Living Safely, Aging Well A Guide to Preventing Injuries at
Home
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CONTENTS
Chapter 1. What’s “Old” Got to Do with It?
Chapter 2. Don’t Fall!
Chapter 3. Too Hot and Too Cold
Chapter 4. Poisoning
Chapter 5. Preventing Asphyxia
Chapter 6. When Driving Is Dangerous
Chapter 7. The Backyard and the Workshop
Chapter 8. All around the House
Chapter 9. Seeing the Doctor
Appendix A. Injury Statistics for People 65 and Older
Appendix B. Agencies and Organizations that Can Help
References
Index
LIVING SAFELY, AGING WELL
WHAT’S “OLD” GOT TO DO WITH IT?
Our definition of “old” changes over time. When we were children, we may
have thought that 30 was old. In our thirties we probably thought that 50
was “over the hill.” As we age, we push “old” into the future—to 65, say,
the age long viewed by Social Security as normal retirement age. But as we
approach 65, our concept of old age may drift to 75 or 80 or even older.
Regardless of our personal perspectives on age, “old” today is older than it
was a generation ago.
Part of the reason for this revised image of old age is that people are
living longer. According to the U.S. Census Bureau, the population of
Americans age 65 or older grew rapidly for most of the twentieth century,
from 3.1 million in 1900 to 35.0 million in 2000. In April 2010, there were
40.3 million people 65 or older, constituting 13 percent of the total U.S.
population. And the older population is on the threshold of a boom. The
Census Bureau projects a substantial increase in the number of older people
from 2010 to 2030; after all, the first Baby Boomers turned 65 in 2011. The
older population in 2030 is projected to be twice as large as it was in 2000,
growing from 35 million to 72 million. This group of people will represent
nearly 20 percent of the U.S. population.
So, no matter how you define “old,” there will soon be lots of old people
—and these will be old people who will do what it takes to defend their
independence and lifestyles. To maintain one’s independence and lifestyle,
however, one must age well; to age well, one must remain healthy; and to
stay healthy, one must avoid injury. Whether you are an older person
looking out for your own safety, an adult child taking care of parents, or a
caregiver helping someone stay safe from injury in the home, this book
should provide much helpful—indeed critical—information.
If there were no increased risk of injury for older people compared to
younger people, the rates of injury to people of different ages from the same
cause would be the same, but they certainly are not. The U.S. Consumer
Product Safety Commission has found that about three times as many adults
75 or older as one would expect are treated in hospital emergency rooms
each year for injuries associated with consumer products. When older
people are injured, their injuries are often more serious than a similar injury
in a younger person, they may need to be hospitalized, they take longer to
recuperate, they are at higher risk for infections and complications, and they
are more vulnerable to repeat injuries. In short, people over age 75 are a
fragile population when it comes to injuries. Since most accidents—
including the majority among people 75 or older—happen at home, taking
steps to be safe at home is essential.
What makes older persons so much more vulnerable to injury? While
there is much individual variation in the aging process, age-related changes
affect most older people. They include deterioration in the senses (vision,
hearing, smell, taste, and touch) and an array of possible physical,
cognitive, and health-related changes. Any of these alterations can make a
person more susceptible to injury—whether it’s the ability to recognize a
hazard, the ability to react to it in time, or the greater likelihood of getting
hurt than a younger person might under the same circumstances. Whether
you are engaged in an everyday activity like walking or are using a
harmless-seeming product like a vacuum cleaner or an obviously dangerous
one like a car, your safety depends on the extent to which you have the
abilities to meet the demands of the activity.
The rest of this chapter describes natural age-related changes and
illustrates how they can contribute to increased risk of injury. No one can
predict exactly when or to what degree these changes will begin to occur in
any particular person. They may be so gradual that they aren’t even noticed.
Aging is highly personal! I will occasionally illustrate a point with
examples from real life of people I have known.
PHYSICAL CHANGES
If we try to list the physical changes that go along with aging, we naturally
think first of the most visible ones—wrinkles, graying hair, baldness,
sagging skin, and so on—but these features are not important for safety.
