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Jun.19.2020View related content

Home Adaptations: Bathroom (Rehabilitation Therapy)

ALERT

Provide special consideration to patients who are at an increased risk for falls due to impaired cognition or vision or to decreased strength or balance.

OVERVIEW

The Occupational Therapy Practice Guidelines for Home Modifications defines home modifications as adaptations to environments that are intended to increase use, safety, security, and independence.6 Modifications may include, but are not limited to, the use of medical equipment or universally designed products, architectural modifications or major home renovations, and education of the patient regarding new strategies to use in the home environment.6

Therapeutic intervention that includes home modifications may prevent premature long-term care by supporting aging in the home,5 as well as improve the patient’s functional performance and reduce the risk of falls and physical demands on caregivers.4 Additionally, home adaptations may reduce costs while older adults age in the home.6

When considering home modifications, the patient’s physical functionality is one of the main factors for the therapist to keep in mind.7 The therapist must also take into consideration the patient’s perception of the home modifications, readiness to change the environment, and costs.7 The therapist must work with the patient or caregiver (or both) and have the patient’s consent before making any changes in the home.

The home bathroom poses many risks for falls with and without injury and, in most cases, is a needed area of focus for home adaptations.5 Correct installation of grab bars by the toilet and shower has been identified as an important preventive measure to increase safety. Although the American with Disabilities Act has specific recommendations for grab bar installation, considering the patient’s individual needs through an assessment of his or her shower and toilet transfers is important.3 Grab bars may be installed horizontally, vertically, or transversely and should be fixed to the studs in the wall. Other considerations for grab bars include ensuring that the bars can accommodate the patient’s weight and preference for the diameter of the bar for comfortable fit in the hand. Seating in the shower, the use of bath rugs and tub mats, and the height of the toilet seat are additional areas to consider for home adaptations in the bathroom. These modifications make the bathroom safer for the patient, which is especially important because the bathroom is one of the most common sites for falls in the home.

SUPPLIES

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EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Educate the patient and caregiver on home modification recommendations.
  • Educate the patient and caregiver on the use and installation of adaptive equipment.
  • Instruct the patient to report pain or dizziness experienced during the transfers.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Assess the patient for pain.
  6. Assess the patient's strength, balance, and vision.
  7. Review risk factors that predispose the patient to falls or accidents in the home.
    Take note of preexisting conditions such as visual or hearing impairment, neuromuscular dysfunction, fatigue or reduced energy, and postural hypotension.
  8. Assess the patient's thoughts and perceptions on home adaptations.
  9. Partner with the patient and caregiver to conduct a home bathroom safety assessment.
  10. Have the patient complete a toilet transfer, with assistance as needed. Observe and document the safety of the transfer, including any trouble the patient has with stand to sit, sit to stand, and balance.
  11. Have the patient complete a tub or shower transfer, with assistance as needed. Observe and document the safety of the transfer.
  12. Make specific bathroom modification recommendations based on the patient's needs and comfort.
    1. Advise the patient to have grab bars installed by the toilet as needed, with the bars secured into the studs of the wall either vertically, horizontally, or transversely on the side wall closest to the toilet and on the back wall behind the toilet.1
      1. Explain that horizontal grab bars should be placed between 84 and 91.5 cm (33 and 36 in) from the floor, have a 3.8-cm (1.5-in) clearance from the wall and a 30.5-cm (12-in) clearance from any other projecting objects on the wall (Figure 1)Figure 1.1
      2. Explain that a grab bar on the side wall should be a minimum of 106.5 cm (42 in) long and a maximum of 30.5 cm (12 in) away from the rear wall (Figure 2)Figure 2.1
      3. Explain that a grab bar along the rear wall should be a minimum of 91.5 cm (36 in) long and when centered over the toilet, extend a minimum of 61 cm (24 in) on one side and 30.5 cm (12 in) on the other side (Figure 3)Figure 3.1
    2. Advise the patient to use either a bedside commode placed over the toilet, a raised toilet seat with safety frame, or an elevated toilet seat with handles if he or she is unable to have grab bars installed on the wall.
      1. Explain that the height of the toilet seat can be adjusted as needed within the recommended distance of 43 and 48.5 cm (17 and 19 in) from the floor.1
      2. Explain that the patient should be at a comfortable height while seated and able to place his or her feet on the floor while still being within the recommended distance from the floor.
    3. Advise the patient to have two grab bars installed on the back wall of the shower or tub.
      1. Explain that the two grab bars should each be a minimum of 61 cm (24 in) long and 20.5 to 25.5 cm (8 to 10 in) up from the rim of the tub.1
      2. Explain that the grab bar on the end wall should be a minimum of 61 cm (24 in) long and the grab bar on the head wall should be a minimum of 30.5 cm (12 in) long (Figure 4)Figure 4.1
    4. Advise the patient to use a shower chair or tub transfer bench or removable in-tub seat while showering.
      1. Explain that a shower chair or tub transfer bench should be set 43 to 48.5 cm (17 to 19 in) above the shower floor.
      2. Explain that a removable in-tub seat should have a depth of 38 to 41 cm (15 to 16 in) and be able to be securely placed (Figure 5)Figure 5.1
    5. Advise the patient to secure all mats and to place nonskid backing under small rugs.
    6. Advise the patient to place a nonskid mat in the bathtub or shower.
    7. Advise the patient to have a handheld or adjustable showerhead installed as needed.
  13. Perform hand hygiene.
  14. Document the procedure in the patient's record.

