that prevents older adults from aging in place.

Examples of home environments poorly accommodated to the needs of an aging population include homes without step-free entryway, lacking a bedroom and full bathroom on the entry-floor, and deficient in bathroom accessibility features (i.e., handrails, grab bars, shower seat) (Vespa et al., 2020). Mismatches between the demands of the physical environment and the functional ability of older persons can exacerbate disability (Czaja et al., 1993; Gill et al., 1999; Leclerc et al., 2010; Oswald et al., 2007; Pettersson et al., 2018; Schwanen & Ziegler, 2011; Verbrugge & Jette, 1994; Wahl et al., 2009) and can lead to falls (Leclerc et al., 2010; Nicklett et al., 2017; Verma et al., 2016), emergency department utilization (Runyan et al., 2005), and nursing home or long-term care admission (Freedman & Spillman, 2014; Gaugler et al., 2007; Smith et al., 2000). The majority of falls, which account for nearly 3 million emergency department visits annually (Bergen et al., 2016), occur inside or near the house (i.e., mailbox) (Moreland et al., 2020).

Currently, 135 million older adults are enrolled in Medicare and/or Medicaid for health care services. The CDC reported that $50 billion each year was spent on medical costs related to nonfatal falls, of which $38 billion (76%) was paid for by public payors (Peterson et al., 2021). These payors cover home modifications with the intent of increasing the safety and independence of older people. Home modifications can include installing grab bars in the bathroom, ensuring the path from the bedroom to the bathroom is well-lit, and repairing loose-fitting carpets which create an uneven surface. Numerous home modification models have been developed for older adults, but there is significant heterogeneity between models in design and outcomes. Previous reports (Chase et al., 2012; Georlee et al., 2020; Pighills et al., 2011; Stark et al., 2017b) demonstrate that home modifications delivered by an occupational therapist (OT) led to the best outcomes in safety and functional independence in older adults compared to interventions led by other providers. Still, there is no consensus on the critical features of home modification interventions.

Since 2021, there has been an increasing number of investments into home and community-based services (HCBS) for older people. Federal policy such as the American Rescue Plan Act of 2021 highlights the shifting energy to expand, enhance, and strengthen HCBS. With these funding opportunities, public health agencies, payors, and health systems are considering home modifications for older adults, but may not know which model to implement or may have unique geographic or cultural needs requiring iterations of established models. Thus, a systematic review of published home modification interventions for older adults was performed to better inform policymakers and other stakeholders on model choice and available features.

Methods

Literature Review

A systematic search of scientific literature was conducted in April 2022 on geriatric home modification interventions incorporating OT practice searching three databases: PubMed, Embase, and Web of Science. Search terms were adapted from a strategy developed by the American Occupational Therapy Association (AOTA) and validated by an expert panel to focus on (i) home modifications and (ii) OT practice (Stark et al., 2017a). Databases were searched leveraging a combination of controlled vocabulary (i.e., MeSH), Boolean operators, and keyword terms. The search was limited to articles with a publication date since 2000 to ensure comparability with current practice.

Articles were included if they were published in peer-reviewed journals, reported an evaluation of a home modification interventions with intervention personnel including an OT, studied community-dwelling adults aged 60 years or older (studies either limited to those aged 60 years or older or with a mean age of sample participants 60 years or older), and written in English. Articles were excluded if methodology was not a randomized controlled trial (RCT), the intervention did not meet American Occupational Therapy Association (AOTA) definition of home modifications (Fagan, 2011), were pilot or feasibility trials with a total sample size of fewer than 50, or did not report at least one primary or secondary outcome related to patient’s functional status (e.g., only outcomes for the caregiver were reported). Presentations, conference proceedings, dissertations, and theses were also excluded.

All studies reviewed for this paper were publicly available. Articles were managed in Endnote software. After duplicate records were removed, titles and abstracts were scanned for relevancy. Full-text versions of remaining articles were retrieved and evaluated for inclusion. In addition, reference lists from selected articles and journals (Chase et al., 2012; Gillespie et al., 2012; Hopewell et al., 2018; Stark et al., 2017a) were hand-searched for relevant articles. The final sample was abstracted into Figure 1.

Figure 1.

Flow chart of literature screening and selection process.

Data Extraction

Data elements were systematically extracted from each study and used to group models based on study descriptions using classification taxonomy for fall prevention programs previously used in the literature (Gillespie et al., 2012; Hopewell et al., 2018; Lamb et al., 2011). Articles were grouped based on whether the home modification intervention was single component or multicomponent. Articles with multicomponent home modification interventions were further subdivided according to the domain(s) of productive aging actively addressed in each intervention. There were clinical, physical activity, behavioral, and social domains. The framework used to classify articles is later described. Due to the heterogeneity of outcomes in studies, individual articles were evaluated based on the achievement of primary and secondary outcomes defined a priori. Intervention effects were categorized as positive (all outcomes improved), mixed positive (more than half of the outcomes improved), mixed effects (on average, the outcomes did not improve), mixed negative (more than half of the outcomes did not improve), and negative (no outcomes improved). A p-value less than or equal to 0.05 for statistical significance was used.

Methodological risk of bias was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions using the risk of bias tool in the Cochrane Collaboration’s review writing software RevMan 5.3. This involved the following elements: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, and selective outcome reporting. Each item was judged as high, low, or unclear risk of bias. Studies were deemed to be at the highest risk of bias if they were scored at a high or unclear risk of bias for either incomplete outcome data, blinding of outcome assessment, or selective outcome reporting.

Results

Initial scientific literature search yielded 331 records (Figure 1). After duplicates were removed, 299 remained. From those, all except 64 were excluded based upon title scan and abstract review. After a full-text review, 9 studies described models and outcomes of home modification models for community-dwelling older adults delivered by an OT. Citation searching produced three additional studies which met the inclusion criteria, yielding 12 studies for inclusion. This resulted in 11 models for evaluation, as two studies evaluated the same model. Of the 11 models reviewed, six originated in the United States, two from England, and one each from New Zealand, France, and Germany.

A summary of the models, components, and reported outcomes is presented in Table 1. The risk of bias for each included study is presented in Figure 2. Broadly, the studies were organized into either single-component home modifications or multicomponent interventions, as shown in Table 2.

Table 1.

Home Modifications Models for Older Adults (n = 11).