How safe a person is depends on how he or she functions in and interacts
with the immediate environment—the activities and products involved in
everyday life.
We spend our childhoods growing taller and stronger, and then most
people plateau in height and strength as teenagers or young adults. Later,
we realize that our youthful strength and stature do not endure. In general,
people tend to get shorter and weaker as they age. These changes are related
to natural alterations in bone and muscle structure. The amount of bone
mass we have is greatest when we are about 30 years old; after that, bone
loss continues faster than bone growth, resulting in ever-decreasing bone
density. Loss of bone mass, called osteoporosis, is assumed to be one reason
for the increase in bone fractures among older adults. It is also thought to be
a factor in the flattening of the spinal vertebrae and the discs between them,
as well as in the spontaneous fracture of vertebrae that some people
experience—all of which contribute to making us shorter as we age. By
some point between 65 and 79 years of age, most adults have lost about 3 to
6 percent of their peak height. At the same time that our bones are getting
more fragile, our muscles are on the decline, too.
Men fare a bit better than women with regard to these particular physical
changes. Men start with more bone and muscle mass than women do, and
men do not go through menopause. Menopause brings reductions in
hormones, like estrogen, and this contributes to bone loss in women.
The loss of bone and muscle mass can make it slower, more difficult,
and sometimes painful to walk, get in and out of a chair, climb stairs, and
do other simple physical activities. It can also affect fine motor skills,
strength, and balance. These consequences of aging create a “fragile
infrastructure” that makes it more challenging for us to function safely in
our environment. It is therefore not surprising that bone and muscle
deterioration are a major underlying cause of falls, which in turn are the
most common cause of injury among older people. In addition, these
physical changes increase older people’s susceptibility to fractures, and if a
fracture occurs before or as a result of a fall, the injury will take longer to
heal. Fall-related injuries are the leading cause of death among people older
than 75.
CHANGES IN THE SENSES
How accurately we see, hear, smell, taste, and feel diminishes with age.
These changes in older people are not usually visible to others in the same
way that loss of height and loss of muscle strength are, but there is other
evidence that they are happening. For example, many people can’t read
small print when they get older. Or, an older person may often ask that
someone repeat what they said, because they can’t hear as clearly as they
used to. Because we don’t “see” these changes, we may forget that they are
present, and we may not always be conscious of their impact on safety.
Even the person experiencing sensory losses may not be conscious of their
impact. Sensory impairment can decrease functional independence. In
particular, reductions in hearing and vision can lead to isolation, depression,
and withdrawal. The social impact of these losses is significant.
The effect of sensory losses on safety is enormous. When a person can’t
see clearly, she may take the wrong medication; when a person can’t hear or
smell well, he may not hear a teapot’s whistle or smell the burning pot;
when a person can’t taste accurately, she may consume spoiled food and
become ill; when a person has lost sensitivity in her hands, she may touch a
hot surface but not remove the hand quickly enough to prevent a serious
burn. By age 70, about one in five people have deficiencies in two senses,
increasing their risk of injury and illness. People with both vision and
hearing loss are more likely than those without either impairment to fall,
break a hip, develop hypertension or heart disease, or have a stroke. Also
important are two sensations not among the classic five senses, and those
are sense of balance and sense of core body temperature.
Hearing
Hearing loss is the most common age-related sensory decline, affecting
about one in three people aged 65 to 74, and nearly half of people 75 and
older. Not only is reduced hearing the most common change, but it is the
most gradual, making it difficult for the person to recognize and accept.
Men are more likely than women to suffer hearing loss. Risk factors, in
addition to aging, include smoking, a history of middle ear infections,
exposure to certain ototoxic (damaging to the ear) chemicals or
medications, head injury, tumors, stroke, and exposure to loud sounds. It is
not unusual for construction workers, heavy equipment users, musicians,
and military personnel to experience hearing loss.
