Exploring the Use of Color Cueing on an Assistive Device in the Home

Physical & Occupational Therapy In Geriatrics

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Exploring the Use of Color Cueing on an Assistive Device in the Home: Barbara Acheson Cooper, Lori Letts & Patricia Rigby To cite this article: Barbara Acheson Cooper, Lori Letts & Patricia Rigby (1994) Exploring the Use of Color Cueing on an Assistive Device in the Home:, Physical & Occupational Therapy In Geriatrics, 11:4, 47-59, DOI: 10.1080/J148v11n04_04 To link to this article: http://dx.doi.org/10.1080/J148v11n04_04

Published online: 28 Jul 2009.

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Exploring the Use of Color Cueing on an Assistive Device in the Home: Six Case Studies Barbara Acheson Cooper, POT (Dip), MHSc Lori Letts, OT (C), MA Patricia Rigby, OT (C), MHSc ABSTRACT. Color cueing is recommended as a means of improving the visual distinction of environmental objects and as a mnemonic device. As such, it is a strategy for facilitating the independent function of elderly people. However, this use has not been well validated. This pilot study with six individuals, ages 68-92, employed a before-after design to explore the effect of applying color or no color to an assistive device that promoted safe transfers in the home. Qualitative and quantitative data on functional performance, safety, anxiety about falling, vision, and the environment were collected over a three month period. Results suggest that color cueing may facilitate the use of assistive devices and at least, may give seniors the perception that their function is more secure.

The number of people in North America over the age of 65 is increasing dramatically (Organization for Economic Cooperation Barbara Cooper is Associate Professor, Associate Dean and Director of the School of Occupational Therapy and Physiotherapy at McMaster University, HSC 1 J 11, 1200 Main Street West, Hamilton, Ontario, Canada L8N 325. She is currently enrolled in a PhD in Architecture (ABD) at the University of Wisconsin-Milwaukee. Lori Letts is Researcher, Community Occupational Therapists and Associates, 3101 Bathurst Street, Suite 200, Toronto, Ontario, Canada M6A 2A6. Patricia Rigby is an Occupational Therapy Consultant in Toronto. The authors wish to acknowledge and thank the following: The Institute of Aging and Environment, University of Wisconsin-Milwaukee for providing funding for the study; The North Hamilton Community Health Centre for amging for participants in the study; and Lifestyle Innovations Inc., Oakville Ontario for providing the "Sturdy-Grip Poles" used in the study. Physical & Occupational Therapy in Geriatrics, Vol. 1l(4) 1993 O 1993 by The Haworth Press, Inc. All rights reserved.

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and Development, 1988). Most elderly people live in their own homes and value this status highly (CMHC, 1982). However, older people are prone to develop age-related impairments in vision and mobility which can critically limit their ability to carry out the activities of daily living (ADL) necessary for independent living (KL) (Matthews & Shipsides, 1989). These restrictions may result in dependence and set seniors at risk for undesired institutionalization and the sequelae of accelerated functional decline, diminished quality of life and associated expense (Patterson & Torresin, 1984). Strategies that address these mobility/visual barriers to IL are therefore of major interest and concern. Lawton (1986) postulates that as personal competence declines, the influence of the physical environment on behaviour becomes more noticeable. The notion of considering the physical setting itself as a therapeutic tool is relatively new, most previous environmental interventions having focused on reinforcing social supports (Lawton, 1986). Lawton's theoretical approach suggests that strategies that introduce positive changes into the physical environment will help seniors resist the decline associated with age and enable them to maintain successful IL.

COLOR CUEING One strategy that is frequently suggested as a means of compensating for the decreased visual ability of elderly people is the use of contrasting color cues to increase environmental legibility (Cooper, 1985; Cristarella, 1977; Hiatt, 1981, 1987). It is argued that these cues alert seniors to key environmental features and remind them to perform activities safely. Limited evidence supports this contention, however (Cooper, Mohide, & Gilbert, 1989; Hiatt, 1981,1987), and it has not been rigorously tested. Effective color cueing largely employs principles of contrast (Cooper, 1985). It is unclear whether any one color is most effective as a cue. A case can be made for both yellow and red. The eye is most sensitive to receive wavelengths interpreted as yellow (Bornstein, 1977; Cooper, 1985), while red is considered to have arousal qualities (Cooper, 1985; Kwallek & Lewis, 1990), although this attribute is disputed by some authors (Mikellides, 1990). The ability

