Fall prevention in the toilet environment

Abstract

This study was carried out to determine the need for more appropriate fall preventive measures and create a knowledge base for design criteria to be implemented in the Friendly Rest Room project. Literature research and interviews with users and caretakers were used to create the FRiTA Model, which was used to identify 'basic toilet activities' with an increased fall risk within the 'Dutch' toilet ritual. Next, a new toilet support was developed which provides a fine-tuned all-in-one support solution with an inviting appeal, representing luxury, serenity and hygiene. Several elementary aspects have been implemented in FRR prototypes. The results of usability tests with these functional FRR prototypes look affirmative and promising.

Full text

Fall Prevention in the Toilet Environment
Sonja N. BUZINKa,1, Renate DE BRUINa, Theo J.J. GROOTHUIZENb, Eva M.
HAAGSMANa and Johan F.M. MOLENBROEKa,1
a Delft University of Technology – Faculty of Industrial Design Engineering –
Section Applied Ergonomics and Design, Delft, The Netherlands
b Groothuizen Beheer bv, Rotterdam, The Netherlands
Abstract. This study was carried out to determine the need for more appropriate
fall preventive measures and create a knowledge base for design criteria to be
implemented in the Friendly Rest Room project. Literature research and interviews
with users and caretakers were used to create the FRiTA Model, which was used to
identify ‘basic toilet activities’ with an increased fall risk within the ‘Dutch’ toilet
ritual. Next, a new toilet support was developed which provides a fine-tuned all-in-
one support solution with an inviting appeal, representing luxury, serenity and
hygiene. Several elementary aspects have been implemented in FRR prototypes.
The results of usability tests with these functional FRR prototypes look affirmative
and promising.
Keywords. Slips, Trips and Falls, Inclusive Design, Toilet, Support, Assistive
Devices
1. Introduction
Statistics show that people are getting older and in the near future, elderly people will
represent an increasingly larger group of the population. Social structures are changing
and many elderly people expect to enjoy a more active lifestyle and benefit from better
living conditions [1,2,3]. Fall accidents are responsible for the majority of serious
injuries amongst the elderly in the category of home accidents. More than one out of
three people over 65 and about 50% of the elderly over 85 years of age fall at least once
a year. The consequences of these fall accidents for elderly people are diverse and can
affect the mental, social and physical condition of the elderly individual. That is why
falls often have a strong impact on daily life [1-7]. The prevention of falls in the toilet
environment is an important theme within the FRR project.
2. Investigating Fall Accidents in the Toilet Environment
The research project was started with the general aim to help prevent fall accidents of
elderly people when they visit a public or semi-public toilet. The first phase existed of
a profound literature investigation on related aspects in the multidisciplinary field
including the geriatric process, falls and fall prevention, Dutch legislation and
1 Corresponding Authors: Sonja Buzink and Johan Molenbroek, Faculty of Industrial Design Engineering,
Delft University of Technology; Address: Landbergstraat 15, 2628 CE Delft, The Netherlands; Email:
s.n.buzink@tudelft.nl, j.f.m.molenbroek@tudelft.nl
A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People
J.F.M. Molenbroek et al. (Eds.)
IOS Press, 2011
© 2011 The authors. All rights reserved.
doi:10.3233/978-1-60750-752-9-183
183

standards on rest room design and the toilet routine in general. This was complemented
with a set of investigations on current available assistive devices for the toilet
environment, the present-day situation for Dutch (semi-)public toilet environments for
elderly people and the handicapped, the view of elderly people (n=10) and nursing
professionals (n=6) on falls and fall prevention by interviewing them [2].
This knowledge was used to develop the FRiTA model for fall risks assessment in
toilet routines [2]. The model was used to identify toilet activities with an increased fall
risk within the ‘Dutch’ toilet routine and reveal potential problem areas (locations and
actions) within the toilet environment and ritual. This resulted in a set of
recommendations for fall preventive measures in the toilet environment as a whole
[1,2,3], preliminary design criteria and a refined design assignment focussing on
physical product interactions in one specific problem area and aesthetic experiences.
Additional research focussed on area-specific aspects of fall prevention,
ergonomics, usability, aesthetics, and stigmatising design aspects [1,2,3]. Input on the
latter aspects was obtained by literature, using collages and by means of a
questionnaire filled out by seniors (n=19) on their perception of toilet environments.
