Safe Home Program

Abstract

Objective:

To report the implementation/adoption of the Safe Home Program to support caregivers of persons with dementia in (1) ongoing surveillance, (2) provision of care, (3) prevention of injuries, and (4) improving home safety.

Methods:

For this demonstration project 4 assessment questionnaires (Safety Assessment Scale, Vigilance Scale, Peace of Mind Scale, and Sleep Disorders Inventory) were administered to each dyad to understand their technological needs. After identification and installation of appropriate technologies and education of the caregiver, a final visit (at 3 months) determined whether technologies were useful and being used.

Results:

The majority of caregivers utilized technologies for ongoing surveillance; other technologies included an identification program and medication organizer.

Conclusion:

Technologies focused on ongoing surveillance for persons with dementia at the home are needed. These technologies could be quickly adopted by caregivers to ameliorate some of the stress and burden associated with providing care for persons with dementia.

Introduction

Dementia is a debilitating and costly illness characterized by a progressive loss of memory and other cognitive functions (eg, executive function). ¹ There are an estimated 44.4 million caregivers (21% of the adult population) who provide unpaid care to an adult in the United States. ² The value of this informal caregiving is an estimated $257 billion a year. ³ Many of these caregivers are spouses or relatives performing everyday activities of daily living (ADLs; eg, dressing) and Instrumental ADLs (IADLs; eg, shopping for groceries, managing finances) for a person with dementia. The caregiver also protects the person with dementia from unsafe events with ongoing, continuous eyes-on surveillance. For example, persons with dementia require ongoing surveillance to prevent injuries, including a fracture or dislocation, even at night. ⁴ Other adverse events, including unintended exits from the home and missing incidents while out in the community, are common among persons with dementia. ⁵ For example, longitudinal studies report that about 40% of males living in the community with dementia leave the home unattended and require a third party to return home safely. ⁶ The overall prevalence of missing events may actually be higher; most persons with dementia are quickly found by caregivers, family, or neighbors and other missing incidents occur when person with dementia are independent in the community.

Identifying technological systems or devices that could help caregivers monitor and prevent injuries among persons with dementia, as well as reduce caregiver burden, may effectively prevent adverse events and/or delay institutionalization among persons with dementia. There are currently no resources identifying commercially available devices for the caregiver. Working with the Tampa Veterans Health Administration (VHA) Home-Based Primary Care (HBPC) program, the Safe Home Program team assessed the safety needs of caregivers and persons with dementia at home and provided the caregivers with commercially available technologies or devices that may aid in their caregiving role. The primary aim of this article is to report the implementation and adoption of the Safe Home Program and the caregiver assessments of these technologies and devices to determine which ones may be used to support caregivers in 4 categories: (1) ongoing surveillance, (2) provision of care, (3) prevention of injuries, and (4) improving home safety.

Methods

Identifying Appropriate Technologies

Using a wide array of terms for searching the Web as well as interviews with experts in informal caregiving, we identified technologies that are both targeted for caregivers and those that could be adapted to address the above-mentioned 4 primary areas of caregiver concern. The identified technologies in each of these categories are discussed below.

Ongoing Surveillance

Motion Sensor With Remote Alarm (Driveway Sensor Product)

This battery-operated sensor and alarm kit was designed to monitor motion outside of the home. For this project, the device was used to monitor movement near a doorway, driveway, or garage. The device’s portable receiver emits high or low chimes to alert the caregiver of movement across the sensor. This device may be particularly useful for surveillance when the caregiver and person with dementia are in separate areas of the home.

Wireless Camera With Handheld Liquid Crystal Display, Color, and Night Vision

This device includes 1 camera with night vision capabilities and 1 monitor with a 2.5-in liquid crystal display (LCD) screen, slightly larger than most on the market. The camera can be used freestanding or secured to a wall and transmit color video and sound up to 200 feet. For this project, the device was used inside the home for nighttime tracking. The LCD screen was placed on a nightstand with the camera focusing on the room of the person with dementia. During the day, the camera and LCD could be moved around the home, so the caregiver can watch the person with dementia in multiple locations inside the home.