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to see red appears to be least affected by aging itself (Cooper, Ward, Gowland & McIntosh, 1991) and this factor alone might justify its inclusion as a cue. In addition, it can be argued that people may attend better to a cue if a preferred color is used (Ball, 1965). Finally, recent evidence suggests that the ability to discern brightness is preserved longer than the ability to discriminate hue, and therefore this attribute of color may prove to be the most critical factor to consider when cueing the environment for elderly people (Cooper et al., 1991). A literature review identified only four empirical studies which directly linked color cueing with elderly function. Two by Cooper and colleagues (Cooper, Gowland & McIntosh, 1986; Cooper et al., 1989) explored the functional use of color in institutions. The first was aborted because of sampling problems. The second suggested that color, used as a camouflaging agent, influenced the elimination of certain undesired behaviours among cognitively impaired residents (n = 24; mean age 75.6); color cues were not found to foster desired behaviours in this population. Two other studies explored the use of color and medications. One, a community study by Martin and Mead (1982), employed randomization and a control group to explore the use of color to promote drug compliance among 109 elderly subjects (mean age = 74.4). Compliance was significantly improved (p c 0.001) only with the use of color cueing and coding. One other community study reported on the problems encountered by elderly people (n = not reported; mean age = 70.9) in discriminating among pills of closely related colors, and illustrates one of the safety concerns related to the visual deficits associated with aging (Hurd & Blevins, 1984). None of these studies is sufficiently rigorous to allow definitive conclusions to be drawn, but together they support the contention that color can be used to facilitate elder performance and the need to investigate this area further.

PURPOSE A larger study to investigate the effectivenessand acceptance of color cuing in seniors' homes is being planned. The pilot reported on here was intended to test the viability of the proposed design, sampling and instruments of measure. The results will be used to

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modify the second phase of the study. The principal questions of this research are: 1. Does color cueing really facilitate safe elder function? 2. Will seniors accept the introduction of color cueing into their residential environment for these purposes? 3. Is acceptance contingent on other factors, such as reaching a certain threshold of visual and functional disability? 4. Are some color cues more effective than others?

METHODOLOGY Study Variables

The dependent variables of the study were defmed as effectiveness and acceptance of color cueing. Effectiveness was operationalized as: function, defined as ease of mobility and the ability to make successful independent transfers; safety, defined as stability and number and location of falls or near falls; and anxiety, defined as the degree with which function could be carried out without concern. Acceptance was operationalized as use, defined as the degree to which the device was used voluntarily during and after the study, and the individual's stated attitude towards the strategy of color cueing; and final choice, defined as the color cue chosen by the subject for the pole left in place at the end of the study. We anticipated that effectiveness could covary with the environment (defined as ambient light and home hazards), but acknowledged that it was not within our ability to control this in a longitudinal residential study. We also anticipated that effectiveness and acceptance could covary with visual acuity and age. These confounding variables were therefore measured during the study, in the first instance, to monitor the stability of individual environments across the study, and in the second, to begin to explore the relationship of vision and age on outcome. The independent variable in the study was the color of the cue(s). On the basis of the literature review, two color cueing conditions and an achromatic control were explored. For the first cue, subjects were offered a choice (preferred color) from a palette of 7 saturated

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colors which included a bright yellow (optimal visual sensitivity); red (arousal/spared) was used for the second cue. Grey was used for the achromatic control. The question of what to cue posed a dilemma. Because falls and their sequelae play such a major role in determining the ability of individuals to live independently, we argued that the color cue should be placed on a device that facilitated safety and mobility in some manner. This decision was reinforced by the findings of Brennan, Moos and Lemke (1988) who reported that while elderly people generally prefer homes that are free of obvious assistive devices, they will accept these in the interests of safety. Therefore, a free-standing pole (Sturdy-Grip Pole) that could be erected without structural modification and which could facilitate transfers and stability prior to ambulation was chosen as the object to receive the color cue. The poles used were grey in color; a 12 inch central section of the grip component was painted in the color required for cueing; control poles were lefi completely grey. Sample The nurse manager of an urban community health centre identified potential subjects for the study who were representative of elderly subjects seen by that practice. Criteria for inclusion included: being age 65 and over, living independently in the comrnunity, understanding English, cognitive competence and a Barthel Index score of 60 or greater. These individuals were contacted until a total of six (four of whom were women) agreed to participate. The mean age of the sample was 77.5, with a range of 68-92 years demonstrated. All subjects were able to walk around their homes without assistance, but all had a previous history of some lower extremity dysfunction consistent with aging.

