Green Healthy Housing for Older Adults

Jill Breysse, CIH National Center for Healthy Housing Sherry Ahrentzen, PhD University of Florida

By 2030, more than 70 million Americans – and 960 million people worldwide – will be 65 years or older

Seniors Susceptible to Housing Conditions • • • • • •

• Many older adults spend 80% to 90% time indoors at home

• Bronchial hyper-responsiveness, respiratory, diabetes

More likely to live in older homes

• Arthritis, osteoporosis, muscular atrophy, visual impairments

With older heating/cooling systems

• Thermal stress, lower activity and metabolic rate, visual impairments

Older homes can be damp, noisy, stuffy, dark

• Anxiety, depression, 11.2 million seniors living alone in 20 08

Homes built prior to ADA, Fair Housing, or visitability legislation

• Physical, sensory and cognitive disabilities

Majority live in auto-dependent suburbs

• Limited mobility, diverse population with diverse housing needs

More likely to engage in pro-environmental behaviors, purchases

• Depression-era frugality, practices, familiarity, consumption values

Is Green Housing Healthy Housing for Seniors?

Two Retrofit Case Studies

• • • •

GREAT Study: Mankato MN

• • • • Cold Climate (Zone 6) 7-story, circa 1970s Public housing, primarily seniors and disabled Retrofit to Enterprise Green Communities & LEED Lengthy construction (~2 yrs) Environ. monitoring, health interviews, VA, bldg performance HOS-based interview Panel study, pre- and post • • • • • • • •

GAP Study: Phoenix AZ

Hot, Arid Climate (Zone 2) 3-story, circa 1970s Project-based Section 8, seniors only Retrofit to ARRA Green Retrofit Program Short construction (~6 mos) Environ. monitoring, health interviews, bldg performance, environ. perceptions NHIS-, BRFSS-based interview Panel study, pre- and post-

Health Outcomes Among Primarily Elderly Residents Associated with Green-Renovated Public Housing

Study Team

Orness photo: Blumentals Architects

Research Goals

Baseline to 1-year post:

• Resident physical and mental health change • If health declined, resident health declined less than that of general MN population • Improvements in temperature, RH, CO2, allergens, total volatile organic chemicals (TVOC), & formaldehyde levels • Decrease in # of housing condition deficiencies

PRE-RENOVATION

Source: Blumental Architects

RENOVATION

Source: Blumental Architects

Methodology

• • • – –

Health Interview:

Physical &Mental Health: Medicare Health Outcomes Survey (HOS) • VR-12 Health Survey Physical Component Score (PCS) & Mental Component Score (MCS) • Limitations in Activities of Daily Living (ADL) Housing condition •

Visual Assessment Environmental Monitoring and Sampling Building Performance Testing 11

Study and Comparison Groups

Study Group: • Baseline: 53+19=72 residents in two stages • 1-Yr Post: 40 of 49 baseline participants • 2 study groups: All Ages (33-86 yrs; n=40) & Elder (65-86 yrs; n=22) Comparison Group: Medicare HOS: HOS All Ages group (n=40); HOS Elder group (n=572)

Study Group Baseline Demographics (n=40)

• Median age 66 years • 70% female • 95% non-Hispanic White • 92% had incomes <$20,000 • 82% high school or college

13

All Ages: Mental Health Outcomes

Outcome Study Group Change HOS Group Change Study vs HOS

Mean # of good days Mean VR-12 MCS

1.6

(p=0.066)*

1.9

(p=0.159) -1.5

(p=0.167)

-2.8

(p=0.071)* p=0.026** p=.023**

All Ages: Physical Health Outcomes

Outcome Study Group Change HOS Group Change Study vs. HOS

% who fell in past year % in fair or poor health % with ≥1 ADL limitation Mean VR-12 PCS Mean # of good days -16% (p=0.134) -8% (p=0.317) 8% (p=0.257) 2% (p=0.705)

p=0.055*

p=0.314

28% (p=0.002)** 13% (p=0.096)*

p=0.196

-1.1

(p=0.578) 1.4

(p=0.366) -0.3

(p=0.797) 0.7

(p=0.546) p=0.737

p=0.704

*marginally significant and **significant at p<0.05

ELDER: Physical Health Outcomes

Outcome

% who fell in past year % in fair or poor health % with ≥1 ADL limitation Mean VR-12 PCS Mean # of good days

