The design of the housing environment has been found to have an impact on an individual’s (particularly older individuals) quality of life and independence (Oswald, 2007). If a house is not properly structured, and does not have the needed equipment/adaptations, it can significantly impact someone’s functional independence (De-Rosende-Celeiro, 2019). This dependence on others is likely to result in the need for care assistance within the home, or for the individual to move to an aged care facility (Carnemolla, & Bridge, 2019).

A study by Carnemolla and Bridge (2019), completed a ‘before and after’ comparison of in-home care being provided to individuals who had received home modifications within the past 6 months. The study results showed that there was a 42% reduction in hours per week of care required after the individual received home modifications and adaptations. The study’s results prove the importance of home modification and housing design, and how they correlate with an individual’s level of independence.

Within the home, issues in daily functioning often arise within the bathroom environment (De-Rosende-Celeiro, 2019). Three areas to consider within bathroom design are the bath or shower design itself, the toilet design, and the lighting (Afifi, 2015).

The Bath: There is found to be a significant association between the use of assistive products/proper bathtub design, and functional independence for older individuals (De-Rosende-Celeiro, 2019). Bathing is also the first activity of daily living (ADL) in which older people have difficulty (Murphy, et al., 2007), furthermore, the transfer into the bathtub was found to cause the greatest overall difficulty. This shows the importance of designing the bathtub environment in an accessible way. Equipment and adaptations including grab bars, raised toilet seats, or a bath transfer bench can allow an individual enough assistance to be independent when getting into the bathtub, and completing their desired tasks within the bathtub (De-Rosende-Celeiro, 2019).

A second alternative would be to have a walk-in shower with a shower seat. A walk-in shower would eliminate the need for the individual to complete the transfer into the bathtub at all, which was found to be the most difficult aspect of bathing (De-Rosende-Celeiro, 2019). Having a seat once in the shower would also allow the individual to sit down to complete tasks and take breaks from standing which could make showering much easier and safer.

The Toilet: When looking at the design of a toilet, it has been found that 50% of individuals over the age of 85 no longer have the ability to perform a sit-to-stand transfer from a toilet, thus the height of a toilet needs to be adjusted appropriately for the individual (Afifi, 2015). To assist with the sit-to-stand transfer, the toilet height should be 100% to 120% of the person’s lower leg length (Capezuti, 2008). Along with an appropriate height for the toilet, grab bars should be installed to assist with the independent transfer off the toilet. The installation of grab rails should include one that is horizontal next to the toilet, and one that is on a diagonal and slightly in front of the toilet (still on the side wall) (Afifi, 2015).  For best practice refer to Approved Doc M guidance.

If an individual still struggles to independently complete a sit-to-stand transfer after these adjustments have been made, they may require a mechanical toilet lift to further assist with the transfer. This would allow them to complete the transfer independently, but not require the same level of upper or lower body strength as before.

Lighting and Contrast: Not having appropriate lighting or contrast has been identified as a hazard that would increase an individual’s fall risk, decreasing their ability to complete activities independently. This may be due to the risk of fall or their fear of falling. Within the bathroom, it is recommended that a minimum of 300 lux for ambient light, as well as a minimum of 600 lux for task lighting be used (Afifi, 2015). Task lighting is used to illuminate further the areas that an individual uses to complete specific tasks, for example at the sink, while ambient lighting is the overhead lights used to light the whole environment. Colour contrast is also very important, particularly for those with a visual impairment. A difference of at least 30 points light reflective value (LRV) between adjacent surfaces is recommended (Colour Contrast, 2021). This means that the difference between the floor and wall, or wall and grab rail colours should have a difference of 30 LRV. By ensuring there is appropriate lighting, as well as appropriate contrast between items within the bathroom, an individual will be able to complete their activities more independently, and safely.

Bathroom floor: One area that may be overlooked but is important in maintaining independence and increase safety is the bathroom floor. If the surface of the floor is slippery, or there are loose mats, an individual’s fall risk can greatly increase.

When looking at the optimal flooring for a bathroom, testing of floor slipperiness is conducted using a ramp test which is completed in accordance with the DIN 51097 and DIN 51130 standards (Coskun, 2018; CD, 2012). The standard method tests the floors slipperiness when it is in different conditions. For DIN 51097 standards, the flooring is then categorized into class A, B, and C according to the areas they can be used. For the bathroom, class C is recommended as it is the safest for barefoot users (Coskun, 2018). For DIN 51130 standards, R 10 is recommended as it is still comfortable for walking barefoot and offers sufficient grip when wearing shoes as well. The research regarding the relevance of the ‘R’ classification is mixed, as the test is completed with heavy cleated safety boots on and motor oil on the surface, which is not a condition commonly found within the environment (CD, 2012). However, there often may be oils (shampoo, soap, etc.) on a bathroom floor, so it can be argued that the R classification results are still very relevant particularly regarding the older population. Due to this, the optimal floor for a bathroom would be a slip resistant surface and that does not exceed tested standards when wet.

Designing an accessible bathroom environment will allow an individual to maintain their independence for as long as possible. Maintaining independence within the bathroom is essential to avoid feelings of loss of self-esteem in older individuals (De-Rosende-Celeiro, 2019). Since the bathroom is often the location where difficulties with independence in ADL’s arise first, focusing on the accessibility within the bathroom is a great place to start when creating supportive home environments for older individuals.

• Afifi, M., Al-Hussein, M. and Bouferguene, A., 2015. Geriatric bathroom design to minimize risk of falling for older adults–a systematic review. European Geriatric Medicine, 6(6), pp.598-603.
• Capezuti, E., Wagner, L., Brush, B.L., Boltz, M., Renz, S. and Secic, M., 2008. Bed and toilet height as potential environmental risk factors. Clinical nursing research, 17(1), pp.50-66.
• Carnemolla, P. and Bridge, C., 2019. Housing design and community care: How home modifications reduce care needs of older people and people with disability. International Journal of Environmental Research and Public Health, 16(11), p.1951.
• CD, C., 2012. Assessing the slip resistance of flooring.
• Ncscolour.co.uk. 2021. Colour Contrast. [online] Available at: https://www.ncscolour.co.uk/training/training-DDA2.html#:~:text=30%20points%20colour%20contrast,the%20wall%20and%20the%20floor. [Accessed 18 July 2022].
• Çoşkun, G., 2018. A new slip safety risk scale of natural stones with statistical K-means clustering analysis. Arabian Journal of Geosciences, 11(24), pp.1-14.
• De-Rosende-Celeiro, I., Torres, G., Seoane-Bouzas, M. and Ávila, A., 2019. Exploring the use of assistive products to promote functional independence in self-care activities in the bathroom. Plos one, 14(4), p.e0215002.
• LaPlante, M.P., Harrington, C. and Kang, T., 2002. Estimating paid and unpaid hours of personal assistance services in activities of daily living provided to adults living at home. Health services research, 37(2), pp.397-415.
• Murphy, S.L., Gretebeck, K.A. and Alexander, N.B., 2007. The bath environment, the bathing task, and the older adult: a review and future directions for bathing disability research. Disability and rehabilitation, 29(14), pp.1067-1075.
• Oswald, F., Wahl, H.W., Schilling, O., Nygren, C., Fänge, A., Sixsmith, A., Sixsmith, J., Szeman, Z., Tomsone, S. and Iwarsson, S., 2007. Relationships between housing and healthy aging in very old age. The Gerontologist, 47(1), pp.96-107.