PREPARING THE HOME. A Home Improvement Guide to Prevent Falls in the At-Risk Elderly. odontogeriatria.net.br

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1 PREPARING odontogeriatria.net.br THE HOME A Home Improvement Guide to Prevent Falls in the At-Risk Elderly Kristin Wheeler Morgan Alford Sabrina Anene HPRB 5410 Dr. Lauckner July 31, 2017

2 Table of Contents Preface...2 Knowing the Problem Risk Factors for Falling 4 Environmental Hazards..7 How to Use this Manual..8 Improvements Kitchen.10 Bathroom 12 Bedroom.14 Outdoor..15 Ramps..17 Eliminating Various Hazards.. 22 Ways At-Risk Adults Can Help Themselves.24 Conclusion..26 References..27 1

3 Preface In the US, falls are the leading cause of accidental death and the 7th leading cause of death in people 65 and older (Merck, 2016). A fall is defined as a person coming to rest on the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders like a stroke or seizure, or overwhelming environmental hazards like being struck by a moving object, are not considered falls(merck, 2016). Falling increases risk of injury, hospitalization, and death, especially for older adults who are frail and have preexisting disease conditions like osteoporosis. Falling is also one of the top causes for traumatic brain injury (TBI) in elderly adults (CDC, 2016). Medical costs to Medicare alone for fall injuries were $31 billion in 2015 (FPCE, 2017). And in 2011, nearly 23,000 people over age 65 died and 2.4 million were treated in emergency departments because of falls (CDC, 2016). Longer-term complications can include decreased physical function, fear of falling, and institutionalization. Falls reportedly contribute to 40% of nursing home admissions (Merck, 2016). Causes of falls have many factors, and include age and illness-related decline in function, environmental hazards, and adverse drug effects (Merck, 2016). If you or your loved one have a disease called osteoporosis, you are more likely to break a bone if you fall. Osteoporosis is a bone disease that occurs when the body loses too much bone, makes too little bone, or both (NOF, 2017). Osteoporosis is called the silent disease because bones become weak with no symptoms. An individual may be completely unaware they have the disease until a strain, bump, or fall causes a bone to break (NIH, 2014b). Falls are especially dangerous for people with osteoporosis because broken bones may need a long amount of time to recover. The good news is that falls can be prevented in part by making physical adjustments to the home. The purpose of this manual is to thoroughly describe the ways in which an individual can prepare their residence to be fall-proof and decrease or prevent the likelihood of experiencing a fall, thereby maintaining one s quality of life. 2

4 Knowing the Problem Source: This section will explain the risk factors for falling, both personal health factors and external environmental factors. It will also explain the ways you can use this manual to prepare your home, or that of a loved one to help protect against harmful falls. 3

5 Risk Factors for Falling It is important to recognize when it is time to prepare an older adult s home to prevent an injury from falling. Some risk factors for falling include being older than 65, living alone or being homebound, being female, and being Caucasian (Merck, 2016). The best predictor of falling is a previous fall, however, falls in older adults rarely have a single cause or risk factor. It is important to recognize and take into account a few risk factors, so that the individual does not need to sustain an injury first before fixing their home. A fall is usually caused by an interaction among behavioral and environmental factors (CDC, 2016). Behavioral risk factors for falls include any preexisting conditions that the individual may be suffering from. A few examples of diseases that are risk factors for falling include dementia, stroke, arthritis, osteoporosis, Parkinson, cataracts, glaucoma, arrhythmias, hearing loss, and Meniere s disease. More factors that could lead to falls are listed in Table

6 A Few Disorders That Contribute to Risk Functional Impairment BP Regulation Central Processing Gait Neuromotor Function Vision Disorder Anemia Arrhythmias COPD Dehydration Infections Metabolic disorders (diabetes, thyroid disorders, hypoglycemia) Valvular heart disorders Delirium Dementia Stroke Arthritis Muscle weakness Inflammation of joints Parkinson disease Peripheral neuropathy Stroke Cataract Glaucoma Table 1 lists several disorders that may contribute to a fall risk in the elderly (NIA, 2013). 5