Author (Date)	Location	Study Design	Demographic of Interest	Model Summary	Intervention Personnel	Outcomes
Pardessus et al. (2002)	Lille, France*	2-arm RCT (n = 60) with usual-care control group	65+ with recent hospitalization from falling	Home visit and assessment by MD and OT during time of hospitalization to identify environmental hazards and facilitate modifications, with 6- and 12-mo. telephone follow-up	OT, MD, SW	At 12 mo., decreased loss of dependence, though rate of falls, hospitalization for falls, institutionalization, and death were not different
Nikolaus and Bach (2003): HIT trial	Southern Germany	2-arm RCT (n = 360) with usual-care control group	Older adults with functional disability	Comprehensive geriatric assessment followed by home assessment, home modifications, and education on home modifications or use of technical and mobility aids over multiple visits; 1-year in-home follow-up	OT, RN, PT, SW	At 12 mo., 31% improvement in fall rate and 75.7% compliance with at least 1 home modification, with the most common recommendation being the addition of shower seats
Campbell et al. (2005): VIP trial	Dunedin and Auckland, New Zealand*	2 × 2 factorial RCT (n = 391) with attention-controlled group	75+ with severe visual impairment	Home safety assessment and modification program delivered by OT with 6-mo. telephone follow-up, Otago exercise program prescribed at home by PT plus vitamin D supplementation, or both	OT, PT	Home safety program saw a 41% reduction in falls (after 6 mos.), whereas exercise program group saw 15% more falls (after 12 mos.). Neither group had an effect on injurious falls. Those who adhered to the exercise routine reported fewer falls
Gitlin et al. (2006): ABLE	Philadelphia, PA, USA*	2-arm RCT (n = 319) with usual-care control group	70+ with functional disability	5 OT (4 in-person, 1 telephone) and 1 PT session over 6 mos. with assessment, home modifications, and training in their use; patient-centered instruction in strategies of problem-solving, energy conservation, safe performance, and fall recovery techniques; and balance and muscle strength training	OT + PT	At 6 mo., improvement in ADLs, IADLs, fear of falling, overall functional efficacy, home hazards, and adaptive strategies, with most benefits sustained at 12 mo
Gitlin et al. (2010): COPE	PA, USA*	2-arm RCT (n = 237) with quasi-attention control group	21+ with dementia and caregiver	12 home or telephone contacts over 4 mos. by health professionals to assess patient capabilities and deficits; obtain blood and urine samples; and train families in home safety, simplifying tasks, and stress reduction	OT+APRN	At 4 mo., improvement in overall functional dependency and activity engagement in patients and well-being, confidence in activities, and perceived benefit in caregivers, though no group differences maintained at 9 mo
Pighills et al. (2011)	Yorkshire, England	3-arm RCT (n = 238) with non-OT-led intervention and usual-care control group	70+ with recent history of falls	Environment and behavioral assessment, recommendation-making, and modification with follow up contact after 4 weeks and 12 mos, led by either OT or trained assessor	OT	At 12 mo., OT-led group saw improvement in the number of falls, but no effect on fear of falling, quality of life, or ADLs
Sheffield et al. (2013): Aging in place	Howard County, MD, USA	2-arm RCT (n = 60) with delayed-treatment control group	65+ with functional disability	Environmental and behavioral assessment, patient–family collaboration, provision and training in the use of assistive devices and home modifications, training in medication management, and education in adaptive strategies; 4 OT home visits over 3 mos	OT	At 3 mo., significant improvement in home safety, health-related quality of life, fear of falling, and need for continued assistance (39% reduction); no effect in functional status or actual falls
Stark et al. (2018)	St. Louis, MO, USA*	2-arm RCT (n = 92) with attention-control group	65+ with history of falls and functional disability	6 90-minute sessions with OT over 8 weeks to target participants’ problematic daily activities, leveraging motivational enhancement and shared decision-making to support environment and behavioral assessment, modification, and education	OT	Improvement in self-related performance, self-rated satisfaction with performance, and objective activity performance score at 6 and 12 mos. 91% adherence to received home modifications at 12 mo
Szanton et al. (2019) and Breysse et al. (2021): CAPABLE	Baltimore, MD [S] and NC, VT, PA, CA [B]	2-arm RCT (n = 300 [S]; n = 153 [B]) with attention-control group [S] and delayed treatment control group [B]	65+ with functional disability and low-income	Up to 10 person-centered sessions with assessment of functional difficulties, pain, depression, and home environment; up to $1300 worth of home repairs, modification, and assistive devices	OT, RN, HW	[S] At 5 mo., 30% reduction in ADL disability and nonsignificant 17% reduction in IADL disability at 5 months. [B] At 12 mo., improvements in ADL limitations, falls, falls efficacy, depression, and pain; non-significant reduction in QoL and IADL limitations
Cockayne et al. (2021): OTIS RCT	England	2-arm RCT (n = 1331) with usual-care control group	65+ with recent history of falls or fear of falling	Home environmental assessment to identify personal fall-related hazards and modifications with 4–6-week telephone follow-up	OT	No improvement in fall rate or any secondary outcomes (falls, single/multiple fallers, fear of falling, fracture rate, time to fall, health related quality of life, and health service utilization) at 12 mos
Stark et al. (2021): HARP	St. Louis, MO, USA*	2-arm RCT (n = 310) with usual-care control group	65+ with functional disability	Environmental and behavioral assessment and hazard removal plan through home repair, adaptive equipment, task modification, and education; shared decision-making and motivational enhancement; 2–3 OT home sessions with 6-mo. booster.	OT	38% reduction in rate of falls with 91% adherence to modifications at 12 mo.; no significant effect on hazard of falls, daily activity performance, falls self-efficacy, or health-related quality of life

Figure 2.

Risk of bias assessment. Author’s judgements about each study are presented across all included studies.

Table 2.

Categorized Home Modifications Models and the Outcomes of the Trials. Models Were Either Single Component or Multicomponent. If Models Were Multicomponent, Domains of Productive Aging Targeted in Each Intervention are Noted.

	Intervention Category					Study Outcome
		Multicomponent
	Single-component	Clinical	Physical Activity	Behavioral	Social
Pardessus et al. (2002)	☒	☐	☐	☐	☐	Mixed negative
Nikolaus and Bach (2003): HIT trial	☒	☐	☐	☐	☐	Positive
Campbell et al. (2005): VIP trial	☐	☒	☒	☐	☐	Mixed effects
Gitlin et al. (2006): ABLE	☐	☐	☒	☒	☐	Mixed positive
Gitlin et al. (2010): COPE	☐	☒	☐	☒	☒	Mixed positive
Pighills et al. (2011)	☒	☐	☐	☐	☐	Mixed negative
Sheffield et al. (2013): Aging in place	☐	☐	☐	☐	☐	Mixed negative
Stark et al. (2018)	☐	☐	☐	☒	☐	Positive
Szanton et al. (2019) and Breysse et al. (2021): CAPABLE	☐	☒	☒	☒	☐	Mixed effects/Mixed positive
Cockayne et al. (2021): OTIS RCT	☒	☐	☐	☐	☐	Negative
Stark et al. (2021): HARP	☐	☐	☐	☒	☐	Mixed negative

Single-Component Interventions

Four models evaluated single-component models, where environmental modification was the only aging-in-place intervention. Of these interventions, one trial showed positive outcomes (Nikolaus & Bach, 2003), two demonstrated mixed negative outcomes (Pardessus et al., 2002; Pighills et al., 2011), and one produced negative outcomes (Cockayne et al., 2021).