2.1. The Consequences of Falls for Elderly People
For elderly people falls are, more often than in other age groups, the cause of severe
physical injury and rank high on lists of causes for accidental death [2,6,8]. In the
group of elderly people, 25-50% of falls cause some kind of physical injury [2,5].
Although less than 10% of all falls lead to a fracture, about 52% of fractures in the
older age group are caused by a fall, with hip fractures as most frequently occurring
type of fracture [7]. According to Spirduso [6], more than half of the elderly
hospitalised due to a fall die within one year, and Fuller [8] additionally reports that
approximately 25% of the elderly with a fractured hip as result of a fall die within six
months. In general, elderly women appear to fall more often than elderly men do,
whereas elderly men have a higher mortality rate due to falls.
The fear to fall alone can affect the daily life of an elderly person significantly.
Next to the fear of falling again, elderly people are often afraid of their first fall
accident. Many consider the occurrence of falls a sign for the beginning of the end [6].
Fall-related fears repeatedly result in stiffened locomotion, loss of self-confidence, and
subsequently lead to self-inflicted functional limitations. This, unfortunately, mostly
brings about an increased risk of falling and growing social isolation [2,6,7].
The fear to fall (again) often makes elderly people decide not to lock the rest room
door, not even in a public or semi-public environment. The anxiety of ending up
injured inside a toilet booth, helpless or even dying after a fall is stronger than the
potential embarrassment of a complete stranger entering while using the toilet [2,9].
2.1.1. Risk Factors in General
A broad variety of intrinsic (individual/personal) and extrinsic (external/environmental)
factors influence the extent and presence of the risk to fall for elderly people. These
affect either the stimulus responsible for the initiation of a loss of balance, the
capability to recover a loss of balance or, in some cases, have an effect on both. Most
often though, falls are caused by a combination of several intrinsic and/or extrinsic
factors [2,6,7,10].
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Falls themselves are, apart from any fall-related fear, also responsible for
increasing the risk to fall, especially when multiple falls occur within one year [2,5]. A
repetitively falling person does not necessarily fall due to a similar combination of
factors each time. And while many single risk factors by themselves do not entail a
notably increased fall risk, interaction between risk factors can intensify the fall risk
significantly. Many times, they create a vicious circle, eventually leading to a fall
accident [2,6,8].
Decrease of physical activity and difficulties during the execution of movements
are important contributors to the in intrinsic causes for fall accidents, while physical
limitations together with a more cautious performance of movements reduce the
exposure to extrinsic fall risk factors. This subsequently causes a further decline of the
capability to act in response to danger and risks [5,6].
3. Preventing Falls When Using the Toilet
Everybody has their own toilet ritual, which includes a variable number of relatively
small movements and tasks. In early childhood, one is trained in these activities and the
tasks unite to become, as it were, one activity to be performed almost automatically,
without thinking. This changes when people get older. The ageing process often affects
some of the movements and postures that are part of the toilet routine. This causes the
ritual as a whole to disintegrate, and a task within the toilet ritual previously without a
significant fall risk can suddenly change into a hazardous activity [2,11,12]. In most
cases, people will first try to compensate and slightly adjust their ritual, or use already
present objects for support to accommodate geriatric complaints, before relying on any
additional assistive device [2,9,10].
3.1. Current Fall Prevention Strategies
Currently, a diverse range of fall prevention strategies is in use, which all attempt, by
following various paths, to reduce the occurrence of falls, also for the toilet
environment. The first major step in almost all of these prevention programmes is to
create awareness of fall risks present in the surroundings of an elderly individual.
Multi-faceted approaches tailored to the elderly individual, assessing and modifying
both intrinsic and extrinsic fall risk factors, appear to be the most successful in
reducing the number of fall accidents [2,6,7].
Fortunately, the use of assistive devices in toilet environments seems to be less
affected by the reluctance often shown with other assistive devices [4,11]. Supports in
the toilet environment are the second most frequently used type of assistive devices
after ambulatory aids. For various reasons, their presence, though, does not always
imply (correct) usage. Some elderly people state they not always recognize grab bars as
such. In some cases they are thought to be a towel rack [10], in other cases the user
lacks the necessary strength to use a particular type of support [2].
