Is the typical modern house designed for future adaptation for disabled older people?
Keywords: Housing, Old age, Disability.
The 1991 census showed that just less than 8 1/2 million pensioners were living in just over 6 million households (one in three of all households) . In addition to the physical comforts, many appreciated the closeness of friends and social facilities, personal independence and autonomy, and so important are these that elderly persons prefer to remain in their own homes . Indeed, in 1970 the Chronically Sick and Disabled Persons Act made it a `duty’ of local authorities to make arrangements for the `provision of assistance ….. in arranging for the carrying out of any works of adaptation in [a person’s] home or the provision of any additional facilities designed to secure his greater safety, comfort or convenience.’ The NHS and Community Care Act of 1990 supports this choice and has theoretically reorganised services to effect it .
Maintenance of the home becomes more difficult with increasing disability, extreme age  and falling income. Failure to achieve regular maintenance may lead to more extensive repairs in the future. The mortality of older people living at home is affected by housing conditions . Of the pensionable population living in independent households in 1991, 40% were regarded as having long-term limiting illness . Disability and disease limit mobility within the home perhaps to the point where a person is unable to use stairs and is therefore confined to a downstairs room. If the bathroom and toilet are upstairs the elderly may not be able to bathe as often as they would wish [6, 7]. Some may even become trapped in a standard bath . Exercise is related to the number of rooms available in a dwelling  and this in turn is related to mortality .
Some of these problems might be overcome by adapting the home. The cost for such adaptation, together with technical aids for the mild to moderately disabled, may postpone or even avoid institutionalization or the need for care services . However, for the more severely disabled and for certain houses, this may be expensive and influence the decision to move. The cost of adaptation could be reduced if the house was potentially adaptable to meet future needs.
The UK National Housing Building Council has recently produced a draft of proposed amendments to the House and Building Regulations to cover `visitability’ and `adaptability’ standards . A `visitable’ home would incorporate standards to enable even those with severely restricted mobility to go outside. An `adaptable’ home would be one `in which the changing needs of the occupants through illness, disability or ageing, can be specifically accommodated without major structural alteration and expense’. The recommendations do not cover specific needs but consider general points such as access from a car to the dwelling, entrance to the dwelling, internal circulation, kitchens, toilet facilities, stairs, bedrooms, and access to service controls. If accepted, these provisions could become mandatory in all new houses. The purpose of this study was to assess the extent to which companies already design and build houses which can be readily adapted in the future, should their elderly occupants become disabled.
The Building Employers Confederation in London was asked to provide a list of the largest house-building companies in England. The list for 1992 contained 80 names. Eight of the companies were involved in take-overs and mergers and were excluded. The final sample was thus 72 companies.
A letter was sent to the Managing Director of each company. Each was asked to comment on a list of provisions he or she considered important when designing a house to be adaptable (Table I). Some of these are included in the draft amendment to the building regulations. Comments were also invited about factors affecting adaptable housing design. Following the postal survey, the non-respondent companies’ design departments were telephoned and asked `Is your typical house for the mainstream market designed for future adaptation by a disabled elderly occupant?’ If they gave a positive response, further details were requested.
Table I. Items for consideration when designing a home to be adaptable in the future
1. Wheelchair access.
2. Structure of walls to allow handrails or chairlift to be
3. Plumbing facilities for downstairs toilet or shower.
4. Position of electrical switches and power points.
5. Gradient and dimensions of stairs.
6. Design and use of bathroom suites.
7. Lighting of passageways.
8. Position of light switches in bedrooms.
9. Access to electricity and gas meters.
10. Access to heating controls and availability of individual
controls in each room.
11. Security and safety.
12. Provision of telephone points.
13. Use of energy efficient systems.
14. Use of fire-resistant materials.
15. Cavity-wall and loft insulation.
Table III. Number of companies giving consideration to the needs of elderly and disabled people when designing specific items in housing
Item Yes No
Position of power points 13 13
Stair design(a) 1 25
Position of switches 8 18
Bathroom design 3 23
Lighting of passages(b) 3 23
Bedroom light switches(c) 3 23
Position of meters 3 23
Heating controls(d) 13 13
Security(e) 4 22
Telephone points(f) 9 17
Energy efficiency 5 21
(a) Wall structure to allow for installation of chair lift or hand rail. Stairs should have a clear run for the lift.
(b) Above standard requirements to allow for visual impairment.
(c) Additional switches to the standard switch inside the door.
(d) e.g. individual radiator controls in each room.
(e) In addition to standard requirements of door and window locks.
(f) In addition to standard single downstairs point.
A number of housing options exist for elderly and disabled people. These include purpose-built flat complexes and sheltered housing which offer increased security, reduced maintenance and lower running costs. However, this may involve an unwelcome move to considerably smaller accommodation. Home Improvement agencies exist throughout the UK, co-ordinated nationally by `Care and Repair’. The `Staying Put’ (e.g. Anchor Housing Association) and `Care and Repair’ schemes offer advice to older people about home adaptations to meet their changing needs. Unfortunately, these schemes, although expanding, are not yet well known by either the general public or health workers. Our survey looked at the possible alternative of designing normal houses which would be easily adaptable to future needs, and is therefore applicable to tomorrow’s elderly population.