Compared to other sensory deficiencies, hearing loss has the most
damaging effect on social life. Not being able to hear well what people are
saying to you or to share with others in activities that involve listening can
lead to withdrawal, depression, and isolation. Observers may confuse
hearing loss with dementia or forgetfulness, because the person who is
missing much of what is being said may have trouble following a
conversation. A person with hearing problems might even be mistaken as
being uncooperative or nonresponsive.
In addition to its impact on social wellbeing, hearing loss puts people at
increased risk for injury. They may not be able to hear a smoke alarm or a
timer on the stove. They may not hear the phone ring or may answer the
phone but not be able make out what is being said by the caller. Not hearing
the siren or horn of a vehicle behind you while you are driving can be very
dangerous. Any sound-generated alert or warning may be completely
useless to a hearing-impaired person.
In spite of how deeply hearing loss impacts quality of life and personal
safety, it is often undetected and untreated. Older people are less likely to
have hearing evaluations and to use hearing aids than they are to have
vision exams and to wear glasses. A partial explanation may be that there is
still a stigma associated with wearing hearing aids, whereas glasses may be
viewed as trendy and even attractive. (Hearing health care is addressed in
detail in Chapter 9.)
Not all hearing loss is the same, and it isn’t just sounds being softer than
they used to be. Sometimes people lose the ability to recognize only certain
kinds of sounds, like high-pitched sounds; sometimes speech seems
mumbled; sometimes they can’t distinguish between similar sounds; and
hearing is often difficult when there is competing background noise, as
there is in a loud restaurant. Some people with Alzheimer’s disease or
another kind of dementia effectively lose hearing ability, not because there
is something wrong with their ears, but because their brain cannot interpret
what the ears hear. The person can hear the sounds, but their brain cannot
understand the meaning of the sounds. This situation causes additional
confusion for them.
Hearing loss is usually gradual, with continuing degradation as people
age; sometimes it can be sudden, the result of an infection, for example.
Some people with hearing loss develop a ringing, hissing, or roaring sound
in the ears; this condition is called tinnitus. The sounds may be intermittent
or constant and may be soft or loud.
In communicating with older adults with impaired hearing, some people
might employ “elderspeak,” a simplified speech, with exaggerated
intonation patterns, word stress, loudness, and speech timing. Elderspeak
also uses simplified grammar, limited vocabulary, and a slow rate of
delivery that is similar to the speech directed toward young children. The
inclination to speak this way to people who seem to be having trouble
hearing is understandable, but it can create unintended problems. While
evidence indicates that elderspeak may improve older adults’
comprehension, it also may contribute to giving them an “old” identity,
reinforcing negative stereotypes about older adults, and lowering their self-
esteem. Elderspeak can be viewed as patronizing. It can convey an
impression of disrespect and a belief that the older person is cognitively and
communicatively impaired. So, be cautious in using elderspeak if it seems
called for; and if someone is using elderspeak in talking with you and you
don’t like it, say so.
Vision
After hearing loss, vision impairment and loss of visual acuity constitute the
second most prevalent disability in people 65 or older. Vision begins to
decline earlier than any of the other senses do. Changes in some external
parts of the eye, such as the cornea and lens, begin in a person’s thirties or
forties; changes to the retina (the tissue lining the inner surface of the eye)
and to vision-related parts of the nervous system become noticeable in one’s
fifties and sixties. The greatest losses occur later in life. The near reading
visual acuity of the average 70-year-old is 30 percent of that of a 20-year-
old.
“Visual impairment” is defined as a vision loss that cannot be fully
corrected by glasses or contact lenses alone. Underlying causes of visual
impairment are cataracts, glaucoma, macular degeneration, and diabetic
retinopathy.
