Dementia is a progressive degenerative disease of the central nervous system. It is the main clinical manifestation of progressive memory impairments, general mental decline, personality changes, and mental behavior abnormalities[1]. There are currently more than 35 million patients with dementia worldwide, and by 2050 this number is expected to increase to approximately 120 million. Dementia has become one of the most serious chronic diseases leading to loss of physical function [1].
Homecare involves elderly patients who live in their homes and not in old-age care institutions [2]. This model is currently the most important pension model in China [2]. Ten departments, including the Office of the Old Age and the Ministry of Civil Affairs, jointly issued the “Opinions on Comprehensively Promoting the Work of Home Care Services” as early as 2008. This document promoted the development of home care services [3]. The home environment is an important supporting means for home-based care services. Guaranteeing the safe and efficient development of home-based care services is necessary in order to provide a suitable living environment. An aging home environment can help elderly patients maximize their self-care ability and fully integrate and utilize the currently available resources. Therefore, a key part of home care services is the assessment of the needs of the home environment. At present, some home environments can no longer meet the needs of the elderly population, especially those of elderly people with disabilities. Many home environment designs have the following related problems: lack of elevators, unreasonable design and spatial layout, and lack of a safe bathroom space. Additionally, there is a lack of auxiliary facilities and imperfect alarm and help sign systems [4-5]. In view of this, the author created a suitable aging transformation demand scale and evaluated its reliability and validity.
Research status of foreign aging transformation scales
(1) The Comprehensive Assessment and Solution Process for Aging Residents (CASPAR): CASPAR was developed in 2002 by a multidisciplinary team of rehabilitation, construction, management, etc. professionals in the United States. Experts designed this system to save costs and achieve retrofit assessments under extreme conditions [6]. The tool collects the daily activities and environmental related information of elderly subjects, and assesses the needs of the home care environment, so that experts can develop appropriate transformation plans without visiting the site [6-7]. The evaluator can also evaluate the methods through which elderly patients or their family members request for elderly care professionals such as rehabilitation teachers, medical staffs, and case managers. It also includes a small amount of on-site measurements and photographs. The entire assessment takes about 25 minutes [6].
CASPAR [8] consists of 6 parts. The aging transformation scale proposes to list the care services that will be provided to the elderly to match t those provided by professional care services. Aging reform experts typically use the information collected via the scale to provide a transformation plan after a comprehensive analysis [6]. Several studies have shown that CASPAR has good inter-rater reliability and validity, and the correct recognition rate of environmental problems is above 88% [7]. At present, the tool is widely used in aging transformation of elderly subjects in the United States [8] and has also been adapted for research of aged care services [9-11]. Weeks et al [12] believe that CASPAR adopts a cooperative approach to assess the needs of the home environment transformation of the elderly, which is simple and easy, but requires more time to obtain photographs and field measurements. If the scale of the living environment needs to be reduced, the photographing and field measurement can be omitted.
(2) Housing Enabler: Housing Enabler was prepared by the Swedish rehabilitation engineer Iwarsson [13] in 1996 to assess the accessibility of a living environment. The tool provides a system for collecting and organizing data to provide supporting information for the aging transformation of the home environment. The tool was updated twice in 2000 and 2010, and there are currently two versions of the complete tool and the screening tool [14], and development of an internet platform based on the tool is underway. The full version of the tool has been evaluated by specially trained professionals, including personal, environmental, and score calculations [13]. Fourteen items are present in the personal part, while 12 items are used to assess whether an individual function is limited, 2 items are used to evaluate the use of mobile aids [15], the environment part consists of 3 dimensions including the external environment, entrance, and indoor environment, which are comprised of 28 entries, 46 entries, and 87 entries, respectively, for a total of 161 entries [16]. The higher the score, the greater the problem of the living environment and the stronger the demand for transformation [14]. The full version of the tool was used to conduct an inter-rater reliability test in the elderly populations of five European countries. The results showed that the individual part-to-evaluator consistency ratio was 91%, the environmental part-evaluator agreement ratio was 85%, and the personal part kappa coefficient was 0.43. The environmental part kappa coefficient was 0.50, which proves that the reliability of the evaluators was good [17-18]. Iwarsson et al. [19] confirmed that non-professionals were trained to use the tool screening version, and the results were highly consistent with those obtained by professionals. Because the tool is more comprehensive and systematic, it has been used in a joint study by five European countries (Germany, UK, Sweden, Hungary, Latvia). The study lasted for 3 years and investigated the relationship between the home environment and the healthy life of the elderly [ 20].