Proper installation of assistive products in toilet environments is determinative for
the suitability and amount of support offered in real use [1,2,3,10,12,13]. The design of
public or semi-public toilet facilities generally follows a minimal set of accessibility
regulations and guidelines, which are mostly based on average dimensions. In many
situations, anthropometrics guidelines based on averages are acceptable; applying these
guidelines in assistive products for elderly people though, will result in excluding a
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considerable number of people from (comfortable) use, since elderly people are,
anthropometrically speaking, far from average.
3.2. Risk Factors within the Toilet Environment
Implementation of a broader range of fall-preventive measures in building regulations,
for instance, should be considered as very important to bring down the number of falls
in toilet environments. Extrinsic aspects of toilet environments can be divided into two
categories: ‘fixed toilet environment’ (the floor, toilet bowl, etc.) and ‘additional
objects’ (towels, floor carpets, etc.). Both categories entail a varied, though different
range of risk factors. As the Friendly Rest Room project concentrates on public and
semi-public toilet environments, the fall risk factors incorporated in the ‘fixed toilet
environment’ will be focussed on.
The layout and interior design of the toilet environment has to be spacious,
practical and clear to be easily accessible for elderly people. The space to manoeuvre in
many toilet environments is very limited, which hinders many, especially those using a
mobility aid like a rollator [2,11]. In a confined, narrow rest room it is easy to find
support against walls; getting up after a fall, though, becomes almost impossible.
A toilet environment accessible for people using a mobility aid like a rollator
should at least have the dimensions of a rest room ‘plus’, see Figure 1. Non-elderly
users will most likely appreciate this relatively new type of spacious public toilet
environment as well, for example obese people and people with infants. This set-up
simultaneously removes the first barrier for many elderly to visit a public toilet, as they
no longer will depend on the stigmatised toilet for the handicapped [1].
The nature of the floor surface influences the fall risk strongly. The level of slip
resistance should be sufficient, both in dry and wet circumstances. Various gaits and
types of shoe wear should be taken into consideration in the assessment of the floor
surface as well, as combinations suitable for some can be hazardous for others [2,6].
Figure 1. Dimensions of a toilet room ‘plus’ Figure 2. The toilet bowl as object to trip over (upper left),
lack of contrast (lower left), visual support and a
deceptively continuing floor (both on right)
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The floor should be level, without any thresholds or other trip objects. Wall-
mounted toilet bowls are preferred over floor-mounted ones, as feet or rollator wheels
easily hook behind them [2], see Figure 2.
Elderly people often experience visual difficulties. For this reason sufficient
contrast between all objects in the toilet environment, including walls and floor, is
indispensable, see Figure 2. Clear visual support as in contrasting vertical or horizontal
lines, at or above eye height, will help many elderly people to maintain postural
balance [1,2], also see Figure 2. Usage of wall plinths in the same colour as the rest
room floor should be avoided. They complicate the assessment of the environment for
the visually impaired by creating a deceptively continuing floor [2], see Figure 2.
Blinding or disorientation due to glare or reflections should be avoided. Sufficient
lighting is essential for elderly people to assess the interior of the rest room properly,
but light transitions should be gradual to avoid dizziness or disorientation when
entering the room [2].
Figure 3. Manikin Mathilde demonstrates the basic toilet activities with the highest fall risk (by Landmark
Design Holding BV)
The style and ambience of a toilet environment can be of influence on the possible
risk to fall. Activities connected to urination and defecation are generally considered
very intimate and private [11]. Thoughts about our own toilet ritual already raise some
negative, uncomfortable feelings; those of strangers are seen as even more unpleasant.
The more publicly accessible a toilet is and the less familiar the people are who use it,
the more important it becomes that the environment appears hygienic and ‘as if never
used before’. In different ways, this is connected to the perception of the toilet
environment and the behaviour of people during a toilet visit [11]. The way people
perceive the environment determines their well-being, which in turn influences the use
of the facilities and therefore the potential fall risk. Hygiene, privacy and a safe,
S.N. Buzink et al. / Fall Prevention in the Toilet Environment 187

comfortable surrounding should therefore also be considered as essential attributes
within the overall toilet environment design to avoid fall accidents [1,3]. Elements, like
assistive devices, bearing a stigma should be banned or redesigned to become an
integral part of the environment.
Figure 4. Several preliminary scale models in different stages of the design process
3.3. Risk Factors within the Toilet Ritual
Transfers onto and from the toilet are well known as one of the most difficult personal
care activities to perform for elderly people [2,10,11]. Many elderly people also
experience difficulties when rising, standing, turning, (un)dressing and reaching [9,13].