Cataract describes a clouding of the lens of the eye; it makes the image
the person sees fuzzy (as in Figure 1.1). Cataracts usually grow slowly, so
the change in vision is gradual—the person may not notice it. Symptoms
include blurry vision, seeing a “halo” around lights, perceiving headlights
or other lights as being too bright at night, seeing colors as faded, and
needing frequent changes in one’s eyeglass prescription. Most cataracts are
related to aging. Excess sun exposure and certain medications can stimulate
or exacerbate cataract growth. Cataract-related loss of vision cannot be
corrected with eyeglasses; surgery to replace the lens is required.
Glaucoma results in increased pressure in the eye. There is no pain along
with the pressure, so a person may not realize that glaucoma is developing.
Symptoms may include seeing things clearly in the center of the visual field
but missing things in one’s peripheral vision (see Figure 1.2). A person with
glaucoma can end up with “tunnel vision.” During an eye exam, when the
optometrist or ophthalmologist sends that puff of air to your eye, he is
measuring eye pressure, checking for signs of glaucoma.
Macular degeneration affects what a person sees in the middle of his
visual field. The retina of the eye consists, in part, of specialized cells called
rods and cones. The cones are for color vision, and the rods are for black-
and-white vision. The macula is the central part of the retina. It is very rich
in cones and it’s where our vision is sharpest. There are two kinds of
macular degeneration—dry and wet. Dry macular degeneration is more
common, but we don’t yet understand how or why it happens. Wet macular
degeneration, which often leads to blindness, is caused when blood or
another bodily fluid leaks behind the retina. Figure 1.3 shows what a person
with macular degeneration might see.
Diabetic retinopathy is a form of damage to the blood vessels of the
retina, caused by diabetes. The blood vessels may swell and leak fluid, or
abnormal new blood vessels may grow on the surface of the retina. What a
person with diabetic retinopathy sees is not only fuzzy but has blackened-
out chunks in the visual field (see Figure 1.4). Diabetes also puts people at
risk for developing cataracts and glaucoma at a younger age.
Figure 1.1. Vision with cataracts
Figure 1.2. Vision with glaucoma
Figure 1.3. Vision with macular degeneration
Figure 1.4. Vision with diabetic retinopathy
In people with Alzheimer’s disease or another kind of dementia, the
same functional disability can happen with their vision as happens with
their hearing. That is, how well they can see things declines, not because
there is something wrong with their eyes, but because their brain cannot
understand or interpret the messages the eye is collecting and sending to the
brain. I observed this in my mother, and at the time I thought maybe she
just needed new eyeglasses. I remember her being seated at the dinner table
but not “seeing” the fork she was to eat with. When I had told her several
times where the fork was and she still asked, “Where?” I realized that her
brain had lost the ability to understand the signal sent from her eyes
conveying the image of the fork.
The inability to see our surroundings clearly increases our risk of injury.
For example, we might take the wrong medicine if the bottles appear
similar, or take the wrong amount if we cannot read or understand the label;
we might trip and fall if we cannot see obstructions in our path or if we
have poor depth perception; and we might incorrectly adjust a heating pad
too high and be at risk for burns.
As can happen to people with hearing loss, some people with diminished
vision begin to withdraw because they feel uncomfortable in their
surroundings. They may choose not to go out, insecure because they can’t
get around well. They may alter their gait, adopting a more cautious way of
walking. Feeling at risk may make them limit what they do, which in turn
can affect their social and other activities, and lead to depression.
Balance
Poor physical balance increases the risk of falling, and it is related to the
two sensory losses just described. Vision and hearing are two of the senses
that work together to help us know where we are in space; we see our
surroundings and hear sounds, and the vestibular system (the balance
system that works in concert with the hearing system) tells us where our
head is in space, keeping us upright and not dizzy. Losses in vision and
hearing, and disruptions to the vestibular system can put us out of touch
with our environment. Not knowing where we are in space can affect our
sense of balance.