Proximity Range Alarm

This device was designed to be used in both indoor and outdoor locations. The device includes a transmitting unit that can be attached to the belt of the person with dementia and a receiver unit used by the caregiver. If the person with dementia moves farther than a preset range from the caregiver, the caregiver unit alarms, alerting the caregiver that the person with dementia is too far away. The unit will continue to alert the caregiver until the person with dementia is back in range of the caregiver or until the system is manually reset.

Wireless Home Security System

This home security system will alarm if someone enters or exits the home. The alarm has a wireless control panel that can be mounted on the wall of the home. The system can incorporate a door/window sensor and wireless motion detector that can be used throughout the home. In this project, these systems were installed to alert the caregiver whenever the person with dementia tried to exit doors or enter a space that was determined to be unsafe or off-limits.

Provision of Care

Medication Organizer

This medication system can be set for up to 4 daily alarms to provide an alert to the caregiver when medication is due. A repeating friendly reminder notifies the user of the time, date, and which daily dose to take (eg, “Good morning! please take your morning pills for the 20th”). The caregiver can also press the “alarm-acknowledged button” to confirm compliance and the talking alarm clock feature lets them know when the next daily dose is due.

Prevention of Injuries

Identification Program for Person With Dementia (With Wearable Device)

For this project, MedicAlert + Safe Return (MASR) was used. The goal of the MASR program is to assist a third party when the person with dementia is found in the community. Using registration information, operators on an 800 number can facilitate a return of the person with dementia to the caregiver. The MASR also facilitates notification of law enforcement agencies when a caregiver reports an enrolled individual as missing.

Identification Program for the Person With Dementia (Iron-on Labels)

Iron-on labels were provided to all caregivers in the Safe Home Program. These labels have 4 lines for the name and contact telephone number of the person with dementia and their caregiver. Permanent markers were used to write contact information on the labels, and the labels were ironed inside of the clothing of the person with dementia. The iron-on labels provide reliably-worn identification information for law enforcement and hospital personnel. However, it is unlikely that this strategy will be helpful if the person with dementia is found by good Samaritans in the community due to the inconspicuous placement of the labels.

Locating Technologies (eg, Project Lifesaver)

In order to reliably find an individual in areas within structures or in very remote areas, radio-frequency locating technology has been successfully used. Project Lifesaver (PLS) is one program that combines both radio-frequency identification technology and law enforcement support to find an individual missing in the community. The PLS uses a transmitter, about the size of a large wristwatch, on the wrist or ankle of the person with dementia. The transmitter is checked daily by the caregiver and monthly by the law enforcement agency. In this project, this tracking technology, owned by the law enforcement agency, would be used to find person with dementia when a missing incident is reported.

Bed Occupancy Sensor

This bed sensor consists of a unit with a bed sensor and remote alarm to alert the caregiver whenever the person with dementia leaves the bed. The remote alarm buzzes when the person with dementia leaves the bed and stops buzzing with the person returning to the bed or caregiver reset. The bed sensor is for the full length of the bed and the width of a twin size bed to outline the entire sleeping area of the individual and reduce false alarms (Figure 1).

Figure 1.

Bed occupancy sensor.

Improve Home Safety

The following types of outside door locks were made available to the caregivers in this project. The purpose of these locks was to prevent unattended home exits. Note that some of the locks offered serve the same purpose—for example to prevent home exits with an inside keyed lock. The reason several types of locks were purchased in the Safe Home Program was to change the current look of the lock to be unfamiliar to person with dementia per common recommendations to improve home safety. Thus, if the caregiver currently had a lever door lock, a dead bolt was recommended and vice versa.

Dual Function Door Security Bar

This security bar fits most of the doors including sliding doors, entry doors, interior doors, and garage access doors. The bar is placed behind doors to grip the floor’s surface and deter a person with dementia from opening exit doors.