Pardessus et al. (2002) described an intervention where participants (n = 60), at time of fall-related hospitalization, received a home visit from a physical medicine and rehabilitation doctor and an OT, who evaluated the home environment for problems encountered during activities of daily living (ADLs) or instrumental activities of daily living (IADLs), performed minor home modifications, and provided advice on how to live safely with unremovable hazards. Telephone follow-up was provided at 6 and 12 months by the OT. Pardessus et al. did not significantly modify risk for further falls or rehospitalization but did preserve patient autonomy as measured by functional autonomy measurement system (SMAF) score (p = 0.001) at 12 months, which has strong reliability.

The Home Intervention Team (HIT) trial by Nikolaus and Bach (2003) recruited subjects from a geriatric clinic in Germany, who received a comprehensive geriatric assessment and at least two post-discharge follow-ups (median = 2.6) from the interdisciplinary HIT team. The first visit was conducted by an OT with either a registered nurse (RN) or physical therapist (PT), depending on anticipated needs of the patient, to assess the home using a standardized assessment tool developed by the primary author. Further home visits were made to prescribe technical aids, inform participants about fall risks at home, facilitate home modifications, and educate participants on their use. Compared to the usual care control group, the fall rate for the intervention group was 31% lower (p = 0.032). Though the proportion of frequent fallers did not differ between groups, the intervention did reduce the fall rate amongst frequent fallers by 37% (IRR = 0.63; p = 0.028). At 12 months, Nikolaus and Bach reported a compliance rate of 75.7% to recommended home modifications.

Pighills et al. (2011) conducted a 3-armed RCT to assess the effect of environmental assessment and modification, by either a qualified OT or an unqualified trained assessor, on functional ability. Both intervention groups received home assessments using the Westmead home safety assessment, a written summary of recommendations, and referrals to other agencies to facilitate home modifications not completed during the home visit. 4-week and 12-month telephone follow-up showed 70% full or partial adherence to recommendations; adherence was markedly (p = 0.04) higher in the OT group. The OT-led intervention group saw a significant reduction in the number of falls compared to control (p = 0.005), but no effect was seen in fear of falling (p = 0.90), quality of life (p = 0.38), or ADL independence at 12 months (p = 0.87). Cockayne et al. (2021) conducted the OTIS RCT in England from October 2016 to April 2018. Similar to Pighills et al., a singular home visit was conducted by the OT with 4–6-week telephone follow-up using the Westmead home safety assessment to identify fall-related hazards, review strategies to mitigate fall-risks, and make recommendations on changes to the home environment. For modifications not able to be completed by the OT during the home visit, their provision was either reviewed with family members or participants were referred to other agencies. This trial did not yield significant results in any primary or secondary endpoints: number of falls per participant (p = 0.56), proportion of participants who reported one or many falls (p = 0.65), fracture rate (3.7% in intervention group vs. 4.2% in control group), fear of falling (p = 1.0), time to fall (p = 0.12), and quality of life (p = 0.814). The OTIS RCT was associated with additional falls compared to usual care (p = 0.07).

Multicomponent Interventions

Multicomponent models were defined as interventions that included home modifications with at least one other aging-in-place intervention, thematically stratified into clinical, physical activity, behavioral, and social interventions based on groupings adapted from Lamb et al. (2011). Of the eight trials evaluating multicomponent models, one showed positive outcomes (Stark et al., 2018), four showed mixed positive outcomes (Breysse et al., 2021; Gitlin et al., 2006, 2010; Sheffield et al., 2013), two showed mixed effects (Campbell et al., 2005; Szanton et al., 2019), and one showed mixed negative outcomes (Stark et al., 2021).

Clinical Interventions

Three models incorporated clinical interventions. The Care of Patients with Dementia in their Environments (COPE) trial (Gitlin et al., 2010) recruited patient-caregiver dyads (n = 284), where patients had diagnosed dementia and caregivers lived within five miles of the patient. Through up to 10 OT and two advanced practice nurse (APN) sessions over 4 months, the intervention sought to enhance functionality, re-engage patients in daily living, and alleviate caregiver burden by addressing caregiver-identified concerns. Home modification, task simplification, and stress reduction were essential features to enhance occupational ability. Comprehensive urine and blood sample evaluation, standardized medication review for appropriateness, polypharmacy, dosing, and caregiver education were central features of the clinical intervention. Undiagnosed illnesses were uncovered in 37.3% of patients. Significant improvements were observed in overall functional dependence (p = 0.02) and activity engagement (p = 0.03) in patients and well-being (p = 0.002), confidence in activities (p = 0.002), and perceived benefit in caregivers at 4 months; however, no group differences were observed at 9 months. Gitlin et al. reported 78.4% of dyads completed 8 to 12 sessions. The Community Aging in Place—Advancing Better Living for Elders (CAPABLE) model was evaluated in two trials at multiple testing sites, recruiting low-income older adults with functional disabilities (Breysse et al., 2021; Szanton et al., 2019). CAPABLE was a multidisciplinary intervention of an OT, RN, and handiworker (HW) who collaborated to help participants improve on self-identified functional goals. The OT evaluated home safety and functional disability while the RN assessed pain level, depression, medication understanding, primary care practitioner communication, strength, and balance. Over up to 10 home visits—6 with an OT and 4 with an RN—participants worked on self-identified goals, with HW provisioning ∼$1300 of home modifications and/or assistive devices. Szanton et al. reported a 30% reduction in ADL disability (p = 0.01) and a nonsignificant 17% reduction in IADL disability (p = 0.13) at 5 months compared to an attention-control group, with 92.8% of participants completing 8 to 10 sessions. Breysse et al.’s CAPABLE trial saw long-term improvements in ADL disability (p = 0.012), falls efficacy (p = 0.012), depression (p = 0.021), and pain (p = 0.002) at 12 months post-randomization, relative to delayed-treatment control. Non-significant reductions were seen in quality of life (p = 0.377) and IADL limitations (p = 0.093) at 12 months. Remarkably, CAPABLE participants saw significant improvement in long-term fall rate (p = 0.037), observing on average one fewer fall per person over the follow-up year compared to the year before baseline.

Campbell et al. (2005) outlined the VIP trial in New Zealand for older adults aged 75 years and older with severe visual impairment, measured as visual acuity of 6/24 or worse. The 2 × 2 factorial trial consisted of a home safety program, an exercise program with vitamin D supplementation, or both. Vitamin D supplementation was provided if the patient was not already taking the supplement. Of the 145 patients prescribed vitamin D at the start of intervention, 100 (68.9%) continued taking the supplement after a year. However, falls in this group were 15% higher than in the social visit attention-control group (IRR interval 0.82–1.61).