7 Testing Your Risk at Home The National Institute for Health and Care Excellence (NICE, 2017), recommends the following as tests which can be used to determine risk of falling. Timed Up and Go Test: requests that the individual rise from a chair without the support of his or her arms, walk three meters, turn around and sit down again. A walking aid can be used if required. Completion of the test without unsteadiness or difficulty suggests a low risk of falling. A step-by-step example can be found below, in Figure 1. Figure 1 shows step-by-step motions of the recommended Timed Get Up and Go (TUG) test. Source: Turn 180 Test: requests that the individual being evaluated stand up and step around until they are facing the opposite direction. If more than four steps are required to do this, further assessment is indicated (NICE, 2017). 6

8 What are Environmental Hazards? Environmental hazards are any objects or physical circumstances in the environment that can increase a person s risk of falling. These hazards can be found inside and outside the home, and consist of things like clutter, loose carpet or rugs, unstable furniture, a lack of handrails, stairs, wet surfaces, inadequate lighting, or even cracks or rocks on the sidewalk. These types of hazards are often the easiest to fix for this population. Especially being that older adults are often prescribed multiple medications that also put them at risk for falling. Some of these common medications include: analgesics, antipsychotics, diuretics, antiarrhythmic, and psychoactive drugs (NIA, 2013). While it is possible to attempt to change dosage of medications to prevent falls, medications are crucial to maintaining quality of life for older adults, and it may be difficult to completely get rid of or switch medications. This is why this manual will focus on the groups of risk factors that can be modified the easiest, which are environmental hazards. 7

9 How to Use This Manual This manual will provide detailed instructions on how to fall-proof every room in a house, including the outdoor space. The reader can go through the home and make a checklist of problems that could lead to falls. They can then formulate a plan fix them. Afterwards, utilize this manual to understand how to install your environmental modifications to create a safer home, and decrease the likelihood of falls. 8

10 Improvements Fall hazards can be found in many different rooms of the typical home. This manual will take you through each room of the home, covering items and furniture that could present a threat to an at-risk adult. We will cover the following areas: Bedroom Bathroom Stair & Ramps Outdoors Kitchen 9

11 Kitchen Items used in the kitchen are often bulky, heavy appliances. These frequently used items should be lowered to shelves or cabinets that are easily accessible (MSC, 2004). Ideal storage for these heavy items is waist height to ensure that they do not require stretching or stooping to be reached ("Preventing falls in the kitchen," 2017). Be sure to relocate frequently used items that may be hard to reach, not just the heavy items in the kitchen. For example, if you or a loved one frequently use a heavy glass pitcher for beverages, consider switching to a smaller, plastic pitcher and store it on the middle shelf of the refrigerator for safe, easy access. Reorganizing your own or a loved one s kitchen is an easy, inexpensive fix for a big hazard. However, there are other options. If you have the means available, there are few products that could make the kitchen an even safer environment. Figure 2 shows an example of one of the options. The pricing on this system is $ as listed (Rev-a-shelf, 2017). Other options include a Lazy Susan that can be installed in a cabinet to allow for more safe storage. This option is less expensive starting at $25 (Reva-shelf, 2017) Figure 2. This image shows a product that can be purchased at any home improvement store and simply installed by following the enclosed directions. This product allows for more storage while still keeping frequently used items in reach. Source: 10

12 Step stools are also an inexpensive solution to many kitchen hazards. It is important however to make sure that the step stool that you or your loved one are using is safe. There are many options of step stools in stores, but it is recommended that your stool have a sturdy base, a bracing bar for balance, and non-skid steps to ensure sure-footing (MSC, 2004). In Table 2, average prices and features of popular, safe step stools are listed out to help in your decision. Step Stool Features & Average Price - Adjustable height - Adjustable handle - Rubber tipped legs - All-steel handle - Cost: $64.11 AdjustaStep Deluxe Step Stool with Handle - Lightweight - Rubber grip on hand rail - Non-slip mat on platform - Supports up to 250 pounds - Cost: $36.73 Duro-Med Step Stool with Handle - Two steps - Plastic (extremely lightweight) - No handrail - Supports up to 300 pounds - Cost: $20.00 Rubbermaid RM-P2 2-Step Molded Plastic Stool Table 2. This table lists the features and prices of top-rated step stools for older adults ("Best step stools for the elderly (seniors)," 2016). 11