Touch Pad Key Locks

Key locks can be installed on exit doors of homes to help monitor and prevent unwanted home exits by the person with dementia. The touch pad key lock is activated using a programmed 4-digit code selected by the caregiver. For caregivers of persons with dementia, we installed the keypad inside the home instead of outside, given that the intent is to keep the person with dementia safe in the home and prevent unwanted home exits.

Door Handle Set

Double-keyed locks are installed on exit doors to help monitor and prevent unwanted home exits by the person with dementia. These handle sets require a key to get out of and back in an exit door. The handle lock may also be used inside the home to prevent a lever-type handle from being opened. To release, the caregiver uses a second hand to hold and release the lock.

Sliding Door Lock

The sliding door lock is mounted on the stationary side of the glass door to prevent the door from opening. It is designed to be colorless so that it blends in with the glass.

Grip-and-Twist Door Knob Cover

A rubberized door knob covers the door knob; it is used to make it difficult for the person with dementia to turn the door knob. The cover must be grasped firmly to grab the handle otherwise just the cover will turn. The cover blends in with home decor and glows in the dark for nighttime safety.

Window Sensor

This device is designed to alarm the caregiver when a window is opened. The system can be used with a wireless alarm control center and wireless motion detector to monitor home exits.

Dead Bolt

The purpose of this double keyed dead bolt lock is to secure the home from outside intruders. The dead bolt requires a key to get out of and back in an exit door and may be useful in preventing the person with dementia from leaving the home unattended.

Other Home Safety Products

Water Detector Alert

This water detector is used inside the home to detect standing water, usually on a floor from instances such as a washing machine overflow or pipe leak. This device may be useful for caregiver to ensure that the person with dementia does not leave water running—particularly when the sink or tub is plugged.

Stove Knob Covers

These knob covers slip over the knobs of a stove to prevent the stove from being used and may be useful if there are issues with the person with dementia safely using the stove.

Carbon Monoxide Detector

This carbon monoxide (CO) detector is battery operated and designed to alarm if CO is detected in the home.

Smoke Detector

The smoke detector is designed to alarm when smoke is detected in the home. This detector was provided when there was no detector in the sleeping area of the person with dementia or offered when caregivers expressed the need for an extra detector.

Developing a Method of Assessment for Individual Caregivers

In this demonstration project, the project team reviewed the literature to identify a variety of questionnaires that could be used to conduct individualized needs assessments in 4 areas: ongoing surveillance, provision of care, prevention of injuries, and improving home safety. The questionnaires, along with individual caregiver interviews, were used as needs assessment tools to determine individual caregivers needs. The selected instruments were the Safety Assessment Scale ⁷ (to assess hazards in the home); the Caregiver Vigilance Scale (to determine the need for constant surveillance) ⁸ ; the Peace of Mind Scale ⁹ (to determine how caregivers were impacted by the ongoing requirement for direct care to maintain safety); and the Sleep Disorders Inventory ¹⁰ (to assess impact of nighttime activity of the person with dementia on caregiver sleep).

Rollout of the Program to HBPC

Sixty persons with dementia were referred to the Safe Home Program by the Tampa VHA HBPC and Patient Aligned Care Team. The HBPC program provides long-term, comprehensive care to Veterans with complex medical, social, and behavioral conditions in their homes. The VHA HBPC uses a strong interdisciplinary team approach to health care and these programs continue to expand due to clinical success and high patient satisfaction rates (see Table 1).

Table 1.

Demographic Characteristics and Results of Caregiver Needs Assessments.