Physical Activity Interventions

Three of the reviewed models included a physical activity component, with either supervised or unsupervised physical activity. Patients receiving the physical activity intervention in Campbell et al.’s 2 × 2 factorial trial utilized the Otago exercise program with the goal of exercising three times per week and walking twice per week, and Vitamin D supplementation if needed. Exercises were prescribed by a PT, who made five home visits over 6 months. For those in the home safety program, home safety assessment using a modified Westmead home safety assessment was conducted to enable the OT to make and deliver fall-prevention recommendations. Campbell et al. reported 85% retention for the home modifications group at 6 months, with 90% of participants fully or partially compliant with at least one recommendation. Only 18% and 44% of those in the exercise program reported completing exercise and walking goals, respectively. Home safety program participants reported 41% fewer falls (IRR = 0.59), whereas those in the exercise program reported 15% more falls IRR interval 0.82–1.61) than the social visit attention-control group. Those receiving both home safety and exercise components reported fall-related outcomes similar to the exercise-only group. Campbell et al. concluded that the Otago exercise program delivered by a PT was not successful in this population, but home safety assessment and modifications were effective in reducing falls, injurious falls, and multiple falls.

Gitlin et al. (2006) evaluated the Advancing Better Living for Elders (ABLE) model, consisting of a 6-month intervention of four 90-minute OT home visits, one 20-minute OT phone contact, and one 90-minute PT visit. Sessions were rooted in control-oriented strategy training and leveraging cognitive, behavioral, and environmental modifications to improve on areas identified by the patient as problematic. Each participant received training in balance, muscle strengthening, and fall recovery techniques. In this model, interventionists served as consultants to the patient to help patients reduce perceived functional difficulties, self-efficacy, and fall-related concerns. ABLE participants (n = 319) saw improvement in ADL difficulty (p = 0.03), IADL difficulty (p = 0.04), functional efficacy (p = 0.02), fear of falling (p = 0.001), home hazards (p = 0.05), and adaptive strategies (0.009) at 6 months compared to no-treatment control, with significant effects observed in fear of falling (p = 0.008) and adaptive strategies (p = 0.01) retained at 12 months. No significant group differences, however, were seen in mobility at 6 months (p = 0.15) or 12 months (p = 0.07). The CAPABLE model assessed by Szanton and Breysse, designed as an extension of ABLE, included active strength and balance training components for participants delivered by either the OT or RN (Breysse et al., 2021; Szanton et al., 2019).

Behavioral Interventions

Six of the reviewed models incorporated behavioral interventions, which incorporate cognitive and/or behavioral assessment and subsequent intervention. ABLE, with a theoretical foundation in the life span theory of control, trained participants in simple control-oriented strategies to address everyday difficulties. Simple cognitive and behavioral strategies, such as active problem-solving, reframing, and sitting instead of standing to perform tasks enhanced both objective and self-perceived outcomes related to falling. Similarly, the COPE trial aimed to target caregiver-identified concerns to reduce stress by conducting cognitive testing in patients assessing attention, initiation and perseveration, construction, conceptualization, and memory. CAPABLE RNs utilized behavior activation strategies to manage depressive symptoms in patients. Furthermore, motivational interviewing and enhancement were used to encourage function improvement.

Sheffield et al. (2013) assessed the Aging in Place (AIP) model, conducted in the context of an Area Agency of Aging in Howard County, MD. AIP was modeled after ABLE, with four OT home visits over 3 months. Though intervention personnel did not include a PT and participants did not receive an intensive exercise component, AIP included environment and behavioral assessment using SAFER-HOME, patient–family collaboration to achieve mutual goals, provision and training in the use of assistive devices and home modifications, removal of environmental hazards, training in medication management, and education with training in adaptive strategies. 3-month follow-up showed improvement in home safety (p = 0.005), health-related quality of life (p = 0.03), fear of falling (p = 0.05), and a 39% reduction in recommended hours of personal care (2.36 hours per week per patient). Though, no marked effect was seen in functional status (p = 0.15) or actual falls.

Both intervention models led by Stark utilized standardized tailoring via shared decision-making, education and training in self-management strategies, and motivational enhancement as active intervention components (Stark et al., 2018, 2021). These strategies mitigated fall risk by ensuring that patients managed changes to their homes, brought heightened awareness to fall hazards, and encouraged adherence to the intervention. The 2018 Stark trial recruited participants to receive six 90-minute visits over 8 weeks, consisting of OT environmental and behavioral assessment using the In-Home Occupational Performance Evaluation (I-HOPE), shared decision-making to determine optimal treatment, selection and installation of home modifications and adaptive equipment, and participant training and active practice in the modified home environment. The intervention yielded significant improvement relative to the attention control group at 6 and 12 months in self-related performance (p = 0.005), self-rated satisfaction with performance (p = 0.046), and objective activity performance (p = 0.024). Furthermore, 91% adherence to home modifications was reported at 12 months. The second model developed by Stark was the Home Hazard Removal Program (HARP) intervention. In 2–3 sessions over approximately 4 weeks, HARP consisted of evaluation using the Westmead home safety assessment and a tailored barrier removal plan in the initial visit followed by facilitation, installation, and training in home modification in subsequent visits. 6 months following the initial visit, an in-person booster session was conducted. The intervention group saw no effect in fall hazard (hazard ratio = 0.90), daily activity performance (p = 0.60), falls self-efficacy (p = 0.84), or health-related quality of life (p = 0.35). However, there was a 38% reduction (p = 0.03) in the rate of falling in the intervention group and self-reported adherence was 91% at 12 months.

Social Environment Interventions

Only the COPE trial incorporated intervention targeting the social environment of older persons. The COPE intervention was driven by caregiver-identified concerns. Identifying caregivers as indispensable in supporting successful aging for those with dementia, Gitlin et al. assessed, educated, and trained caregivers in their trial to alleviate their burden. COPE caregivers reported improvement in well-being (p = 0.002) and enhanced confidence using activities (p = 0.002) at 4 months, as well as reporting improvement in overall life (p = 0.001), disease understanding (p = 0.001), confidence managing behaviors (p = 0.001), ability to care for patients (p = 0.001), and ability to keep patients home (p = 0.001).

Discussion

This is the first paper to systematically identify and review randomized controlled trials on home modification interventions for older adults. This report divided models into single-component and multicomponent interventions. Multicomponent interventions were categorized into the following productive aging categories: clinical, physical activity, behavioral, and social. Multicomponent models were more likely to support healthy aging and achieve study outcomes compared to single-component interventions. All multicomponent models evaluated achieved at least half of the intervention’s primary and secondary endpoints, with the exception of one model (Stark et al., 2021). Comparatively, three of four single-component home modification interventions demonstrated negative or mixed negative outcomes. Multicomponent models which spanned several domains (i.e., clinical, physical activity, and behavioral) were more likely to show mixed positive (three out of five trials) or mixed effects (two out of five trials) compared to multicomponent models spanning only one domain (two out of three trials produced mixed negative outcomes). Overall, this review supports the use of multicomponent models which incorporate two or more domains of productive aging.

