Since its approval in 1991, the Americans with Disabilities Act (ADA) accessibility guidelines have included design requirements for restrooms in a wide range of facilities, including those specifically serving older people. While ADA guidelines have been a great help to many people with disabilities, there’s reason to reconsider an update for today’s population of aging adults. When drafted in the early 1990s, the ADA was based on earlier accessibility requirements that were designed with younger people in mind, particularly returning Vietnam veterans—those who had enough upper body strength to pull themselves from a wheelchair to a toilet without assistance, for example.
Today, those same guidelines are widely used to design toileting rooms in facilities that cater to older adults (e.g., senior centers, nursing homes). But the abilities of this current population, which includes the now aging Vietnam veterans, vary widely from those that originally shaped the rules.
In fact, according to research presented in “An E for ADAAG: The Case for ADA Accessibility Guidelines for the Elderly Based on Three Studies of Toilet Transfer,” published by Physical & Occupational Therapy in Geriatrics, only 20 percent of today’s population of people with disabilities suffers from paraplegia, amputation, etc., while approximately 80 percent have age-related disabilities including stroke, arthritis, poor balance, and varying other ailments. According to the National Center for Assisted Living, 41 percent of assisted-living residents and 78 percent of skilled nursing patients needed toileting assistance due to mobility limitations or cognitive impairment. For such populations, the ADA guidelines may actually be inhibiting safe transfer by not providing enough space for caregivers to maneuver and creating a potentially precarious situation for patients and caregivers.
To test the safety of ADA configurations for older adults needing assistance with transfers onto and off of the toilet, the research study “An Investigation of Noncompliant Toilet Room Designs for Assisted Toileting” was conducted by the AIA-Academy of Architecture for Health (Tampa Bay); the Georgia Institute of Technology; and Gresham, Smith and Partners, with Florida Presbyterian Homes (FPH), a retirement community in Lakeland, Fla.
An adjustable mock toilet room was constructed to test four different toileting room configurations: one acting as the ADA-compliant baseline and three others that variously manipulated the size of the room and the position of grab bars. Overall, 18 caregivers and 20 patients of an average age of 87 years participated, testing each configuration and providing feedback. The medical conditions that patients suffered varied widely but included blindness, Parkinson’s disease, stroke, stenosis of the spine, and diabetic neuropathy. Some could walk into the testing facility and some required wheelchairs, but they all required caregiver assistance to safely use the restroom.
Through post-test surveys and video analysis, the research team was able to better understand how ADA guidelines are promoting or inhibiting successful assistance, with results indicating that while the guidelines are helpful, the current specifications might not be the safest or most comfortable approach to assisted toileting for older adults, and certain modifications must be considered.
Compare and contrast
The four toileting room configurations used three independent variables: the amount of space available for assistance (measured by the distance from the wall to the center of the toilet); the number of grab bars provided (one or two); and the type of grab bars provided (sidewall-mounted and fixed versus rear-mounted and swinging).
Configuration 1 was the ADA-baseline, with the toilet centerline located 18 inches from the sidewall and one sidewall-mounted, fixed grab bar. Configuration 2 was also 18 inches from the sidewall with one sidewall-mounted, fixed grab bar and an additional swing-away grab bar on the rear wall. Configuration 3 was 24 inches from the sidewall with two swing-away grab bars on both sides of the toilet. Configuration 4 was 30 inches from the sidewall with swing-away grab bars on both sides of the toilet.
After helping participants transfer to and from the toilet in each of the four configurations provided, caregivers were asked to respond to a five-question survey regarding the sufficiency of space provided, the utility of the grab bar location and style, the ability to get close enough to the individual to assist with transfer, and the ability to properly protect themselves from injury. Overall, 88 percent of caregivers preferred a configuration other than the ADA-compliant model, and the majority (58 percent) preferred the largest configuration, Configuration 4.