Study Group Change HOS Group Change Study vs HOS

-5% (p=0.739) -9% (p=0.317)

32% (p=0.008)**

-2.1

(p=0.503) 0% (p=1.000)

6% (p<0.001)** 4% (p=0.024)** -0.7

(p=0.064)*

p=0.742

p=0.094* p=0.021**

p=0.669

0.9

(p=0.729)

-0.7

(p=0.099)*

p=0.526

*marginally significant and **significant at p<0.05

Housing Condition Tobacco Smoke: -20%** Water/Dampness: -30%** Insecticide Use: -38%** Kitchen Fan Use: 0.6** Bathroom Fan Use: 2.9**

**significant at p<0.05

Environmental Monitoring and Sampling

• Dewpoint: Connection between indoor and outdoor • CO 2 levels significantly improved • No significant change in TVOC, formaldehyde, most allergens

18

Building Performance

• Fresh Air Ventilation: 1-BR: 53 cfm (ASHRAE 20 cfm) • Bathroom Exhaust Testing: 29 cfm (ASHRAE 25 cfm) • Pressure Balance: minimal deviations from design • Energy Use: 44% reduction

19

Conclusions

• Greatly improved building, esp. HVAC system • Improved mental health • Improved general physical health • Fewer falls • Substantially less indoor smoking

20

Green Apple Project [GAP] Phoenix, AZ

Green Apple Project Research Team

Sunnyslope Manor — Phoenix

After a green retrofit of assisted housing development for low-income older adults… • IEQ will show sustained improvement although it may be worse immediately • If IEQ improves, residents will perceive this change • Environmental and IEQ improvements will correlate

with corresponding changes

in resident health, behavior and attitudes • Retrofit changes may result in healthcare cost savings, for falls prevention

Research Methodology • Panel Study: O X O O • Data Collection Periods P1: June-July 2010 X: Feb – July 2011 P2: April – Sep 2011 P3: June – Aug 2012 • Sample Size — P1: 77 residents in 73 units — P1 + P2: 59 residents in 55 units — P1 + P3: 57 residents in 53 units • Proxy + Threshold Measures

Major Renovations • • • • • • • • PTAC system updated Energy Star exhaust fans, appliances New bedroom ceiling fan Double-pane, low-E sliding balcony

door and window

Low-flow plumbing fixtures

New roof primer, insulation

Complete kitchen remodel and bathroom remodel with low-VOC materials Low-VOC flooring, paint, adhesives

Resident Characteristics • • • • • • • • 74% women, 26% men Average age: 73 (range 62 to 92) Race/ethnicity: 83% White, 5% Native American, 4% African American, 2% Asian American, 14% Latino 21% smoke 88% live alone 65% report at least 1 respiratory problem # days in last 30 that physical health not good (at P1): 3 (median) Emotional distress significantly higher than national sample (NHIS) of low-income older adults

IEQ Data Collection • • • • • • • Temperature RH CFM50 Particulate Matter Formaldehyde Acetone Acetaldehyde

Health Data Collection (NHIS, BFRSS/Arizona) • • • • • • Quality of Health/Life Respiratory-related Emotional distress Sleep Functional activities Falls • •

also

Comfort/satisfaction of lighting, thermal, air quality, humidity Household cleaning frequency, products

Panel (Fixed-Effects) Regression Analyses “Scorecard” • • • • • • •

Immediate Outcomes

Temperature RH Air Infiltration Particulate Matter Formaldehyde Acetone Acetaldehyde • • • • • • • Overall Quality of Health/Life Respiratory Emotional Distress Sleep Functional Limitations, Falls IEQ Perceptions Cleaning Behaviors19 • • • • • • •

Sustaining Outcomes

Temperature (min, max, extremes, var) RH (variability) Air Infiltration Particulate Matter (for smokers) Formaldehyde Acetone (i/o only) Acetaldehyde • • • • • • • • Overall Quality of Health/Life Respiratory Emotional Distress (improve) Sleep Functional Limitations, Falls IEQ Perceptions Cleaning Behaviors + Booklet Use Falls Risk Cost Threshold Exceeded

1. Major Finding: Extreme Temperature Reductions in Units Overall across panels, a noticeable reduction in extreme indoor temperatures Count = # of times of 448 data points that Indoor temperature exceeded 81º

Extreme Temperature Reductions in Units (cont.)