Heightened toilet seats can cause constipation problems and prolonged sitting can
cause legs to ‘fall asleep’ [2,11]. To obtain a complete and proper impression of the
potential risks within the toilet ritual of elderly people, a process tree of the ‘Dutch’
toilet routine was created. A broad range of over 40 activities was identified with
changing movements and postures [2,11]. The basic toilet activities, which were
always performed by nearly all users, are most important to focus on when designing a
public or semi-public toilet environment.
An evaluation of hazardous movements within the toilet ritual was performed
which revealed that the activities of opening and closing the door, manoeuvring
through the rest room, turning in front of the toilet, (un)dressing, sitting down,
performing perineal cleansing, rising and checking clothing after dressing were the
‘basic toilet activities’ with the highest fall risk [1,2,3,5,11]. In Figure 3, Mathilde, a
manikin designed by Landmark Design Holding Bv for the FRR project, illustrates
these activities.
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4. The Design of a New Assistive Product to Prevent Falls
The study above was used as an outline to describe the need for an assistive product to
prevent falls in toilet environments, and to define a design assignment for such a
product. To design a support for a (semi-)public toilet environment with an as large
assistive effect as possible, the design phase focuses on basic toilet activities, as those
activities are performed almost every time by nearly all users. The largest number of
fall-riskful basic toilet activities is performed by Dutch elderly people in the vicinity of
the toilet bowl [2]. Therefore, the design focuses on assisting elderly people properly
during their movements and postures while standing still and manoeuvring in front of
the toilet bowl, (un)dressing, sitting down, performing perineal cleansing and standing
up. The target group consisted of people older than 60 years of age that are able to visit
a public toilet autonomously (whether or not using a simple mobility aid like a walking
stick or rollator) and use the facilities in it without the help of another person. The
product should in no way (physically or mentally) hinder or complicate the use of the
toilet environment by any user, including secondary and tertiary users.
The semi-public environment the product is designed for implies a setting with
durable products, used by multiple users with varying demands and styles of usage.
This also means a relative high level of cleaning and maintenance by specialised staff
(and not/less by the primary user self), and makes a product with a relative higher level
of luxury, compared to a fully public situation, possible.
The emphasis in most current assistive products is on technical functionality and
reliability in assistive behaviour. The new design should distinguish itself from those
products by taking also the usability, ergonomic functionality and aesthetics into
account as equally important.
Through a creative design phase, involving various design techniques, a broad
range of ideas was generated. The most promising ideas were combined to form
interim conceptual solutions. Next to additional research and design sketches,
preliminary scale models played an important role during the following design process,
see Figure 4.
In subsequent design phases, the conceptual design was further developed to a
more detailed level, mapping experiential aspects to physical properties. Design
decisions were made based on aspects of usability and perception of hygiene. The
limited space of toilet environments and the potential big influence of an assistive
device on the perception of the whole environment require the manifestation of the
design to be simple, open, and inviting.
Next to a 3D computer model (see Figure 5), a full-scale visual model of the grab
bar section (see Figure 6) was made as well to evaluate the manifestation of the grab
bar in full scale [1,3].
4.1. S’wing
The final support proposal, named S’wing, consists of several specially designed
components (see Figure 5): a toilet lift module, a toilet seat and two grab bars alongside
the toilet [1,3]. Each component provides users assistance when performing their toilet
ritual and helps them prevent fall accidents. When applied collectively, though, they
reduce the fall risk even further, as they intensify and supplement each other’s fall-
preventive qualities.
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Figure 5. The 3D computer model of S’wing
The design of S’wing facilitates a varied range of support to choose from for
elderly users. The design enables sufficient support and assistance for elderly people
between the 5th (often a small female) and 95th (often a tall male) anthropometric
percentiles during various activities of the toilet ritual.
The toilet seat and grab bars are height-adjustable because they are mounted on a
lift module. Ergonomic research during the design process showed that when choosing
for such a type of adjustability, anthropometric needs could be met with a design that is
more compact and less visually present in direct sight. Next to a less complex product
to use for the elderly, this helps to avoid a potentially deterring and stigmatising effect
caused by the dimensions of the supports. The curved surface of the toilet lift module
also includes a back support to provide extra stability while seated.