(3) The Safety Assessment of Function and the Environment for Rehabilitation Tool (SAFER): SAFER was designed in 1993 by a Canadian occupational therapist Oliver [21] for occupational therapists to implement in homes for the elderly in the community. Before an environmental safety intervention, an assessment of the function of the elderly and the home environment is necessary. Each entry in the tool combines the function of the elderly with the environment and does not simply evaluate one of the two. The occupational therapist uses the tool during a home visit to score the environment based on observation, interview, and by asking the elderly to complete an activity, and the entire evaluation process takes about one hour [21]. The tool has been revised several times and the final version includes 97 entries in 14 dimensions [22]. The score is based on questions requiring “yes” or “no” answers, and the higher the score, the less suitable the current environment is for the elderly [21]. The operational therapist Letts [22] tested the reliability and validity of this scoring system in 1995 and 1998. After expert evaluation, the tool has shown content validity; with a KR-20 coefficient of 0.82, a good internal consistency; both the degree and the test-retest reliability have been shown to be good [23]. In 2006, Canadian occupational therapists transformed SAFER into a more sensitive environmental intervention measurement tool, for functional and rehabilitation environmental safety assessment and for health outcome measurement and evaluation. The scope of this tool is to allow the occupational therapist to measure the suitability for the elderly before and after intervention and to evaluate the effectiveness of environmental safety interventions [24]. The improved version consists of 93 entries in 10 dimensions, using a 4-level scale. The higher the score, the more serious the problem [24]. The tool has good reliability and validity, and the internal consistency is 0.859; the difference in validity is good, and it is negatively correlated with body function status, indicating that a SAFER-HOME not only measures the physical functional status, but also evaluates body function and the environment to a matching degree [24].
(4) Home Assessment Profile (HAP): Designed by the American physiotherapist Chandler [25] in 2001 to assess the environmental factors that may affect the ability of the elderly. The tool assesses the match between the environment and the elderly by trained professionals to observe the activities of the elderly in various areas of the home [25]. HAP consists of 58 items in 7 dimensions. Studies have shown that [25], after balancing other age-related factors such as age, cognitive function, and mobility, the tool can effectively predict the occurrence of falls in the elderly. The higher the HAP score, the greater the likelihood of a fall. The inter-evaluator reliability was 0.92, and the test-retest reliability was 0.92 after two weeks [25].
Research status of domestic aging transformation scales
With the changes in China's social economy, population structure, and other factors, the aging process is accelerating. With such a background, Chinese scholars have included several adaptations to the living environment of the elderly, the aging of the houses, and the aging of the settlements. Theoretical research and practice of aging construction and transformation design have achieved relatively fruitful results. Li Xiaoyun conducted research on urban elderly community-friendly planning strategies for elderly people, and proposed an elderly friendly community social service planning strategy including housing, health and safety, old age culture, old age service system, age integration, and other planning contents such as, the living unit, friendly open spaces, friendly traffic environment, elderly service facilities, the old community suitable for aging design, and other planning content of the elderly friendly community material environment planning strategy [26]. Zhou Yanqi and others analyzed the causes and performances of the current residential areas in terms of suitable aging design from different subjects such as developers, designers, and buyers. In combination with the needs of outdoor activities, the design principles for an outdoor environment suitable for the elderly were proposed. The design points for different types of activity spaces, outdoor facilities and garden elements in the outdoor environment have also been addressed [27]. Yang Shenmao and others proceeded from the design concept of residential fitness and discussed the "dwelling residential design" in the United States, the "House Design Guide for Longevity Society" in Japan, and the "Residential Design for the Elderly" in China. The difference between the design criteria of the three design guidelines has been previously addressed [28]. Domestic scholars have carried out most of the theoretical research and have been involved in the practice of aging construction and renovation design. There is currently no assessment of the correlation between aging and the home environment, therefore this kind of assessment is necessary in China.
In summary, because of the great differences in China's home environment, living habits and lifestyle, and because China's environmental and pension service professional capabilities are extremely scarce, the feasibility of directly introducing and localizing foreign assessment scales is extremely low. It is necessary to understand the status of the aging environment in China, investigate the living habits of the demented elderly patients in China and understand the requirements of the home environment, and compile a suitable aging assessment scale for elderly Chinese people. Today, with the continuous development of community and home care services, medical staff are no longer merely continuing the basic health service functions of the community. With the deepening of the aging process, the functions of community medical staff are increasingly expanding towards compound professional skills. Medical staff should learn and use the Home Environment Assessment Scale to help design and implement a safer home environment, which will help to improve the quality of community care services.
Purpose of the study
The purpose of this study was to evaluate the psychometric properties of the aging transformation needs scale. Using this scale, we will be able to assess the perceptions of the aging transformation needs for elderly people with dementia in China.