Common features in clinical interventions include standardized medication review and polypharmacy assessment, pain reduction, nutritional education and support, mental health support, health education, and caregiver education of the clinical needs of participants. Clinically significant outcomes in the CAPABLE and COPE trials point towards an important role of nursing professionals in the home modifications team. Both CAPABLE and COPE relied on communication with the participant’s primary care provider to convey clinical concerns and recommendations, largely related to medication or pain (Pho et al., 2012; Smith et al., 2016; Szanton et al., 2014; Taylor et al., 2019). Through the utilization of urine and blood testing by COPE, a high proportion of patients (∼37%) had undiagnosed health conditions which were uncovered, such as bacteriuria and anemia. While urinary and/or bowel incontinence—which affects roughly half of all non-institutionalized older adults and is a significant risk factor for falls, hospitalization, and nursing home placement—was addressed in some participants, it was not systematically assessed nor addressed in any trial (Gorina et al., 2014).

Physical activity interventions varied in whether the prescribed training targeted patient-identified goals (CAPABLE, ABLE) or utilized predetermined routines covering broad ranges of exercises relevant to fall reduction (VIP trial). Two interventions with exercise components monitored falls (Breysse et al., 2021; Campbell et al., 2005). CAPABLE exhibited significant improvement in fall rate, with one fewer fall per participant on average in the year following intervention compared to 1 year before intervention. In contrast, the Otago exercise routine delivered by Campbell et al. produced a nonsignificant 15% higher fall compared to those who received only home modifications. Highlighting the importance of adherence, Campbell et al. noted low rates of adherence to the exercise intervention and the highest incidence of falls in those with poor adherence. Interventions that target self-identified deficits may see higher adherence rates and reduced falls compared to interventions providing scripted exercise programs by ensuring the physical activity intervention is directly relevant to the patient’s own functional goals. With physical activity interventions, population characteristics may be a particularly important factor to consider (Albert & King, 2017). In their evaluation of fall prevention interventions, Balzer and colleagues demonstrate that while positive outcomes from exercise interventions are more likely in young and healthy older adults, opposite effects are seen in the “fragile elderly” (Balzer et al., 2012).

Common features of behavioral interventions include behavioral assessment, active problem-solving, cognitive training (speed of processing, reasoning, verbal episodic memory, etc.), and energy conservation techniques. Interventions with behavioral components presented clinically significant outcomes in measures related to confidence in performing daily activities, such as falls self-efficacy. Previous reviews on fall reduction interventions highlight the role of OT providers in promoting behavioral change and mitigating fear of falling by empowering older adults to practice fear-provoking daily activities under supervision (Leland et al., 2012; Rebok et al., 2014; Willis et al., 2006). The degree to which self-rated measures of functional ability correlate with enhanced objective measures related to aging successfully (i.e., falls, hospitalizations) is not clear (Gleason et al., 2016). Several studies have shown cognitive training alone to enhance balance and gait in cognitively intact older adults (Smith-Ray et al., 2014). Notably, many models in this report used strategies such as motivational interviewing and shared decision-making to promote behavior modification and patient-centeredness. A vast array of literature supports the utility of person-centeredness in physical activity interventions (Fulmer et al., 2021; Mata et al., 2012; Michie et al., 2018; Tay et al., 2022). Models utilizing these features reported the highest rates of adherence to recommendations and completion of the intervention, with some reporting rates greater than 90%.

Modification of the social environment of older adults was included in only one assessed model, namely, caregiver support by the COPE trial. While the trial did yield strong short-term—but not long-term—outcomes in caregiver burden, further trials to evaluate home modification interventions which empower informal caregivers and, more broadly, the social domain of older adults are needed. Pressures brought on by COVID-19 have uncovered the importance of the social environment—inclusive of caregiver support, telephone access, and homecare services—in aging in place and fall prevention. A 2022 review of interventions that reduce the social vulnerability of community-dwelling older adults demonstrates that these interventions have positive influences on function, cognition, subjective health, and hospital utilization (Mah et al., 2022). In addition, a June 2021 AARP survey indicated 76% of older adults report high-speed internet access as very important in their home environment, but more than 25% of older adult households do not have broadband access (Binette, 2021; Martin, 2021). In light of the importance of internet access in social engagement and healthcare access, future home modification interventions should consider modifying the cyberspace of older persons’ homes. Additionally, outcomes for interventions that target at-risk groups can be enhanced by facilitating enrollment in public programs to provide long-term support beyond the intervention timeframe (Herbert & Molinsky, 2019; Stone, 2018). Interventions targeting low-income older adults, for example, are in a strong position to streamline participation in the Affordable Connectivity Program (ACP) to promote internet access. Similarly, future models can mitigate food insecurity by facilitating Supplemental Nutrition Assistance Program (SNAP) participation, shown to have significant long-term cost savings (Berkowitz et al., 2021). Home modification interventions are also poised to promote the provision of advance directives for end-of-life care, only completed by one in three Americans (Yadav et al., 2017).

Limitations

Although this systematic review contributes new knowledge to the field, it was not without limitations. Per the review protocol, included studies were limited to those with a sample size greater than 50; several feasibility or pilot trials were excluded for this reason. While this strengthened the quality of included studies, this may have limited the scope of the review. Furthermore, the search was limited to PubMed, Embase, and Web of Science and articles not indexed in those databases or published after April 2022 may have been missed.

Although some trials (i.e., Breysse et al.) had study sites in rural and micropolitan locations, the majority of trials were conducted in a predominantly urban locale. Furthermore, all trials reviewed had a higher percentage of females, with few (Gitlin et al., 2006; Sheffield et al., 2013; Szanton et al., 2019) having greater than 80% females. The generalizability of model outcomes in different settings (i.e., rural) across diverse demographic groups is unknown. This report should also be viewed in light of varying sample sizes, target demographics, allocation concealment, blinding, attrition rates, intervention personnel, study endpoints, length of intervention, and degree of follow-up. These variations highlight the need for a standardized assessment tool to capture outcomes that assess the efficacy of home modification interventions. The heterogeneity in the study outcomes make it difficult to conduct meta-analysis or discern the efficacy of singular components or features within a model.