Caregiver and person with dementia demographic characteristics
Caregiver gender	Female	88%
Person with dementia gender	Male	94%
Type of caregiver	Informal	69%
	Formal (paid)	31%
Care receiver	Home	82%
Living environment	Medical foster home	18%
Results of caregiver and person with dementia needs assessment
Constant vigilance (surveillance)		25%
Nighttime behaviors		33%
Attempts to exit home		32%
Lost or hurt on an independent		26%
Community activity
Falls		23%
Missing incident when in the community with caregiver		17%
Unattended home exits		14%
Smoke (fire hazard)		4%

In the initial home visit, the assessment tools were administered, and there was an assessment of essential safety materials. If not already in place, the materials were provided to facilitate personal identification (ie, MedicAlert Safe Return plus clothing labels and home CO and smoke detectors). If there was a complex medication regimen (defined as >7 medications/day), a 30-day medication organizer was provided to the caregivers. Assessment questionnaires were administered to each dyad to understand additional needs of the caregiver and person with dementia.

Using the results from completed assessments, the project team discussed and determined a set of appropriate technologies for each caregiver–person with dementia dyad. A second visit was scheduled to introduce the caregiver to the recommended products and determine their willingness to utilize the identified technologies. During the second and third weekly visits, appropriate technologies were installed in the caregiver’s home. For each technology provided, the caregiver received one-on-one education on its use from HBPC program staff until it was evident that the caregiver could use the technology independently. Education of the caregiver usually required a single session. Written materials, including product pamphlets and information and a guide, were also developed for caregiver use by the project team and are available upon request. The guide included step-by-step instructions for use, with extensive pictures to make adoption as easy as possible. All technologies were offered through the Safe Home Program free of charge.

In order to determine whether technologies were accepted and adopted over the short and long term, a series of follow-up visits were completed at 1 and 3 months after installation. During these visits, information was collected using the assessment questionnaires as well as a survey of each technology. For each technology, the study team determined whether it was currently used and assessed whether it was being used correctly. During this time caregivers were encouraged to provide qualitative feedback, discussing how the technologies may be beneficial or of little use and if there is a need for a device that they could use in the home to keep the person with dementia safe, which was not provided in the Safe Home Program or commercially available. Assistive technologies and home modification have been found to provide caregiver immediate relief, reduce stress, and help them provide care more easily and safely. ¹¹

Results

The overall responses to the technologies provided to the caregiver and person with dementia in this study were positive. All but 1 caregiver who was referred to the program received technologies. One- and 3-month visits were conducted for all participants and technologies continued to be used at both the assessment intervals. Most importantly for wider use of this type of project, there were distinct characteristics of the technologies that were accepted by the caregivers. These included:

• technologies that did not alter the appearance of the home or resembled medical devices (which caregivers believed could give their home an institutional look and feel);

• devices that made it easier for the caregiver to provide ongoing surveillance/monitoring when the caregiver was not available to provide eyes-on supervision;

• device alarms that sounded remotely at the site of the caregiver—not at the location of the person with dementia;

• technologies that met unique combinations of caregiving needs (eg, getting lost, sleep disorders)

Table 2 provides information on the types and frequency of technologies desired by the caregiver in Safe Home project. In order to receive the medication organizer, the person with dementia had to have a complex medication regimen (defined as >7 medications/d). Given that all persons with dementia met these criteria, all caregivers received the medication organizer. The characteristics of the organizer that were popular with the caregiver included the ability to set up a month’s supply of medicine (needed particularly if home care is providing this service), the ability to have 4 compartments for each day, and ease of use of each day’s container.

Table 2.

Device Category for Technology Use and Cost.