13 Bathroom The bathroom is often the most dangerous room in the house ("Bathroom safety ", 2015). There are many hazards in this room with the combination of water, soap, and slippery floors. It is important to pay attention to the recommendations of this section to ensure your safety or that of your loved one. Source: Below is a list of recommended improvements to make to a bathroom to ensure it is safe to use if there is a risk of falling (MSC, 2004): Install non-slip strips in the floor of the shower or tub to add texture and help prevent falls. These are a relatively simple fix. Ensure rugs are secured to the floor or removed to eliminate tripping hazards. Purchase a waterproof shower seat. This is especially important if dizziness or light headedness is often experienced while showering. Install or purchase a rack to keep all soap, shampoo, and other items convenient and safe to reach. Install grab rails that are securely mounted to the wall next to the toilet and tub, and in the tub or shower. These rails should support a person s full weight to be completely safe. Purchase and install a raised toilet seat if it is often difficult to get up after using the restroom. Consider adding an additional phone line in the bathroom for added safety in case a fall does occur. Install battery powered lights or nightlights in the bathroom to make nightly trips safer 12

14 The improvements listed above cover a variety of needs and range in cost. Depending on what issues you or your loved one have, you may not choose to improve on every element of your bathroom. In Figure 3, images show the different options at work along with an average cost of some. However, the cost depends on each situation and bathroom. The grab rails in this shower/tub are sturdy and installed on the stud in the wall to ensure that they can hold weight. Average cost: $25.00 (installation cost not included) The elevated toilet seat below helps those at-risk for falls ensure an easy rise from the toilet. Average cost: $40.00 This waterproof shower chair pictured above is helpful to ensure safe showers that are fall-free. Average Cost: $ Another option that is available for bathroom safety improvement is a walk in tub. These tubs have recently become popular and are a great, safe addition to any bathroom. However, they can be expensive. Safe Step Walk-in Tub Company is a company who specializes in the installation of this type of tub. Their costs rage from $1,600 to $7,500 ("Walk-in tubs and bathtubs," 2017). 13

15 Bedroom The bedroom can also present hazards for someone at-risk of falls. Most of the falls that begin here are the result of an unsafe reach, such as reaching to turn off a lamp (MSC, 2004). Listed below are some simple improvements that can be made in the bedroom to ensure it is a safe environment (MSC, 2004) (NIH, 2014a): Clear paths around the bed to prevent tripping over clutter or clothing Ensure rugs are secured to the floor or removed to eliminate tripping hazards Put a telephone close to the bed, or install cordless phones so one can be kept even closer to the bed Move lamps closer to the bed so they do not require leaning over the edge to turn on or off Install sound activated lightbulbs that can be turned on or off by noise, like a clapper light, if better lighting is needed Keep reading or eyeglasses close in reach on the nightstand so they are easily accessed Lower the bed frame, if needed, to ensure feet can touch the floor when getting in and out of bed Consider purchasing bed rails if getting in and out of bed is difficult Consider purchasing a portable toilet if you require frequent trips to the bathroom at night Source: Average cost: $20 Source: Each/dp/B0000CGKLR 14

16 Outdoor The outdoors should be enjoyable to everyone, even the elderly. Many older adults enjoy gardening, watching grandchildren play, or just being outdoors. However, if they are at a higher risk of falling, the outdoors can be a dangerous environment because of the uneven ground and ever changing weather (MSC, 2004). There are a variety of ways you can improve your home or that of your loved one. This section will explain these. Concrete Surface Safety Uneven concrete can cause a dangerous trip/fall, especially for someone who is already at-risk of a fall. Figure 4 shows a hazardous example. It is important to fill in any holes or gaps in sidewalks or driveways, and even out any uneven surfaces surrounding the home (HomeAdvisor, 2016). These projects can be done as do-it-yourself projects, or by professionals. Entryway Safety Entryways are often accompanied by stairs, ramps will be covered in a later section, however, it is important to be sure there is a safe landing for older adults to safely enter the home, especially if the door s arc swings out (HomeAdvisor, 2016) If a landing is outside of the doorway, it should meet the guidelines set by Home Advisor: More than 5 square feet in size Enough room for a standing adult and the arc of the open door It is also important to have bright lighting around the entryway. 15