Within a resident’s

apartment, significant reductions in number of instances of extreme indoor temperatures from baseline to post-retrofit panels

Extreme Temperature Reductions in Units (cont.)

Significant correspondence

between a unit’s sustained (P1P3)

Regression of Exceed 81 Changes on Reported Health Changes, for P1P3

reduction in extreme temperature AND improvements in resident’s reported quality of health/life, emotional distress and sleep Exceed 81 t

Quality of Health/Life

3.179

m .002

t

Emotional Distress

-2.085

p value .039

# Hours Sleep

t 2.150

p value .034

2. Major Finding: Formaldehyde Reduction

Material choices

(i.e. low VOC sealants and paint) had greatest impact on decreased formaldehyde.

Astoundingly high

levels of FA found in Panels 1 and 2; decreased in every unit in the long term.

Initial elevation

can be expected for installation of new carpeting or cabinetry.

3. Major Finding: Reduced Emotional Distress Associated with Changes in Environmental Perceptions Following Retrofit • •

Physiological Changes

– Quality of life/health – Functional activities

Environmental Changes

– Long-term reductions in extreme temperature in unit – Short-term (and marginally long term) reductions in formaldehyde concentrations – Long-term reduction after construction • Environmental Contribution (+P2, -P3) • Resident Perceptions of

Environmental Quality (P3)

– Satisfaction kitchen lighting – Satisfaction kitchen temperature – Satisfaction kitchen air quality – Lighting enhances comfort – Satisfaction with visual comfort 0 -0,1 -0,2 -0,3 -0,4 -0,5 -0,6 Quality of Life Functional Activities Kitchen Light Panel 1 Level of significance Kitchen Temp Kitchen Air Quality Light Enhances Visual comfort Panel 3

4. Major Finding: Expected Reductions in Health Care Costs of Falls Approximate Target Renovation Costs Baseline rate of injuries over 15 years: 330 falls, of which 105 would require medical care

Falls Post Renovation:

After 3 months: 52% reduction After one year: 6% reduction $$$ At 6% reduction, savings in health care costs ($266,000) approximate cost of selected renovations ($286,000) for: • • • Improved lighting Improvements in floor treatments Improvements in stairway hand rails

Take-Home Lessons • Both studies: Green renovation can have positive impact on mental health and fall prevention • GAP: Green renovation may reduce exposure to contaminants, and some health improvements may be tied to changes in environmental quality • GREAT: No-smoking policies may be feasible part of green renovation

Where to Go From Her e Studies of and Programs for Older Adults need to: — Capture impact on healthcare costs — Ask appropriate questions to better assess health- and activity related changes of older people — Oversample those with more serious chronic health problems, especially respiratory illness — Examine relevancy of conventional IEQ standards for older people — Collect biomarker data to objectively measure health changes — In conjunction with home renovations, collect data on non-structural interventions impacting health, e.g., smoking programs, home visits by health professionals

Teams

GREAT Study: Minnesota Jill Breysse:

National Center for Healthy Housing

Sherry Dixon:

National Center for Healthy Housing

David Jacobs:

National Center for Healthy Housing

Jorge Lopez:

Southwest Minnesota Housing Partnership

Billy Weber:

University of Minnesota, Center for Sustainable Building Research

GAP Study: Phoenix, Arizona

Co-PIs:

Ernesto Fonseca, Matt Fraser, William Johnson, Mookesh Patel:

Arizona State University

Kimberly Shea:

University of Arizona

Hugo Destaillats:

Lawrence Berkeley National Lab

Sherry Ahrentzen:

University of Florida

Lead Research Assistants:

Sarah Frey, John Ball, Sarah Stone, James Erickson, Angela Larson

Funding These projects were funded by the U.S. Department of Housing and Urban Development (HUD), Office of Healthy Homes and Lead Hazard Control. The work that provided the data for part of this presentation was supported by “Recovery Act or American Recovery and Reinvestment Act (ARRA)” funding under an award with HUD.

The substance and findings of the work are dedicated to the public.

The authors are solely responsible for the accuracy of the statements and interpretations contained in this publication. Such interpretations do not necessarily reflect the views of the Government.

Contact Information Jill Breysse [email protected]

Sherry Ahrentzen [email protected]