The toilet bowl applied is a wall-mounted type. The fact that it hangs free from the
floor decreases the fall risk by tripping. The design of the toilet seat is trapezoidal.
Together with the enlarged and slightly concave curved surface this shape ensures
(more) stability while seated. This also reduces the hazard of sliding off the seat, while
sitting on one side for wiping ones buttocks, for example. Furthermore, it eases sitting
down and standing up as it offers enough space to place both hands on the seat next to
the upper legs.
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S’wing offers various types of support and can be used in many different ways,
according to the wishes of each individual toilet visitor (see Figure 7). When a user
enters the toilet environment without a FRR personified data carrier, the grab bars will
be in the position shown in Figure 5, this way the user will know that at least two
positions are possible.
When rotated backwards, the support bars present a grip to grasp while sitting
down, as well as an armrest to use when seated. When rotated upwards S’wing offers
grip in front of the toilet seat, and can also be used to lean against with the hip. The
design of S’wing gives the user options to store a walking stick or small bag while
toileting, for example by placing it through the V-shaped opening in the grab bars or
hanging it over the vertical grab bar. In the backwards position, they present a grip to
grasp while sitting down, as well as an armrest to use when seated.
The support and grab bars can be rotated between an upward (vertical) and
backward (horizontal) position and fixed in in-between positions. To change the
position of a grab bar the user grasps and squeezes the button on the lower arch and
give it a slight push or pull in the desired direction until the preferred position is
reached. During this, the mechanism inside carries the largest part of the weight. To
lower or raise the whole toilet unit (including the grab bars), to flush or call someone
for help, the user can use the buttons on top of one of the grab bars.
In the described version of S’wing, the handles are adjustable and actively rotated
by the user. The seat can be adjusted in height and tilt, but still provides a static type of
support. In a more elaborate design, S’wing could offer dynamic assistance. Sitting
down and standing up could be actively assisted by a rotating movement of the support
bars, for example. This would help the user to initiate and coordinate these motions.
Moreover, a more simplified edition could be marketed, which for instance only
offers the grab bar(s) without the toilet lift to be installed at a personally defined, fixed
height.
The colouring and use of materials is chosen such that it helps to increase the
perception of hygiene and serenity. In most sanitary situations, light/pale blue appeals
as more fresh and new to a user, as it is less sensitive for visual contamination and
yellowing due to cleaning chemicals than white, for instance. Parting lines, surface
curves and edges are designed such that they will not collect dirt, and if minimal
amounts of dirt might collect, it will be out of the line of vision for users. Materials to
be used will conduct heat sufficiently to maintain a relatively cold and fresh feeling
when touched by human skin.
Figure 6. Computer-simulated usage examples by a small elderly female, a tall elderly male and an average
elderly person
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Figure 7. The visual full-scale model of the grab bar and some details
5. Conclusions
The fall risk present in toilet environments is determined by the combined action of a
variety of factors. When applying fall-preventive measures in the toilet environment,
the most important thing is to assess and modify the environment as a whole, taking
both intrinsic and extrinsic factors into account. It is possible to reduce the influence of
these factors by applying a full set of appropriate fall-preventive measures.
The conceptual support developed during this graduation project, offers an
innovative and appropriate solution to prevent falls in the toilet environment. Its
components together form a fine-tuned whole with an inviting appeal representing
luxury, serenity and hygiene. In various ways, it offers an enormous improvement
compared to existing assistive products for the toilet environment.
Elderly toilet visitors will no longer be forced to alter their toilet behaviour to
obtain suiting support, as it offers an integrated mix of different types of support. This
ensures that the number of users excluded from usage is minimal.
S.N. Buzink et al. / Fall Prevention in the Toilet Environment192

6. Recommendations
The next step should be the development of a fully functional prototype of the
conceptual design as a whole for usability testing. Only this way it will be possible to
actually verify the design decisions that have shaped the design.
Additionally more fundamental research on topics that have not thoroughly been
studied before would create a better basis to determine the genuine value of the new
design. This includes research into support preferences of elderly, interaction patterns
with different types of support within the toilet environment, as well as a more
elaborate study into the perception of toilet environments by elderly people. This will
create a profound basis for further developments in the field of fall prevention in the
toilet environment.
Finally, it is advisable to re-evaluate current accessibility regulations and
guidelines for toilet environments in detail to include a broader range of criteria
concerning fall prevention.
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