17 Outdoor Lighting If paths from garage/carport to doors are poorly lit, install solar powered lights that automatically operate at night (MSC, 2004). If you are unable to, have someone check all previously installed lighting to ensure that it is working properly and has the highest possible wattage bulb (MSC, 2004) It is important to have adequate and bright lighting outside, especially if eyesight is an issue. These bright lights help to eliminate tripping hazards that can be avoided. Outdoor Decking & Stairs Decking boards made of wood can loosen or rot over time creating a fall hazard (MSC, 2004). If vison/depth perception is an issue, line the edges of stairs/walkways with bright colored tape to insure a safe step. contrast strip (OTA). These contrast strips are inexpensive and easy to install. See the image to the right. Both sides of outdoor stairways should have railings that are fastened to sturdy surfaces and are strong enough to support the weight of an adult (EldercareLocator). Railing may even be needed to allow for safer access to sloped areas of the yard. This is based on your discretion, or that of your loved one. An example of this railing can be seen in the image to the right

18 Ramps Installing ramps for home use is important in preventing falls. When you or a loved one begin to have mobility issues, independent living can become difficult ("The essential advantages of disabled ramps," 2014). By installing ramps, daily tasks can be made easier and less time consuming ("The essential advantages of disabled ramps," 2014). Ramps allow for easy access into the home by creating a slope-like surface that usually takes the place of stairs or gaps from the ground (Aucoln, 2012). Individuals that require wheelchairs, walkers, or any rolling device can use the ramp to ensure transportation into the home (Aucoln, 2012). Ramps play an important role in fall prevention by providing a dependable, smooth transportation method for those struggling with mobility. Ramp installation can also improve quality of life by allowing individuals to live as normal as possible. Types of Ramps There are several different types of ramps that are appropriate for home use. There are permanent, semi-permanent, and completely portable ramps (Aucoln, 2012). Permanent ramps are bolted to the ground or cemented for long lasting effects (Aucoln, 2012). Of the permanent and semi-permanent ramps, there are wood, aluminum, galvanized steel, or concrete (Aucoln, 2012). A detailed list of types of ramps can be found in Table 3. 17

19 Wood Type of Ramp Description The most popular form of ramp and can be made from common materials found at home improvement stores. It is advised that a professional build and install the ramp to ensure safety. Also, it is recommended to apply a non-slip surface to the wood to prevent falls ("Ramps for homes," 2017). Aluminum The second most common type of ramp that comes with modules that fit together in pieces for easy assemblage. Aluminum ramps can be custom made by manufacturing companies for unique requests ("Ramps for homes," 2017). Galvanized Steel These ramps have an open pattern that provides traction and prevents water, dirt, and snow accumulation ("Ramps for homes," 2017). Concrete These ramps allow for the feel of walking on poured concrete ("Ramps for homes," 2017). Table 3: Described above are the different types of permanent ramps available for home use. There are also different kinds of portable ramps. Portable ramps are easy to transport and are most often used in the home (Aucoln, 2012). Of the portable ramps, aluminum portables and threshold ramps are most commonly seen in the household ("Ramps for homes," 2017). 18

20 Types of Ramps continued There are also different kinds of portable ramps. Portable ramps are easy to transport and are most often used in the home (Aucoln, 2012). Of the portable ramps, aluminum portables and threshold ramps are most commonly seen in the household ("Ramps for homes," 2017). These ramps can be seen in Table 4. Type of Ramp Aluminum Portable Description The most popular and inexpensive portable ramp. These ramps are available in different lengths, surfaces, and folding options ("Ramps for homes," 2017). Threshold Ramp Threshold ramps are made for short rises from the ground. Often, they are used at door openings. These ramps are typically made from aluminum with a non-skid surface ("Ramps for homes," 2017). Table 4: This table describes the different types of portable ramps used in the home. Where to Install Ramps often take the place of areas that contain stairs (Aucoln, 2012). Ramps can also be installed in entryways, exit ways, and can fill in gaps from the ground to create a less stressful way to enter, exit, and move around the home. Door openings and places where there are short raises from the ground are also common areas for ramp installation ("Ramps for homes," 2017). By placing ramps throughout the home in areas that prevent easy mobility, individuals can decrease their risks of falling and injury. 19