Design The before-after design of the study employed repeated measures and varied stimuli over a time-line of three months. Subjects were allowed to place up to three poles in their homes, in locations of their choice. One pole could be kept on completion of the study. The poles received one of three cues: preferred color (selected from the fixed palette), red, and grey (achromatic control). Our original

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intent was to change the cue each month so that each subject would experience all three conditions. However, we decided to use the pilot as an opportunity to explore the effects of varying this. As a result, three subjects received one cue only; two received two cues; and one subject received all three (Table 1). Yellow was most frequently identified (416) as the preferred color. Four subjects chose to have only one pole installed; the remainder chose two. These were placed in the bathroom (4), bedroom (2) and living room (2). TABLE 1. Profile and color choices of subjects in study.

Leg&:

VAS

=

Visual Analogue Scale

Y

=

Ye1 low

(low = 1; high = 10)

CRY

=

Grey

=

Green

R

=

PC

=

Preferred Color

FCC

=

Final Color Choice

CUE

=

Color cue on pole

G

Red

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Measurement Subjects were assessed at each visit by an occupational therapist. Baseline, monthly and concluding measures of function, the environment, anxiety and attitudes were made. Visual measures were taken only at the first visit. The instruments of measure used were: 1. The Snellen (Parr, 1982): to determine visual acuity; 2. The Ishihara (Committee on Vision, 1981): to identify color blindness; 3. The Barthel Index (Mahoney & Barthel, 1965): to determine global ADL function and mobility; 4. The Canadian Occupational Performance Measure (COPM) (Law et al., 1991) (Modified): to determine subjects' self perception of mobility function; 5. Questionnaire: to record demographic data and attitudes towards color cueing; 6. Visual Analogue Scale (VAS) (Scott & Huskissen, 1976): to estimate perceptions of anxiety about falling; 7. Environmental assessment: to judge home safety hazards; 8. Photometer: to record home light levels; 9. Log: to record any relevant incidents (falls) or comments about the use of color cueing; and 10. A touch-sensitive device: to record the frequency of use of the pole.

Analysis Given the small sample size, only within subject changes were examined; frequencies and scores are reported here. The raw data of the logs, openended sections of the questionnaires, and recorded comments of the subjects were reviewed line by line and common themes concerning color cueing identified (Miles & Huberrnan, 1984).

RESULTS Eflectiveness of Color Cueing Performance measures showed no discemable differences in function or safety across time for subjects using color cued poles (Table 1).

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Qualitative data on function and safety presented a more mixed picture. Color was perceived as important to function (performance) by some subjects; this perception varied with the number of cue changes experienced (Table 2). Specifically, the three subjects who received the same cue throughout the pilot did not consider that color made a difference. However, those who experienced one or two color changes felt that the color mattered somewhat or a great deal to their function because it reminded them to use the device, or was actually critical to their use of the poles. Questionnaires and logs indicated that the poles improved the subjects' sense of security during performance of the related activity and diminished anxiety about falling as measured by the VAS (Table 1) was reported. A modified version of the COPM was used in the pilot study in order to estimate the subjects' perceptions of the importance of and satisfaction with personal performance on specified items related to mobility within the home. These provided information on transfers, ambulation and standing balance. The COPM asks individuals to rate performance, satisfaction with performance and importance of various functional activities. Subjects in the study judged thirteen mobility activities accordingly on a 10 point scale. Importance was rated only on the first visit; performance and satisfaction were rated each time. The poles were seen to influence performance most for the item called standing balance, which is reported here. A wide range of ratings for this item across subjects (from 2 to 10) was noted, however, no clear trends of change across time emerged. Similarly, no change in satisfaction with performance of standing balance across time was noted.