Device Category	Primary Use of Device	Cost	% Provided With Technology
Ongoing surveillance
Motion sensor with remote alarm  (Driveway sensor product)	Motion sensor to detect: egress from home property—movement through a doorway, driveway, garage	$12.00	80
Wireless camera with LCD, color and  night vision	Monitor movement throughout the home	$184.00	100
Proximity range alarm	Monitor specific area inside or outside	$375.00	30
Wireless home security system	Egress from home property; allows more personal freedom	$120.00	100
Optional additions to home security  system
Door/window sensor	Detect motion when a door/window is open inside and outside the home	$17.00	68
Wireless motion detector		$20.00	65
Provision of care
Medication organizer	Organize medicine by week/day up to 31 days	$69.00	100
Prevention of Injury
Identification program (eg, MedicAlert + Safe Return) with wearable device	Getting lost in the community nationwide registration program	$105.00 (Negotiated rate for this program)	100
Identification program (Iron-on labels)	Getting lost in the community; identification information iron-on inside the clothing	$96.00 per 1000	100
Locating technology (eg, Project Life  Saver)	Getting lost in the community; Sherriff’s office/search and rescue response to missing call	$309.00	88
Bed occupancy sensor	Monitor bed status; alerts caregiver when out of bed	$480.00	95
Home improvement safety
Dual function door security bar	Egress from home property	$17.99	6
Touch pad key locks	Prevent unwanted home exits	$199.00	20
Door handle set	Prevent unwanted home exits with a double-keyed lock	$129.00	25
Door lever handle lock	Prevent unwanted home exits	$8.56	4
Sliding door lock	Prevent unwanted home exits from a sliding door	$4.94	95
Grip and twist door knob	Prevent unwanted home exits	$3.89	80
Window sensor	Prevent unwanted home exits from the window	$13.59	1
Dead bolt	Prevent unwanted home exits with a double-keyed dead bolt lock	$199.00	10
Water detector alert	Prevent water leak	$14.00	1
Door knob covers	Prevent stove use	$9.49	<1
Carbon monoxide (CO) detector	Prevent carbon monoxide exposure	$39.00	100
Smoke detector	Prevent fire/smoke exposure	$39.99	100

In decreasing order, the next most common technologies selected for installation were the bed occupancy sensor, driveway sensor, and wireless home security system. Most notably, these technologies improved the caregiver’s ability to provide ongoing surveillance when eyes-on surveillance was not practical (eg, during the night). Additionally, these items improved safety for the person with dementia (eg, they prevented unattended nighttime activity).

In order to ensure that the person with dementia had a method of identification at all times, clothing labels were provided to all caregivers and these labels were readily adopted. The adoption of identification bracelets was limited, and these were not worn continuously by the person with dementia. Project Lifesaver membership was offered to those persons with dementia at highest risk of a missing incident (based on caregiver report and/or a history of a missing incident). Of the 60 participants, 9 were offered this product/service in conjunction with the local sheriff’s office and all accepted. At the 3-month assessment, all caregivers continued to use this technology—likely because these persons were at high risk for a missing incident.

Less Effective Technologies

One surveillance technology that was chosen, but effective only in limited situations, was the wireless camera with handheld LCD. A strong concern arose in the use of this technology because even a momentary glance away from the LCD screen could cause the caregiver to miss the person with dementia’s movement from a safe to an unsafe area. In one useful example, a caregiver used this technology to observe the person with dementia as they walked laps around the driveway. However, as soon as the person with dementia was no longer in view, the caregiver knew she had to check on him because he was not in the correct location. Thus, it was critical that this device only be used when the camera angle included the entire area of surveillance (eg, to determine movement out of specific location [eg, chair], a well-defined area [a room], or an individual in a fixed location [bed or chair]).

There were several reasons caregivers chose not to adopt and use the technologies/devices offered in the Safe Home Program. First, if the technology made the home appear institutional or the caregiver found it inconvenient to their lifestyle, the technology was rejected. The installation of any new door-locking equipment was met with resistance from almost all caregivers, even if a new lock might significantly improve the safety of the person with dementia (eg, prevent an unattended exit from the home). Caregivers stated that these locks were intrusive to the home environment; new home keys were undesirable; key codes were difficult to remember; and it was difficult to adapt to a new lock type. This is an important finding, since a standard safety recommendation for caregivers is to change locks in the home, a strategy that, in this project, was met with almost complete resistance.