21 Installing Your Own Ramp When planning to build a ramp, there are many factors that must be taken into account before beginning: First, a specific type of ramp must be chosen for installation ("Ramps for homes," 2017). After determining the ramp of choice, the layout of the ramp must then be planned ("Ramps for homes," 2017). Factors such as access point (where the ramp will be installed for use) and appearance must be taken into consideration to form the layout plan ("Ramps for homes," 2017). Along with access point and appearance, measurements such as rise (the vertical distance from the ground to where you want the top of the ramp to be), slope (steepness of the ramp), and width must be collected ("Ramps for homes," 2017). See Figure 4 for measurement guidelines. After determining all of these factors, ramp installation may begin. Materials can be purchased from local home improvement stores depending on the ramp of choice ("Ramps for homes," 2017). Otherwise, a professional company must be contacted for ramp materials and installation ("Ramps for homes," 2017). Keep in mind that it is recommended for an experienced carpenter/professional company to install the ramp ("How to build ramps for accessibility,"). Also, certain guidelines and regulations must be followed depending on local zoning requirements and type of ramp to ensure proper safety and can be found online or by your local building office (Lowe s, 2017). Figure 1: This figure provides an example of the specific measurements that must be collected in order to build your own ramp. 20

22 General Costs Costs can vary greatly depending on type of ramp, location, and specific needs("wheelchair and handicap ramp cost guide,"). When addressing cost, be sure to explore ramp material options ("Wheelchair and handicap ramp cost guide,"). Aluminum and concrete are the most expensive options when compared to wood("wheelchair and handicap ramp cost guide,"). Overall, the general costs in the United States that homeowners pay for professional ramp installation is between $1,285 and $1,841 ("Wheelchair and handicap ramp cost guide,"). Figure 5 shows the range of potential cost for the installation of a ramp. Figure 5: This figure displays the average range of prices that homeowners spend on ramp installation. 21

23 Eliminating Various Hazards Six out of ten falls that take place occur in homes (NIH, 2013). Often, falls that take place in the home are due to hazards that are overlooked and are easy to fix (CDC, 2015). By making the home environment safer, injury and falls can be prevented (CDC, 2017). There are several simple and easy steps that can be taken to improve home circumstances. The following checklist provides insight on how to fix up the home to create a safe living environment. Some of the improvements may have been previously mentioned in the manual, but it is important to check twice to ensure safety. Evaluate the home with this checklist to lower fall risk: Floors: Observe the flooring in each and every room in the home (CDC, 2015). Arrange the furniture in the home to create open spaces to avoid having to walk around furniture (CDC, 2015). Remove all rugs that are not non-slip and replace them with secure, non-slip rugs to avoid tripping and falling (CDC, 2015). Be sure to keep objects off of the floor and out of pathways. Objects such as papers, books, towels, shoes, magazines, boxes, and blankets should be put up in their own, individual places and out of the way (CDC, 2015). If there are wires or cords from lamps, telephones, or extension cords on the ground, be sure to tape them Stairways against the wall to avoid tripping over them (CDC, 2015). Be sure to check every stairway used, both inside and outside (CDC, 2015). ALWAYS keep objects off of the stairway and remove all clutter (CDC, 2015). Repair any loose or uneven steps to avoid losing balance (CDC, 2015). Place an overhead light at the top of all stairways to provide extra light for vision purposes (CDC, 2015). Have an electrician place light switches at the top and bottom of the stairwells. Glowing light switches are ideal (CDC, 2015). If there is loose carpet on the stairs, make sure to get it repaired or install non-slip rubber treads (CDC, 2015). Repair any loose railing or install new ones. Also, handrails should be installed on each side of the stairs for assistance (CDC, 2015). 22

24 Bedrooms Place lamps directly beside the bed for easy access when needed (CDC, 2015). Be sure to place night lights throughout the bedroom in areas of major pathways to ensure that you can see where you are walking at night (CDC, 2015). Other Safety Tips Place emergency numbers in large print directly by each phone in the house (CDC, 2015). Place a phone on the floor, out of the way from walking paths just in case you fall and cannot get back up (CDC, 2015). 23