Acceptance of Color Cueing We cannot report accurately on pole use during the study as only one touch-counting device was available for testing and this was TABLE 2. Perceived influence of color changes on function. Doesn't matter

Matters somuhat

Matters alot

NO change

3

0

0

Om change

0

1

1

TW changes

0

0

1

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introduced late in the study. However, all subjects reported using the device regularly each day. A follow-up call six months after the end of the study found that, with one exception, a l l subjects were still using the poles and had made no changes either to the location or color of the pole. The one exception was the most physically agile subject (#6), who had kept a pole, but later loaned it to a friend, who (he reported) needed it more and was finding it most useful. All subjects exercised their option to keep one pole after the study was completed. All save one maintained the color already in place. The exception (S#3), who was visually impaired, replaced a red cue with a yellow one (Table 1). Qualitative data indicate that only one (S#5) of the six subjects felt that color cueing did not influence the use of the pole. Four stated that the cue(s) acted as a reminder to use it, and one found it critical to her use of the device (Table 3).

Environmental hazards and lighting conditions were judged to be stable across time in each individual setting. No difference in performance across time relative to age was noted in the sample. General endorsement for the visual assistance provided by the color cues can be inferred from comments such as: "I don't think the yellow or red made a difference, but they were better than the grey . . .helps me to locate (the pole)"; and "The red helps me find the pole by my bed,I find it (the yellow) easier to see. I would like the color lower down (on the pole), closer to eye level (when I am) in bed." Negative comments were received relative to the use of the grey control. Subject #3 (acuity 201100) reported that the grey cue on the pole "wobbled" visually and made her feel dizzy when trying to locate it. She appeared to be very dependent on the color TABLE 3. Perceived influence of color on use. Color

No difference t o use

Reminder t o use

C r i t i c a l t o use

YO changes

1

2

0

One ch-

0

1

1

Two changes

0

1

0

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cues and provided the researchers with many positive comments on these. However, another with exceptionally severe visual problems (S#5; 20/200) indicated no reliance on the color cues.

DISCUSSION The purpose of the pilot was to test the methodology and measurement instruments proposed for the larger study and to suggest changes to strengthen this. Three issues in particular stood out. F i t , the reactions of S#3 and preference of other subjects to "safety yellow" lead us to believe that the major study should only test this color as a cue. The use of yellow is well supported theoretically (Bornstein, 1977; Cooper, 1985) and makes particular sense from the perspective of providing a highly lurninant (bright) cue in settings characterized by changing levels of illumination. It may be particularly useful for those who suffer from pronounced visual deficits. Second, there is probably a threshold of visual ability past which color cueing does not help. This interpretation of the data may help explain why subject #5 (acuity 201200) did not find this strategy helpful. It is less clear what the upper limits of this range may be, however, the reactions of subject #3 (201100) give an indication that at least this level of deficiency may find color cueing useful. Finally, it is difficult to tease apart the effect of learning on the use of the pole and the mnemonic effect of color on use. Subjects' comments seem to indicate that both may be at play simultaneously. In other words, color may help people to learn to use the device in a habitual manner, but it may also remind them constantly to use the pole, as well as help them to use it properly. People tended to keep the color already in place on the pole. This may indicate that once the use of the pole has become habitual, cueing no longer matters as much. It may in fact be impossible to measure these effects separately. The pilot study suggests a number of directions for refming the structure of the major study. These are summarized below:

1. At least one color cueing condition seems to be required in order for people to compare this to an achromatic cue. The experience of a second color cue does not appear to add to the data.

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2. Visual acuity appears to be a more important variable than chronological age; a sensitive range may be identifiable. 3. The role and importance of combined visual and activity deficits in defining the acceptance of color cueing remains unclear. 4. "Safety" yellow appears to be the optimal color cue to use under the varying lighting conditions seen in most homes. 5. The Barthel is not sufficiently sensitive to identify functional changes in mobility within a 3 month period of time. 6. Qualitative data on this subject provided more information than quantitative measures.