The intensity of home modifications varied significantly between studied models. Though all but three models (Cockayne et al., 2021; Pardessus et al., 2002; Pighills et al., 2011) evaluated were considered “high-intensity” according to criteria outlined by Clemson et al. (2008), significant differences existed in the available funding, allowable home modifications, and modes of facilitating home modifications. Varied model components and the lack of standardized outcome measures confound the ability to assess singular aspects. Stark et al. (2018) reported home modification costs, inclusive of delivery and labor, at $931 per participant, more than double the $439 per participant in Gitlin et al. (2006), highlighting the extent of variation. Interestingly, Breysse and colleagues delivered the CAPABLE intervention at four different sites. In this trial, the North Carolina site was the only site to provision both “typical” low-cost, high-impact home modifications such as grab bars and retrofits as well as more intensive accessibility modifications such as access ramps or outdoor concrete step repair. Subgroup analysis showed North Carolina site participants saw greater short- and long-term improvement in functional outcomes compared to sites that provisioned just “typical” home modifications, suggesting home modifications beyond traditional low-cost adaptations may yield enhanced outcomes.

Conclusion

In 2022, the National Academy of Medicine identified housing to be a key target in promoting healthy longevity (Medicine, 2022). With an increasing number of older adults aging within their communities, home modifications are a public health priority. This review identified several salient features of home modification models to inform health policy. First, it reinforces the efficacy of home modifications and the leadership role of occupational therapists. Second, it organizes interventions into subtypes of single component, physical activity, clinical, behavioral, and social. Third, it identifies multicomponent models which span multiple categories of productive aging as the most effective components in promoting aging in place. However, social models are understudied and deserve more attention. Fourth, it highlights particularly effective and frequently used interventions within each type of home modification to enlighten policymaking. Fifth, it promotes patient-centeredness, primarily achieved through motivational interviewing and shared decision-making. Finally, it identifies opportunities to improve home modifications for older adults, such as improving incontinence support, broadband Internet access, automatic enrollment into public service programs like SNAP, and advance care planning. Future home modification models are poised to incorporate the learnings of this review to promote healthy longevity.

Supplemental Material

Supplemental Material - Home Modifications for Older Adults: A Systematic Review

Supplemental Material for Home Modifications for Older Adults: A Systematic Review by Sohum Sheth, and Christopher R. Cogle in Journal of Applied Gerontology

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Sohum Sheth

Christopher R. Cogle

Supplemental Material

Supplemental material for this article is available online.

References

Albert

S. M.

King

(2017). Effectiveness of statewide falls prevention efforts with and without group exercise. Prev Med, 105, 5–9. https://doi.org/10.1016/j.ypmed.2017.08.010

Balzer

Bremer

Schramm

Lühmann

Raspe

(2012). Falls prevention for the elderly. GMS Health Technol Assess, 8, Doc01. https://doi.org/10.3205/hta000099

Bergen

Stevens

M. R.

Burns

E. R.

(2016). Falls and fall injuries among adults aged ≥65 Years - United States, 2014. MMWR Morb Mortal Wkly Rep, 65(37), 993–998. https://doi.org/10.15585/mmwr.mm6537a2

Berkowitz

S. A.

Palakshappa

Rigdon

Seligman

H. K.

Basu

(2021). Supplemental nutrition assistance program participation and health care use in older adults: A cohort study. Ann Intern Med, 174(12), 1674–1682. https://doi.org/10.7326/m21-1588

Binette

(2021). 2021 home and community preference survey: A national survey of adults age 18-plus. AARP Research. https://doi.org/10.26419/res.00479.001

Breysse

Dixon

Wilson

Szanton

(2021). Aging gracefully in place: An evaluation of the capability of the CAPABLE(©) approach. J Appl Gerontol, 7334648211042606(3), 718–728. https://doi.org/10.1177/07334648211042606

Campbell

A. J.

Robertson

M. C.

La Grow

S. J.

Kerse

N. M.

Sanderson

G. F.

Jacobs

R. J.

Sharp

D. M.

Hale

L. A.

(2005). Randomised controlled trial of prevention of falls in people aged > or =75 with severe visual impairment: The VIP trial. Bmj, 331(7520), 817. https://doi.org/10.1136/bmj.38601.447731.55

Chase

C. A.

Mann

Wasek

Arbesman

(2012). Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. Am J Occup Ther, 66(3), 284–291. https://doi.org/10.5014/ajot.2012.005017

Clemson

Mackenzie

Ballinger

J. C.

Cumming

R. G.

(2008). Environmental interventions to prevent falls in community-dwelling older people: A meta-analysis of randomized trials. J Aging Health, 20(8), 954–971. https://doi.org/10.1177/0898264308324672

10.

Cockayne

Pighills

Adamson

Fairhurst

Crossland

Drummond

Hewitt

C. E.

Rodgers

Ronaldson

S. J.

McCaffery

Whiteside

Scantlebury

Robinson-Smith

Cochrane

Lamb

S. E.

Boyes

Gilbody

Relton

Torgerson

D. J.

(2021). Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: The OTIS RCT. Health Technol Assess, 25(46), 1–118. https://doi.org/10.3310/hta25460

11.

Czaja

S. J.

Weber

R. A.

Nair

S. N.

(1993). A human factors analysis of ADL activities: A capability-demand approach. J Gerontol, 48(Special_Issue), 44–48. https://doi.org/10.1093/geronj/48.special_issue.44

12.

Fagan

L. A.

(2011). Home modifications and occupational Therapy. American Occupational Therapy Association. https://www.aota.org/about-occupational-therapy/professionals/pa/facts/home-modifications.aspx

13.

Farber

Shinkle

Lynott

Fox-Grage

Harrell

(2011). Aging in place: A state survey of livability policies and practices.

14.

Freedman

V. A.

Spillman

B. C.

(2014). The residential continuum from home to nursing home: Size, characteristics and unmet needs of older adults. The Journals of Gerontology: Series B, 69(Suppl_1), S42–S50. https://doi.org/10.1093/geronb/gbu120

15.

Fulmer

Reuben

D. B.

Auerbach

Fick

D. M.

Galambos

Johnson

K. S.

(2021). Actualizing better health and health care for older adults. Health Aff (Millwood), 40(2), 219–225. https://doi.org/10.1377/hlthaff.2020.01470

16.

Gaugler

J. E.

Duval

Anderson

K. A.

Kane

R. L.

(2007). Predicting nursing home admission in the U.S: A meta-analysis. BMC Geriatr, 7(1), 13. https://doi.org/10.1186/1471-2318-7-13

17.

Georlee

G. M.

Dat

P. N.

Tuan

N. K.

Mehrotra

(2020). Home-modification interventions addressing falls and participation in activities of daily living among older adults: A scoping review protocol. BMJ Open, 10(9), Article e039742. https://doi.org/10.1136/bmjopen-2020-039742

18.

Gill

T. M.

Robison

J. T.

Williams

C. S.

Tinetti

M. E.

(1999). Mismatches between the home environment and physical capabilities among community-living older persons. J Am Geriatr Soc, 47(1), 88–92. https://doi.org/10.1111/j.1532-5415.1999.tb01906.x

19.