25 Ways At-Risk Adults Can Help Themselves In addition to preparing the physical environment; older adults can take their own precautionary steps to prevent the chances of falling. Proper Footwear Older adults should consider changing footwear as part of a fall-prevention plan. High heels, flip flops, and shoes with slick soles can increase chances of slipping, stumbling, and falling(mayoclinic, 2016). Instead, it is important to wear properly fitting, sturdy shoes with nonskid soles. Sensible shoes may also reduce joint pain. Using an Assistive Device Appropriate use of assistive devices can help prevent falls (NIA, 2013). These devices may include canes, walkers, reachers, and wheel chairs if necessary. A cane or walker may help you feel more stable when you walk. There are several types of canes available, but as a general rule, the cane should be the proper length and should fit you well. Different types of walkers are available as well. Some have four wheels and include breaks for going down inclines, while others have two wheels, which work well if you need to put weight on the walker when moving (NIA, 2013). Either way, a walker will help you stay balanced by giving you a wide base of support. You can also add a basket, tray, or pouch to some walkers to carry items. These accessories will make it more convenient to use the walker. A reacher, or grabber can also help prevent falls. This simple tool lets you take lightweight items from high shelves and other places and pick up objects from the floor so you do not have to bend over (NIA, 2013). Reachers, as seen in the photo to the right, can be utilized instead of having to stand on a stool to get something from above or bending down to pick up something from the floor. Reacher htm 24

26 Getting Up and Sitting Down Slowly Standing up slowly after sitting or lying down and taking a moment before starting to move can help prevent dizziness because it gives the body time to adjust to the change in position (Merck, 2016). It is also important to take your time when moving about. Rushing is a notable factor when assessing falls (NIA, 2013). Maintaining Bone & Muscle Health Having stronger muscles can increase stability, therefore helping prevent falls, and having healthy bones can prevent hip or other fractures that may lead to a hospital or nursing home stay, disability, or even death(nia, 2013). One way to maintain bone and muscle health is by staying active and exercising on a regular basis. You should aim for a total of at least 30 minutes of physical activity a day (NIA, 2013). Walking is one of the best and least strenuous forms of exercise. Other ideas for physical activity include dancing, stair climbing, gardening, and weight lifting. Getting enough calcium and vitamin D is also important for keeping bones strong. Women over age 50 should consume 1,200 mg of calcium daily. Men between the ages of 51 and 70 should consume 1,000 mg of calcium a day, and men over 70 should consume 1,200 mg per day. Eating calcium-rich foods and taking calcium supplements can help with this (NIA, 2013). Vitamin D helps your body absorb calcium. Eating foods with vitamin D, taking supplements, and getting exposure to sunlight are all ways to increase vitamin D within the body. 25

27 Conclusion Overall, falls can be prevented when proper caution is taken. Family members should be aware of the signs and symptoms of diseases that could increase the risk of falling, and should also be on the lookout for hazards inside and outside the home that may contribute to falls. Falls can happen anywhere, and it is also important for older adults to protect themselves by wearing the proper footwear, using assistive devices, and exercising and eating properly to maintain bone strength. Utilizing this manual and implementing some of these techniques will assist you or your loved on in maintaining a happy, healthy, fall-free, life. 26

28 References Aucoln, A. (2012). Why wheelchair ramps are important. Retrieved from Bathroom safety (2015). Retrieved from Best step stools for the elderly (seniors). (2016). Retrieved from CDC. (2016). Older adult falls. Retrieved from EldercareLocator (Producer). Preventing falls at home. [Brochure] Retrieved from The essential advantages of disabled ramps. (2014). Retrieved from FPCE. (2017). What is fall prevention?. Retrieved from HomeAdvisor. (2016). Home design for fall prevention for seniors. Retrieved from -.WX-PsdPyuu5 How to build ramps for accessibility. Retrieved from Lowe s. (2017). Build a wheelchair ramp. Retrieved from MayoClinic. (2016). Healthy aging. Retrieved from Merck. (2016). Falls in the elderly. Retrieved from - v MSC (Producer). (2004). Fall prevention home safety checklist. [Brochure] Retrieved from NIA. (2013). Falls and older adults. Retrieved from NICE. (2017). Falls in older people. Retrieved from NIH. (2014a). Home improvements prevent falls NIH Medline Plus, 8, 2. Retrieved from NIH. (2014b). What are ways to prevent falls and related fractures? Fast facts: An easy-to-read series of publications for the public. Retrieved from - broken 27

29 NOF. (2017). What is osteoporosis and what causes it? Retrieved from OTA, A. (Producer). Falls awareness & prevention guide. Retrieved from Preventing falls in the kitchen. (2017). Retrieved from Ramps for homes. (2017). Retrieved from Rev-a-shelf. (2017). Cabinet pull-down shelving system wall accessories. Retrieved from Walk-in tubs and bathtubs. (2017). Retrieved from Wheelchair and handicap ramp cost guide. Retrieved from 28