The majority of the technologies to improve home safety were not accepted—including stove knob covers and flood detectors. The primary reason for the rejection of these technologies/devices by the caregiver was that they changed the appearance of the home. Items that looked unfamiliar in a home environment, such as a flood detector, were particularly unacceptable. Caregivers also expressed some concern about how the person with dementia would respond to unfamiliar objects in the living space.

Issues Incurred Over the Course of the Safe Home Program

A very small number of problems were encountered during the Safe Home Program. One caregiver initially had limited understanding on the scope of the bed occupancy sensor. To address this issue additional education was provided along with extra motion sensors. Also, as discussed above, the Safe Home team could only provide the LCD/remote camera product for very well-defined surveillance situations—otherwise it was unsafe. Also, the reception of this unit could be problematic and interrupt the ability of the LCD to display a clear picture.

Evaluation of the Safe Home Program

The HBPC staff were asked to provide feedback on the Safe Home Program. Informal interviews with caregivers of persons with dementia in the Safe Home Program were conducted after the third month during the evaluation of the technologies/devices to determine the benefits of the program and the areas for improvement.

Feedback From HBPC

The HBPC staff were receptive to the Safe Home Program and recommended dyads who would benefit from the technologies/devices to help keep the person with dementia safe at home. The HBPC staff felt that this project provided a real-time patient-centered assessment of the caregivers needs and provided additional resources for the person with dementia to age in place. According to staff reports, the caregivers felt that the technologies that were issued through this program increased the safety and security of the person with dementia in the home environment. The commercially available technologies and devices identified in the Safe Home Program continued to be distributed by HBPC staff even after the conclusion of the program.

Program Value to the Caregiver and Person With Dementia

Qualitative interviews with caregivers in the Safe Home Program echoed HBPC staff; caregivers reported that the technologies issued through the program increased their sense of security and helped to ensure that the person with dementia remained safe in the home. However, caregivers also identified gaps in the technologies that the Safe Home Program was unable to provide. For example, caregivers stated that there was a need for a chair occupancy sensor. Unfortunately, there were no commercially available sensors appropriate for home use at the time of this program. The problems that we found with the existing commercially available chair occupancy sensors included alarm sounded at the site of the person with dementia—rather than the caregiver; design of the sensor pad could cause injury (eg, from hard plastic electronic components in the seating area); or the technology required the person with dementia to wear a tag or other tracking device. Caregivers also expressed a need for a system to integrate both a bed occupancy sensor and a motion/door opening sensors into one system with a portable unit to receive alarms.

Conclusion

Although technological systems or devices are needed to help caregivers monitor and prevent injuries among persons with dementia, there has been little to no systematic testing of commercially available technologies for these purposes. ¹² In the Safe Home Program, we identified and categorized commercially available technologies/devices that may be used by caregivers to help keep the person with dementia safe. The categories included (1) ongoing surveillance, (2) provision of care, (3) prevention of injuries, and (4) home safety. Of these, caregivers primarily chose technologies in the ongoing surveillance category (eg, motion sensor with remote alarm, wireless camera with handheld LCD, and wireless home security system). Other widely used technologies by caregivers included an identification program and medication organizer. It is notable that many of the most widely accepted devices used by caregivers in this project were able to provide immediate relief, reduce stress, and help them provide care more easily and safely. Although some of the devices used by caregivers were of relatively higher cost than others (eg, the bed occupancy sensor), these devices may reduce the person with dementia’s risk for injury. For example, the bed occupancy sensor was intended to prevent nighttime injuries so even the higher cost would be easily offset by preventing one fracture that resulted in early formal care placement.

Taken together, the findings from the Safe Home Program suggest that technologies focused on ongoing surveillance at home for persons with dementia are needed and that these technologies could be quickly adopted by caregivers to ameliorate some of the stress and burden associated with providing care for persons with dementia. However, this project’s findings also suggest that technologies/devices that alter the appearance of the home (eg, door/window locks) or resemble medical devices will not be used or adopted by this population—even though they may be useful in preventing an adverse event or injury among persons with dementia.