The combined overall response rate to our basic questionnaire was 93%. The written response rate of 49% was more disappointing. However, points outlined by the companies who replied by letter were very similar and telephone conversations with design departments confirmed these to be the important issues. Furthermore, it has been shown that those who fail to reply to questionnaires more often reply in the negative on subsequent enquiry and again our telephone survey confirmed this . The items we asked the companies to consider were similar to those of the NHBC draft document’s standards.
Only two companies (3%) designed houses which might be suitable for future adaptation for an increasingly frail elderly occupant. All companies accepted that people may need to adapt their houses in the face of age and disability but most felt that designing houses to be adaptable would have to be mandatory before it became widespread. This was largely an economic argument. One company commented `it is not cost effective to exceed minimum standards’. Most current designs would need re-working. Even smaller houses would require a substantial increase in floor space and would therefore be higher and less competitively priced. One company stated it had never received enquiries about such properties as people do not anticipate disability, accepting it only when it happens. Another commented that disabled people may prefer to live in a `normal’ house rather than one for the disabled, thus missing the point that the houses should be normal but have in-built adaptability. Even where companies allow customization for disabled persons at the construction stage, uptake rates are low: 0.3% of 8000 properties for Wimpey Homes in the 12 months to June 1994 (M. J. Stamp, Company Architect, Wimpey Homes; personal communication).
An adaptable home should have two design considerations. First, the fixed elements such as door width, presence of thresholds and stair design should be considered when the house is built . Secondly, plumbing for additional toilets or showers, or wiring for additional switches and power points should be provided. If these designs were accepted as standard in all new houses then the unit cost of building would be reduced, a point recognized by several companies. Space is also a factor and many companies felt that modifications would be space dependent and therefore available only to more affluent people who live in larger houses. This is the experience of Denmark where efforts have been made to maintain elderly people in their own homes .
In 1997 the Department of Environment may introduce `visitability standards’ for short visits by disabled persons to domestic properties . These, and the recommendations sited in the NHBC document, may lead to the development of regulations on adaptable housing, not as a total solution, but one option in managing the challenges of an ageing population. It will require the joint effort of Government, the Building Authorities and health professionals to promote it as a viable option. Economic arguments and perceived lack of demand make the building companies reluctant to develop it further at this stage.
1. Houses should be adaptable to allow elderly occupants to remain at home and minimize the cost of service care.
2. Most companies do not design their houses to be adaptable.
3. Demand for adaptable housing is currently low.
References[1.] 1991 Census Report for England. London: HMSO 1993.[2.] Reschovsky JD, Newman SJ. Adaptations for independent living by older frail households. Gerontology 1990;30:543-52.[3.] National Health Service and Community Care Act. London: HMSO, 1990.[4.] Reschovsky JD, Newman SJ. Home upkeep and housing quality of older homeowners. J Gerontol 1991;46:S288-97.[5.] Zhao L, Tatara K, Kuroda K, Takayama Y. Mortality of frail elderly people living at home in relation to housing conditions. J Epidemiol Community Health 1993;47:298-302.[6.] Smith DW, Hogan AJ, Rohrer JE. Activities of daily living as quantitative indicators of nursing effort. Med Care 1987;25:120-30.[7.] Penn ND, Belfield PW, Mascie-Taylor BH, Mulley GP. Old and unwashed: bathing practices in the over 70s. BMJ 1989;298:1158-9.[8.] Gooptu C, Mulley GP. Survey of elderly people who get stuck in the bath. BMJ 1994;308:762.[9.] Kuroda K, Tatara K, Takatorige T, Shinsho F. Effect of physical exercise on mortality in patients with Parkinson’s disease. Acta Neurol Scand 1992;86:55-9.[10.] Grand A, Grosclaude P, Bocquet H, Pous J, Albarede JL. Disability, psychosocial factors and mortality among the elderly in a rural French population. J Clin Epidemiol 1990;43:773-82.[11.] Parker MG, Thorslund M. The use of technical aids among community based elderly. Am J Occup Ther 1991;45:712-17.[12.] NHBC Standards, Chap 1.5: Accessibility [draft document].[13.] Sibbald B, Addington-Hall J, Brenneman D, Feeling P. Telephone versus postal surveys of general practitioners: methodological considerations. Br J Gen Pract 1994;44:297-300.[14.] Iwarsson S, Isacsson A. Basic accessibility in modern housing–a key to problems of care in the domestic setting. Scand J Caring Sci 1993;7:155-9.[15.] Christoffersen H. Housing of the elderly. Dan Med Bull 1992;39:238-41.[16.] Access and facilities for disabled peoples–new dwellings. London: HMSO, 1995.
Appendix. Useful addresses Care and Repair, Castle House, Kirtley Drive, Nottingham, NG7 1LD
Anchor Housing Association Anchor House, 269a Banbury Road, Oxford, OX2 7HU
Department of Medicine, Darlington Memorial Hospital, Hollyhurst Road, Darlington, Co. Durham, DL3 6HX
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