CONCLUSION Although performance measures of function did not demonstrate any change, subjects' perceived their function to be safer and more secure with the use of a color-cued assistive device. We interpreted the general acceptance and retention of poles that were color-cued as further indication that elderly people found color cues helpful. The correlation between the number of color cues introduced and subjects' acknowledgement of its effectiveness indicates that people need to experience both color cueing and no cueing in order to be able to make a comparison. However, the knowledge that color cues may facilitate function was not applied for use after the end of the study by this population. This may be further support of the observation that, left to their own devices, elderly people adapt their behaviour to their disability (CMHC, 1982; Wister, 1989) and generally do not introduce environmental strategies to facilitate their personal function. Further support of this behavioural finding will have an impact on the assumptions we make when teaching older people how to improve their environment. REFERENCES Ball, V. (1965). The aesthetics of color: A review of fifty years of experimentation. Journal of Aesthetics and Art Criticism,23: 441452. Bornstein, R. (1977). Developmental pseudocyanopsia: Ontogenetic changes in human color vision. American Journal of Physiology Optics, 54,464-469.

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Breman, P., Moos, R., & Lernke, S. (1988). A home safety awareness program for the well aged: A preventative approach. The Gerontologist, 28(1), 84-90. Canada Mortgage and Housing Corporation (CMHC) (1982). Environmental competence amongst independent elderly households. Ottawa: CMHC. Committee on Vision (1981). Procedures for testing color vision Washington, D.C.: National Academy Press. Cooper, B.A. (1985). A model for implementing color contrast in the environment of the elderly. The American Journal of Occupational Therapy, 39(4), 253-258. Cooper, B. A., Gowland, C., & McIntosh, J. (1986). The use of color in the environment of the elderly to enhance function. In M. Magenheim (Ed.) Clinics in geriatric medicine, 2(1), 151-163. Cooper, B.A., Mohide, A., & Gilbert, S. (1989). Testing the use of color in a longterm care setting. Dimensions in Health Service, 66(6), 22-26. Cooper, B.A., Ward, M., Gowland, C., & McIntosh, J. (1991). The use of the Lanthony New Color Test in determining the effects of aging on color vision. Journal of Gerontology,46(6), P320-324. Cristarella, M. (1977). Visual functions of the elderly. The American Journal of Occupational Therapy, 31(7), 432-440. Hiatt, L. (1981). The color and use of color in environments for older people. Nursing Homes, 30(3), 18-22. Hiatt, L. (1987). Designing for the vision and hearing impairments of the elderly. In V. Regnier & J. Pynoos (Eds.). Housing the aged. Design directives and policy considerations, (pp. 341-472). New York: Elsevier. Hurd, P., & Blevins, J. (1984). Aging and the color of pills. The New England Journal of Medicine, 310(1), 202. Kwallek, N., & Lewis, C. (1990). Effects of environmental color on males and females: A red or white or green office. Applied Ergonomics, 21(4),275-278. Law, M., Baptiste, S., Carswell-Opzoomer, A., McColl, M., Polatajko, H., & Pollock, N. (1991). Canadian Occupational Performance Measure Manual. Toronto: CAOT Publications. Lawton, M. P.(1986). Environment and aging. (2nd Ed.). Albany, New York: The Center for the study of aging. Mahoney, E, & Barthel, D.W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical J o u m l , 14, 61-65. Martin, & Mead, K. (1982). Reducing medication errors in a geriatric population. Journal of the American Geriatrics Society, 30(4), 258-260. Matthews, A. Martin, & Shipsides, A. (1989). Contributors to the loss of independence and the promotion of independence among seniors. Literature review and consultation with key informants. Executive summary. Guelph, Ontario: Gerontology Research Centre, University of Guelph. Miles, M., & Huberman, M. (1984). Qualitative data analysis: A sourcebook of new methods. Beverly Hills, CA: Sage. Mikelllides, B. (1990). Color and physiological arousal. The Journal of Architectural Planning and Research, 7(1), 13-20.

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Organization for Economic Co-operation and Development (1988). Aging populations: The social policy implications. Paris: author. Parr, J. (1982). Introduction to ophthalmology. (Second Ed) Oxford, England: Oxford University Press. Patterson, C., & Torresin, W. (1989). Falls in the frail elderly-keep your patient's feet o n the ground. Geriatrics, April, 15-25. Scott, J., & Huskisson, E. (1976). Graphic representations o f pain. Pain, 2, 175-184. Statistics Canada (1989). Canada year book 1990. Ottawa: Ministry o f Supply and Services Canada. Wister, A. (1989). Environmental adaptations b y persons in their later life. Research on Aging, 11 (3), 267-291.

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