Gillespie

L. D.

Robertson

M. C.

Gillespie

W. J.

Sherrington

Gates

Clemson

L. M.

Lamb

S. E.

(2012). Interventions for preventing falls in older people living in the community [Review]. Cochrane Database of Systematic Reviews, 2012(9), CD007146. https://doi.org/10.1002/14651858.CD007146.pub3

20.

Gitlin

L. N.

Winter

Dennis

M. P.

Corcoran

Schinfeld

Hauck

W. W.

(2006). A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults [Article]. Journal of the American Geriatrics Society, 54(5), 809–816. https://doi.org/10.1111/j.1532-5415.2006.00703.x

21.

Gitlin

L. N.

Winter

Dennis

M. P.

Hodgson

Hauck

W. W.

(2010). A biobehavioral home-based intervention and the well-being of patients with dementia and their caregivers: The COPE randomized trial. JAMA, 304(9), 983–991. https://doi.org/10.1001/jama.2010.1253

22.

Gleason

K. T.

Tanner

E. K.

Boyd

C. M.

Saczynski

J. S.

Szanton

S. L.

(2016). Factors associated with patient activation in an older adult population with functional difficulties. Patient Educ Couns, 99(8), 1421–1426. https://doi.org/10.1016/j.pec.2016.03.011

23.

Gorina

Schappert

S. M.

Bercovitz

Elgaddal

Kramarow

E. A.

(2014). Prevalence of incontinence among older Americans.

24.

Herbert

Molinsky

J. H.

(2019). What can Be done to better support older adults to age successfully in their homes and communities? Health Aff (Millwood), 38(5), 860–864. https://doi.org/10.1377/hlthaff.2019.00203

25.

Hopewell

Adedire

Copsey

B. J.

Boniface

G. J.

Sherrington

Clemson

J. C.

Lamb

S. E.

(2018). Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev, 7(7), Cd012221. https://doi.org/10.1002/14651858.CD012221.pub2

26.

Lamb

S. E.

Becker

Gillespie

L. D.

Smith

J. L.

Finnegan

Potter

Pfeiffer

Taxonomy

(2011). Reporting of complex interventions in clinical trials: Development of a taxonomy to classify and describe fall-prevention interventions. Trials, 12(1), 125–125. https://doi.org/10.1186/1745-6215-12-125

27.

Leclerc

B. S.

Bégin

Cadieux

Goulet

Allaire

J. F.

Meloche

Leduc

Kergoat

M. J.

(2010). Relationship between home hazards and falling among community-dwelling seniors using home-care services. Rev Epidemiol Sante Publique, 58(1), 3–11. https://doi.org/10.1016/j.respe.2009.10.008

28.

Leland

N. E.

Elliott

S. J.

O’Malley

Murphy

S. L.

(2012). Occupational therapy in fall prevention: Current evidence and future directions. Am J Occup Ther, 66(2), 149–160. https://doi.org/10.5014/ajot.2012.002733

29.

Mah

Rockwood

Stevens

Keefe

Andrew

M. K.

(2022). Do interventions reducing social vulnerability improve health in community dwelling older adults? A systematic review. Clin Interv Aging, 17, 447–465. https://doi.org/10.2147/cia.S349836

30.

Martin

(2021). Computer and internet use in the United States: 2018. United States Census Bureau.

31.

Mata

Pachur

von Helversen

Hertwig

Rieskamp

Schooler

(2012). Ecological rationality: A framework for understanding and aiding the aging decision maker. Front Neurosci, 6, 19. https://doi.org/10.3389/fnins.2012.00019

32.

Medicine

N. A. O.

(2022). Global roadmap for healthy longevity. The National Academies Press. https://doi.org/10.17226/26144

33.

Michie

West

Sheals

Godinho

C. A.

(2018). Evaluating the effectiveness of behavior change techniques in health-related behavior: A scoping review of methods used. Transl Behav Med, 8(2), 212–224. https://doi.org/10.1093/tbm/ibx019

34.

Moreland

B. L.

Kakara

Haddad

Y. K.

Shakya

Bergen

(2020). A descriptive analysis of location of older adult falls that resulted in emergency department visits in the United States, 2015. American Journal of Lifestyle Medicine, 15(6), 590–597. https://doi.org/10.1177/1559827620942187

35.

Nicklett

Lohman

Smith

(2017). Neighborhood environment and falls among community-dwelling older adults. International Journal of Environmental Research and Public Health, 14(2), 175. https://doi.org/10.3390/ijerph14020175

36.

Nikolaus

Bach

(2003). Preventing falls in community-dwelling frail older people using a home intervention Team (HIT): Results from the randomized falls-HIT trial. Journal of the American Geriatrics Society, 51(3), 300–305. https://doi.org/10.1046/j.1532-5415.2003.51102.x

37.

Oswald

Wahl

H. W.

Schilling

Nygren

Fänge

Sixsmith

Szeman

Tomsone

Iwarsson

(2007). Relationships between housing and healthy aging in very old age. Gerontologist, 47(1), 96–107. https://doi.org/10.1093/geront/47.1.96

38.

Pardessus

Puisieux

Di Pompeo

Gaudefroy

Thevenon

Dewailly

(2002). Benefits of home visits for falls and autonomy in the elderly: A randomized trial study. Am J Phys Med Rehabil, 81(4), 247–252. https://doi.org/10.1097/00002060-200204000-00002

39.

Peterson

Miller

G. F.

Barnett

S. B. L.

Florence

(2021). Economic cost of injury - United States, 2019. MMWR. Morbidity and Mortality Weekly Report, 70(48), 1655–1659. https://doi.org/10.15585/mmwr.mm7048a1

40.

Pettersson

Slaug

Granbom

Kylberg

Iwarsson

(2018). Housing accessibility for senior citizens in Sweden: Estimation of the effects of targeted elimination of environmental barriers. Scand J Occup Ther, 25(6), 407–418. https://doi.org/10.1080/11038128.2017.1280078

41.

Pho

A. T.

Tanner

E. K.

Roth

Greeley

M. E.

Dorsey

C. D.

Szanton

S. L.

(2012). Nursing strategies for promoting and maintaining function among community-living older adults: The CAPABLE intervention. Geriatr Nurs, 33(6), 439–445. https://doi.org/10.1016/j.gerinurse.2012.04.002

42.

Pighills

A. C.

Torgerson

D. J.

Sheldon

T. A.

Drummond

A. E.

Bland

J. M.

(2011). Environmental assessment and modification to prevent falls in older people [Article]. Journal of the American Geriatrics Society, 59(1), 26–33. https://doi.org/10.1111/j.1532-5415.2010.03221.x

43.

Rebok

G. W.

Ball

Guey

L. T.

Jones

R. N.

Kim

H. Y.

King

J. W.

Marsiske

Morris

J. N.

Tennstedt

S. L.

Unverzagt

F. W.

Willis

S. L.

(2014). Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. J Am Geriatr Soc, 62(1), 16–24. https://doi.org/10.1111/jgs.12607

44.