MONITORING

  1. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.
  2. Observe the patient for signs and symptoms of orthostatic hypertension. If this condition is suspected, report it to the authorized practitioner.
  3. Observe the patient during the toilet and shower transfers. If the patient is unable to complete the transfers safely, educate him or her and the caregiver on compensatory strategies to ensure safety.

EXPECTED OUTCOMES

  • Patient participates in home safety assessment of bathroom.
  • Patient understands and implements home modification recommendations.

UNEXPECTED OUTCOMES

  • Patient and caregiver do not acknowledge risks identified from the home bathroom safety assessment.
  • Patient or caregiver fails to implement modifications agreed upon during the evaluation and intervention.
  • Patient suffers a fall or injury in the home.

DOCUMENTATION

  • Education
  • Patient’s progress toward goals
  • Unexpected outcomes and related interventions
  • Bathroom safety assessment and recommendations
  • Changes made within the environment
  • Assessment of pain

OLDER ADULT CONSIDERATIONS

  • Older adults are at greater risk for falls due to age-related physiologic changes.5
  • Age-related neurologic and musculoskeletal changes place older adults at risk for decreased balance. Balance is essential for toilet and shower transfers and sitting on the toilet.2

REFERENCES

  1. Department of Justice. (2010). 2010 ADA standards for accessible design. Retrieved May 19, 2020, from https://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards.pdf (classic reference)* (Level VII)
  2. Duchêne, J., Hewson, D., Rumeau, P. (2016). Modified bathroom scale and balance assessment: A comparison with clinical tests. Springerplus, 5, 472. doi:10.1186/s40064-016-2086-8 (Level III)
  3. Kennedy, M.J. and others. (2015). Toilet grab-bar preference and center of pressure deviation during toilet transfers in healthy seniors, seniors with hip replacements, and seniors having suffered a stroke. Assistive Technology, 27(2), 78-87. doi:10.1080/10400435.2014.976799 (Level III)
  4. Lien, L.L., Steggell, C.D., Iwarsson, S. (2015). Adaptive strategies and person-environment fit among functionally limited older adults aging in place: A mixed methods approach. International Journal of Environmental Research and Public Health, 12(9), 11954-11974. doi:10.3390/ijerph120911954 (Level V)
  5. Lim, Y., Kim, H., Cha, Y. (2020). Effects of environmental modification on activities of daily living, social participation and quality of life in the older adults: A meta-analysis of randomized controlled trials. Disability and Rehabilitation. Assistive Technology, 15(2), 132-140. doi:10.1080/17483107.2018.1533595 (Level I)
  6. Siebert, C., Smallfield, S., Stark, S. (2014). Occupational therapy process for home modifications. In Occupational therapy practice guidelines for home modifications (pp. 11-40). Bethesda, MD: AOTA Press. (classic reference)* (Level VII)
  7. Stark, S.L. and others. (2015). Clinical reasoning guideline for home modification interventions. The American Journal of Occupational Therapy, 69(2), 6902290030p1-6902290030p8. doi:10.5014/ajot.2015.014266 (Level V)

ADDITIONAL READINGS

Graybill, E.M., McMeekin, P., Wildman, J. (2014). Can aging in place be cost effective? A systematic review. PLoS One, 9(7), e102705. doi:10.1371/journal.pone.0102705

Kim, H. and others. (2014). Home modification by older adults and their informal caregivers. Archives of Gerontology and Geriatrics, 59(3), 648-656. doi:10.1016/j.archger.2014.07.012 (classic reference)*

Stevens, J.A., Mahoney, J.E., Ehrenreich, H. (2014). Circumstances and outcomes of falls among high risk community-dwelling older adults. Injury Epidemiology, 1(1), 5. doi:10.1186/2197-1714-1-5 (classic reference)*

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports