In the UK today, over a quarter of adults are classed as obese based on a Body Mass Index (BMI) of 30+. The number of obese adults has nearly doubled since 1993 (Baker, 2021).
Using the toilet
If difficulties with using the toilet are identified following an assessment, a thorough understanding of the barriers to independent toileting should be established. A person’s weight, and corresponding size, can influence mobility and agility.
If people need support to lower or raise themselves when transferring on and off the toilet, the basin is often used as a support and the provision of a grab rail may be fitted as an alternative. Because of the person’s weight, consideration should be given to the load placed upon the grabrail and whether this method of supporting safe transfers is suitable in the medium or long-term.
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If the person can weight bear and mobilise and is having difficulty with toilet transfers, a toilet lift should be considered following a thorough assessment, as it may provide appropriate support.
A toilet lift is fitted over the toilet and replicates the natural movement of standing and sitting. They assist people with limited mobility transfer on and off the toilet with minimal or no carer assistance.
The Bariatric Aerolet toilet lift accommodates a weight loading of up to 250kg/39 stone, making use of the ‘Big John Seat’. (See the ‘Bariatric toilet seating’ section).
Note: The Bariatric Aerolet is NOT available as a vertical version.
A shower/toileting chair should have an appropriately positioned opening in the padded seat to enable access to the toilet pan and douche/drying mechanism without the person having to transfer on to the toilet from the chair. The width and weight limit of the shower chair should be reviewed for suitability for people with a bariatric weight/size.
If a person cannot weight bear and transfer, even with assistance, a hoist may be required – taking into account manual handling guidance and weight limits of equipment.
Variants include mobile hoists and ceiling track hoists. Choice should be based on a risk assessment, and whether it is for:
- A single or multi-person environment.
- For use in one room or beyond.
- The layout of the room i.e. whether ceilings and walls are robust enough to bear the necessary load, and the positioning, and style/protuberance of fixtures and fittings.
- The number of carers required to assist the person.
The type of transfer is also a consideration, for example, is the person moving from wheelchair to toilet (at similar height), or is there a requirement for height-adjustability, e.g. from wheelchair to changing table.
Weight loading and body mass
If a person is having difficulty with intimate cleansing after using the toilet, the provision of a wash and dry toilet will often be an appropriate solution to achieving effective cleanliness, independence and reduction in reliance upon carers for assistance.
There are two main influencing factors when working with a person of bariatric weight or indeed plus sized: weight loading and body mass.
The toilet itself needs to have an appropriate weight limit for the person/people using it. The seat and brackets used also need to have a suitable weight limit. Conventional toilets and most wash and dry toilet seats (not the toilet pan) bear up to 127kg/21 stone. Most bariatric aids will withstand up to 346.5kg/55st. The Closomat Palma Vita Bariatric wash and dry toilet accommodates 362kg/57 stone.
The person needs to be able to sit securely on the wash and dry toilet, and in the correct position on the seat and pan. The person must sit comfortably, with their back supported against the cistern and their torso and legs forming a 90° angle.
A larger body can often cause the person to sit too far forward, so their bottom does not cover the seat aperture. If this is not achieved, the person can feel ‘perched’ on the toilet causing instability.
Buttocks need to be supported but slightly parted to enable effective bowel evacuation and cleaning.
Wash and dry (shower) toilets
Wash and Dry Toilets were invented by Closomat over 60 years ago to provide solutions for people having difficulties with toileting and, in particular, with cleaning themselves afterwards.
A wash and dry (shower) toilet eliminates the requirement for comprehensive intimate care. It combines a toilet, washing douche and drier in one unit.
The toilet cleans and dries the person after use, removing the need for manual cleansing with toilet tissue and eliminating associated hygiene and contamination issues. It also enhances the person’s independence and self-care skills.
Cleaning with toilet tissue requires manual, mental and physical dexterity, flexibility, and balance. It requires intimate hand: body contact, either by the person or their carer. As the wash and dry toilet effectively washes the anal area, it eliminates the potential for faecal smearing and/or cross-contamination under fingernails etc.
Cleaning with the function of a wash and dry toilet requires the ability to sit in the correct position (which may require facilitation to achieve the correct posture) and the ability to trigger a switch to begin the wash and dry process.
Selection of a wash and dry toilet will be influenced by individualised assessment, including a thorough evaluation of the person, the environment (including equipment used, current toilet and layout of the bathroom) and the occupation of toileting. The cost is not just that of whichever unit is chosen, but what adaptation – if any – will be required to accommodate the unit, and ensure it works effectively and the potential saving of any carer support that will no longer be required.
Closomat Palma Vita safe working load: 190kg/30st.
Bariatric toilet seating
The Big John seat.
The size of the seat may need to be larger, to accommodate increased body mass. A bariatric seat tends to be deeper – (60mm/2.5ins) and wider – 486mm/19ins compared to 410mm/16ins. Toilet seats are available which will safely bear up to 363kg/57st. For larger-bodied people, a bariatric bench may be more comfortable. This is a padded full toilet seat or horse-shoe seat mounted on a steel frame with the bench positioned over the top of the toilet. Flat-topped versions and armrests are available. A bench will usually hold up to 349kg/55st as standard.
The positioning of the douche can be set in most cases to personal requirements, to achieve the fundamental aim of cleaning the genital/anal area. Once set, it is not likely to be adjusted unless the person’s needs change.
The positioning, and angle, of the douche within the pan is set at point-of-manufacture and varies between models of wash and dry toilets. Expert advice from one of Closomat’s product specialists will facilitate an individualised recommendation.
Ensure there is adequate clearance between the douche and the bottom of the seat for effective cleaning, and any possible avoidance of potential douche/body contact (this may be an issue with a plus-size person due to excess skin in the perianal area).
The douche position and extension are key to effective washing. A standard douche will achieve effective cleansing for most people who can maintain an effective posture. If an appropriate seated position cannot be achieved, an extended douche arm may be specified.
The douche spray pattern also varies and should be wide enough to cleanse effectively.
The amount of water differs between manufacturers: the more water that passes into the douche, the more efficient the clean. Some wash and dry toilets use as little as 2l/minute, others 8l/min.
It is important that the person is able to operate the controls for the wash and dry toilet independently, if possible. The cognitive function of the person should be fully evaluated to ensure that the most appropriate method of operation is chosen. Some units have complex controls positioned on a handset which can be located to the side of the unit and wall mounted.
A flush which incorporates a wash and dry function is located on the cistern of the Closomat which can be operated whilst seated. There are also other options such as a pressure sensitive switch which can be operated with the elbow, foot or fist grip.
Where bolt-on wash and dry units are used, the conventional flush has to be employed before/after the douching process, which will require the person to transfer off the toilet, turn to flush, then manoeuvre back on to the toilet (this may increase the risk of falls).
Further reading: Guide to specification for wash and dry (shower) toilets.
Baker, C. (2021) Obesity Statistics. House of Commons Briefing Paper. Retrieved from: https://commonslibrary.parliament.uk/research-briefings/sn03336/ accessed on 17.01.2021.