Roberts

A. W.

Ogunwole

S. U.

Blakeslee

Rabe

M. A.

(2018). The population 65 Years and older in the United States: 2016. U.S. Government Publishing Office. https://www.census.gov/content/dam/Census/library/publications/2018/acs/ACS-38.pdf

45.

Runyan

C. W.

Casteel

Perkis

Black

Marshall

S. W.

Johnson

R. M.

Waller

A. E.

Viswanathan

(2005). Unintentional injuries in the home in the United States Part I: Mortality. Am J Prev Med, 28(1), 73–79. https://doi.org/10.1016/j.amepre.2004.09.010

46.

Schwanen

T. I. M.

Ziegler

(2011). Wellbeing, independence and mobility: An introduction. Ageing and Society, 31(5), 719–733. https://doi.org/10.1017/S0144686X10001467

47.

Sheffield

Smith

C. A.

Becker

(2013). Evaluation of an agency-based occupational therapy intervention to facilitate aging in place. Gerontologist, 53(6), 907–918. https://doi.org/10.1093/geront/gns145

48.

Smith

G. E.

Kokmen

O'Brien

P. C.

(2000). Risk factors for nursing home placement in a population-based dementia cohort. J Am Geriatr Soc, 48(5), 519–525. https://doi.org/10.1111/j.1532-5415.2000.tb04998.x

49.

Smith

P. D.

Boyd

Bellantoni

Roth

Becker

K. L.

Savage

Nkimbeng

Szanton

S. L.

(2016). Communication between office-based primary care providers and nurses working within patients’ homes: An analysis of process data from CAPABLE. Journal of Clinical Nursing, 25(3-4), 454–462. https://doi.org/10.1111/jocn.13073

50.

Smith-Ray

R. L.

Makowski-Woidan

Hughes

S. L.

(2014). A randomized trial to measure the impact of a community-based cognitive training intervention on balance and gait in cognitively intact Black older adults. Health Educ Behav, 41(1 Suppl), 62s–69s. https://doi.org/10.1177/1090198114537068

51.

Stark

Keglovits

Arbesman

Lieberman

(2017a). Effect of home modification interventions on the participation of community-dwelling adults with health conditions: A systematic review [article]. The American Journal of Occupational Therapy : Official Publication of the American Occupational Therapy Association, 71(2), 7102290010p7102290011. https://doi.org/10.5014/ajot.2017.018887

52.

Stark

Keglovits

Arbesman

Lieberman

(2017b). Effect of home modification interventions on the participation of community-dwelling adults with health conditions: A systematic review. Am J Occup Ther, 71(2), 7102290010p7102290011. https://doi.org/10.5014/ajot.2017.018887

53.

Stark

Keglovits

Somerville

Y.-L.

Barker

Sykora

Yan

(2021). Home hazard removal to reduce falls among community-dwelling older adults: A randomized clinical trial. JAMA Network Open, 4(8), Article e2122044–e2122044. https://doi.org/10.1001/jamanetworkopen.2021.22044

54.

Stark

Somerville

Conte

Keglovits

Y. L.

Carpenter

Hollingsworth

Yan

(2018). Feasibility trial of tailored home modifications: Process outcomes. Am J Occup Ther, 72(1), 7201205020p7201205021https://doi.org/10.5014/ajot.2018.021774

55.

Stone

R. I.

(2018). The housing challenges of low-income older adults and the role of federal policy. J Aging Soc Policy, 30(3-4), 227–243. https://doi.org/10.1080/08959420.2018.1462679

56.

Szanton

S. L.

Wolff

J. W.

Leff

Thorpe

R. J.

Tanner

E. K.

Boyd

Xue

Guralnik

Bishai

Gitlin

L. N.

(2014). CAPABLE trial: A randomized controlled trial of nurse, occupational therapist and handyman to reduce disability among older adults: Rationale and design. Contemp Clin Trials, 38(1), 102–112. https://doi.org/10.1016/j.cct.2014.03.005

57.

Szanton

S. L.

Xue

Q. L.

Leff

Guralnik

Wolff

J. L.

Tanner

E. K.

Boyd

Thorpe

R. J.

Bishai

Gitlin

L. N.

(2019). Effect of a biobehavioral environmental approach on disability among low-income older adults: A randomized clinical trial. JAMA Intern Med, 179(2), 204–211. https://doi.org/10.1001/jamainternmed.2018.6026

58.

Tay

Vlaev

Massaro

(2022). The behavioral factors that influence person-centered social care: A literature review and conceptual framework. Int J Environ Res Public Health, 19(7), 4334. https://doi.org/10.3390/ijerph19074334

59.

Taylor

J. L.

Roberts

Hladek

M. D.

Liu

Nkimbeng

Boyd

C. M.

Szanton

S. L.

(2019). Achieving self-management goals among low income older adults with functional limitations. Geriatr Nurs, 40(4), 424–430. https://doi.org/10.1016/j.gerinurse.2019.01.003

60.

Verbrugge

L. M.

Jette

A. M.

(1994). The disablement process. Soc Sci Med, 38(1), 1–14. https://doi.org/10.1016/0277-9536(94)90294-1

61.

Verma

S. K.

Willetts

J. L.

Corns

H. L.

Marucci-Wellman

H. R.

Lombardi

D. A.

Courtney

T. K.

(2016). Falls and fall-related injuries among community-dwelling adults in the United States. PLoS One, 11(3), Article e0150939. https://doi.org/10.1371/journal.pone.0150939

62.

Vespa

Armstrong

D. M.

Medina

(2018). Demographic turning points for the United States: Population projections for 2020 to 2060. US Department of Commerce, Economics and Statistics Administration.

63.

Vespa

Engelberg

(2020). Old housing, new needs: Are US homes ready for an aging population. Current Population Reports, pp. 23–217.

64.

Wahl

H. W.

Fänge

Oswald

Gitlin

L. N.

Iwarsson

(2009). The home environment and disability-related outcomes in aging individuals: What is the empirical evidence? Gerontologist, 49(3), 355–367. https://doi.org/10.1093/geront/gnp056

65.

Willis

S. L.

Tennstedt

S. L.

Marsiske

Ball

Elias

Koepke

K. M.

Morris

J. N.

Rebok

G. W.

Unverzagt

F. W.

Stoddard

A. M.

ACTIVE Study Group

F. T.

Wright

(2006). Long-term effects of cognitive training on everyday functional outcomes in older adults. JAMA, 296(23), 2805–2814. https://doi.org/10.1001/jama.296.23.2805

66.

Yadav

K. N.

Gabler

N. B.

Cooney

Kent

Kim

Herbst

Mante

Halpern

S. D.

Courtright

K. R.

(2017). Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Aff (Millwood), 36(7), 1244–1251. https://doi.org/10.1377/hlthaff.2017.0175

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