In addition, for both one- and two-person assisted transfers, Configuration 4 was rated significantly higher for both location and style of grab bars than Configuration 1. Finally, although the occupational therapist who observed the transfers didn’t find differences in biomechanics, there was a general trend that indicated configurations with swing-up grab bars (Configurations 2-4) had fewer incidents that put residents at risk of injury compared to Configuration 1.
One-person versus two-person assistance
Of the 20 patient participants, 10 needed assistance from one caregiver and 10 needed assistance from two caregivers. In situations where only one caregiver was required, the surveys showed a less marked preference between configurations, as caregivers indicated they had adequate space in each layout but still preferred Configuration 4. In situations where two caregivers were needed, however, mean ratings increased significantly with each configuration, as more space between the toilet and the wall was provided.
Caregiver teams reported being most comfortable in Configuration 4, saying that it provided enough room and allowed them to get closer to the participant and to position their bodies properly to provide better assistance. This clear preference of the two-person caregiver teams suggests that future changes could have the most impact in facilities catering to far less mobile individuals.
Fold-down grab bars versus side-mounted grab bars
As a general trend, there were fewer incidents in configurations with the swing-away rear grab bars than with those using only side-mounted grab bars (including the ADA-baseline Configuration 1). The additional grab bar provides flexibility, as it can be swung into place to provide extra support (typically when only one caregiver is assisting), or swung out of the way to provide more space (typically when two caregivers are in the room). Providing this option gives caregivers more control over the environment in which they’re working and can help them adapt quickly to different challenges.
Caregiver position
Caregivers placed themselves in different positions based on the configuration that they were working in. For example, in the ADA-compliant Configuration 1, caregivers either placed themselves in front of the toilet or on the side of the toilet without the wall-mounted grab bar. When fold-down bars were added and space increased, more caregivers positioned themselves closer to the grab bars and were able to move closer to the person being assisted. This shift in position indicates that the ADA-compliant configuration could be inhibiting caregivers from taking the position that feels safest and most natural to the caregiver.
The need for more space
Overwhelmingly, favorable outcomes and feedback increased as more space was provided, with the roomiest configuration, Configuration 4, receiving the highest scores. The 30-inch width used in Configuration 4 struck a balance between keeping grab bars and walls within reach while allowing caregivers room to maneuver and position themselves to provide the best assistance.
What’s next
Though the study used a small sample size, the results indicate the need for more space for assisted toileting and that modifications to the ADA guidelines could be very desirable. The needs of older persons, as well as younger people with disabilities, are unique and varied. As researchers continue to investigate and understand each condition, design portfolios can continue to be tested and diversified to create guidelines that are custom-tailored to various needs. This study reveals an opportunity for further research and discussion to drive the next evolution of the ADA.
Sheila J. Bosch, PhD, LEED AP, EDAC, is director of research for Gresham, Smith and Partners (Tampa, Fla.). She can be reached at [email protected]. Jon A. Sanford, M.Arch, is director of the Center for Assistive Technologies and Environmental Access at the Georgia Institute of Technology (Atlanta). He can be reached at [email protected]. The authors would like to thank the sponsors of this research, the Academy of Architecture for Health Foundation and The Hulda B. & Maurice L. Rothschild Foundation, for their support to the AIA–AAH Tampa Bay and the Georgia Institute of Technology to fund this research. The authors also thank the AIA-AAH Tampa Bay members for their intellectual contributions to the study and Florida Presbyterian Homes for its participation in the investigation.
References
For more on the articles cited in this article, see the following:
- “An E for ADAAG: The Case for Accessibility Guidelines for the Elderly Based on Three Studies of Toilet Transfer,” published in the Journal of Physical and Occupational Therapy in Geriatrics
- The Assisted Living Sourcebook, published by the National Center for Assisted Living
- “An Investigation of Noncompliant Toilet Room Designs for Assisted Toileting,” published in the Winter 2013 issue of Health Environments Research & Design (HERD) Journal