Besides being affected by vision and hearing loss, the ability to keep our
balance can also be affected by poor nutrition, reactions to certain
medications, low blood pressure, low blood sugar, vertigo, light-
headedness, and reduced muscular strength, to name a few factors. Age-
related changes in the vestibular system can begin before age 30; by age 70,
there can be as much as a 40 percent decline in the number of vestibular
nerve and inner ear hair cells, which are very important to balance. This
decline can make it difficult for older persons to determine if they are
moving in space or if it is the world that is moving around them. Feeling off
balance or dizzy, feeling as if you are spinning, or not having a clear sense
of where your head and body are in space all make it harder to avoid falls
and collisions with objects.
Smell and Taste
Smell and taste are related senses in that what we taste is influenced by
what we smell. Age takes a greater toll on smell than on taste. Sense of
smell begins to diminish around age 60. During the aging process, the
number of taste buds we have actually decreases, and the remaining ones
get smaller. At around age 75, we have only about a third of the taste buds
we had at 30. With a poorer sense of smell, people are deprived of early
warnings that most of us take for granted. Smell alerts us to fires, poisonous
fumes, and gas leaks; taste warns us of spoiled food and drink and of
substances that are inappropriate for eating. A 2008 study found that people
who had lost their sense of smell or had an impaired sense of smell were
significantly more likely than those with a normal sense of smell to burn
food when cooking and to eat spoiled food. And, of course, they were less
likely to detect a gas leak and to smell a fire.
Decreases in sense of smell and taste lead many people to eat less or to
eat less nutritious food. For most of us, food is a source of pleasure as well
as of nutrition, and when the pleasure diminishes, there is less motivation to
eat. Like vision and hearing losses, loss of smell and taste can lead to
reduction of social activity and to depression.
Touch and Core Temperature
When my elderly father was living with me, I often would get upset with
him for having dirty or sticky fingers and leaving hand prints on the fridge
and table tops. Only much later did I realize that he had lost much of the
feeling in his fingertips due to a combination of chronic disease and aging.
Loss of sensation in extremities can be associated with diabetes (which my
father had), poor circulation, or neurological problems. Even if a person
does not have a chronic illness, with aging comes a reduction in the ability
of the skin to discriminate the pressure and vibration associated with touch.
Aside from personal hygiene issues, loss of sensation of touch can also
increase the risk of injury. For example, not being able to feel the sharp
edge of a knife can lead to cuts, and not realizing when something hot is too
hot can result in scalds and thermal burns (scalds involve a hot liquid or
steam; thermal burns involve a hot surface). The comfort of appropriately
warm bath water or a heating pad can turn into a scald or thermal burn
hazard if excessively hot temperatures go unnoticed.
In addition to a reduced sense of feeling in extremities, older people’s
sensation of their core temperature can become less accurate, because of,
among other factors, skin-related changes. Maintaining overall normal body
temperature is critical to survival. Being too hot (hyperthermia) or too cold
(hypothermia) can be very serious and even cause death. Most of us have
heard that older people are more susceptible than younger people to illness
and death from heat waves and from winter cold.
COGNITIVE CHANGES
The speed and the processes of cognition—how we know and learn things
—change as we get older. As we age, certain parts of our brains shrink—the
parts important to learning, memory, planning, and other complex mental
activities. The typical cognitive functions affected by age are memory and
attention. Most of us will experience some degree of forgetfulness. Where
are those keys? Who was that person? What’s the word I’m looking for?
What did you tell me to bring? All of these examples of memory loss are a
normal part of aging. While there is much variation among individuals, and
while some adults retain excellent cognitive function well into their
seventies and eighties, on average, people have begun to experience some
minimal decline in cognitive abilities by their middle to late sixties and a
more pronounced decline after age 75.
The high-tech world we live in today presents a good example of this
cognitive slowing. Every day most of us deal with automatic teller
machines (ATMs), microwave ovens, smart phones (which seem to do
everything else in addition to allowing conversation between individuals),
computers, cable boxes, remote controls, and more. Typically, when an
older person has trouble with one of these products, the first person
consulted is someone much younger—for many reasons: younger people
grew up with these products, they are highly flexible cognitively, and their
minds work in synch with how the products work, that is, they think like the
products work. In contrast, older people’s brains cannot process as quickly
the information necessary to carry out sequences of steps, like the series and
combinations of buttons to press in order to complete tasks on electronic
products. When receiving instruction on these products, the older person
may not be able to keep his attention focused long enough to learn what to
do. They may have to “look longer” at something in order to understand,
because older brains simply aren’t as nimble as young brains. Because tasks
can take longer to finish and the person may make errors along the way, he
or she may give up in frustration.
Dementia is different from the cognitive lapses of normal aging and can
have one or more of several causes. It is not a disease but rather a group of
symptoms that can include impaired judgment, increasing difficulty in
finding words, mood or personality changes, and difficulty remembering
how to do familiar activities. According to the National Institute on Aging,
about one in seven people aged 71 or over has dementia. The most common
cause of dementia in older people is Alzheimer’s disease, a
neurodegenerative disease that encompasses more than just memory loss.
Another cause is stroke. Alzheimer’s disease affects 5 to 10 percent of
people over age 65 and 20 to 40 percent of individuals over age 80. The
distinction between Alzheimer’s disease and other types of dementia is not
important for the purposes of this book. What is important is that any loss
of cognitive function, regardless of the underlying cause, can increase the
risk of injury.
SEEING THE WHOLE PICTURE
The age-related changes described above usually come on gradually.
Eventually, most people who live beyond age 60 will be experiencing a few
of them simultaneously. In addition, individuals may have other health-
related challenges, such a low blood pressure, diabetes, or heart disease,
that impact everyday life and safety.
It’s not as if an aging person has just one issue at a time to deal with.
Here’s an example from my own experience. I came home one evening and
smelled burning rubber in the house. I tracked the scent to the kitchen sink
mat, but I was perplexed as to how it had been burned. The next day, I
found out what happened. Over breakfast, my 90-year-old dad explained.
He had put a pot of prunes on the stove to cook and gone into another room
to watch TV. At some point, all the water boiled off the prunes, and the pan
itself began cooking. I don’t know if my father had set the stove timer—he
had had trouble learning how to do that. If he had, he probably would not
have heard it in any case; because of his hearing loss, he always had the TV
blaring. I don’t know if the smoke alarm went off; he might not have heard
it for the same reason. The pan was damaged enough that he should have
smelled something out of the ordinary, but he hadn’t. When he realized
what was happening, he took the hot pot directly from the stove and placed
it in the sink. That was a reasonable course of action, but he apparently
didn’t process or detect the consequences of placing the burning pan on the
rubber mat. Here was an example of multiple age-related sensory
deprivations (hearing, smelling, and cognition) synergistically interacting to
put a person at risk for a house fire.
The various changes associated with aging can combine to exaggerate
the effect of each one singly. The more areas where there are losses, the
more a person is put at risk for injury.
Injuries are not random events, and that’s why understanding injury
prevention and home safety for older adults can help you have a little more
control over dangerous events. There are always circumstances that “set the
stage” for injury. The stage includes the person, a thing (which I will call a
product) being used by the person, and the use environment. Each of these
factors can contribute to or be a direct cause of an injury. Let me give you
another example. An 82-year-old who has some dementia (the person) is
trying to heat water for tea on a stove (the product) in her kitchen (the
environment). She is wearing a robe (another product) with long, loose
sleeves. She reaches to the back of the stove to turn the knob for a rear
burner, but instead, she gets confused and turns on a front burner—the one
her arm is reaching over. Her sleeve catches fire, and she doesn’t know
what to do. She is seriously burned before anyone realizes what has
happened.
What might have created a different outcome in this scenario? (1) If
someone, for example a relative or friend of the person, knew of her
tendency to get confused about the knobs on the stove, that person could
have marked one knob with a color, and this knob would be the only knob
the woman was allowed to touch; or the stove could have been made
impossible for the woman to use by covering the knobs with a device used
to keep young children from operating knobs. (2) The designer of the stove
could have put the knobs in a less hazardous location that would have
avoided anyone’s having to reach over the burners. This could have been
