Creating a Dementia-Friendly Bathroom

Few diagnoses carry the weight and fear of dementia. With no known cures for the diseases and disorders behind it, a distinct finality can often hang over the families of those facing its challenges. While there's no denying the hardship and irreversible nature of dementia, there are a number of steps that can be taken to ease the experience of patient and caregiver alike. Modifying the patient's bathroom is key among these, given its potentially hazardous nature.

Cognitive disorders are particularly cruel because they attack the foundations of daily life: perception, memory, and routine. For the dementia-sufferer, the perception of danger can decline, or be exaggerated. People and places that were once trusted and familiar can become strange and frightening, while obvious dangers go unrecognized. Those with dementia are twice as likely to fall, and experience significantly higher mortality rates with those falls than others in the same age group. None of this bodes well for traditional bathrooms.

Although caregivers do much to address physical impediments, the cognitive side of things proves much more challenging, and often does not receive the same degree of attention. Addressing both is key in creating a safe and fruitful environment. Such an environment needs to be planned for and constructed as soon after the diagnosis as possible. The changes involved can be extensive, and stressful for everyone involved; being able to involve the patient in the process while they're still capable of significant engagement can be highly beneficial, and provides an opportunity to get used to new surroundings.

While this article deals specifically with dementia, many of the safety accommodations cited also benefit those with physical disabilities, and can help protect young children from common bathroom risks.

General Bathroom Design

The ideal situation at home is a single-story building, or a multi-story one with bed and bath on the ground level. This makes things far easier for patient and caregiver alike, since stairs present a serious and at times insurmountable challenge for those suffering, eventually requiring a lift, or isolation on a floor. If cost isn't prohibitive, adding a bathroom to the ground floor is a good idea, especially since the necessary safety features can be built-in from the outset.

The path to the bathroom (or any room) should be clear of any obstructions, including furniture, and should be well-lit. Nightlights are a standard option for nighttime visibility, but LED light strips and reflective tape can also be used to line the proper path. Doors should open outwards, and if locks aren't removed, they should be of the type that can be unlocked from outside. Folding (aka concertina or accordion) doors are a popular option, but can create confusion if the patient is unfamiliar with them. Whatever type of door is used, a sign on it may be helpful; try using both words and pictures to help engage and guide the patient. Lighted or glow-in-the-dark signs should also be considered, as they can assist navigation during the night. A recurrent concept in dementia-care is contrast between walls, floors, furniture, and fixtures: this applies to doors, as well. Painting the bathroom door a specific, contrasting color can help differentiate it from other rooms, and provide a small sense of autonomy for the patient.

Quick Tip: Chimes, or a bell, can be placed above the bathroom entrance to alert the caregiver (or anyone else) that it's been entered, and that assistance may be required. A bell, buzzer, or other type of alarm in the bathroom might also be worth considering, but it's important to keep in mind that it may be forgotten in the midst of an accident.

As we age, our sensitivity to light glare is increased, and can prove a distraction for those with dementia. It's important to minimize sources of glare, which include unshielded lighting and shiny flooring (depending on the sheen, flooring can seem wet to the patient, making them nervous or uneasy). Lighting should be installed with consideration so as to avoid shadows as much as possible: these can confuse and even frighten those with dementia.

Motion sensors are a great idea all around the house, and especially in the bathroom. They can be used to turn on the lights as well as the exhaust fan, and with a timer, guarantee the devices will not be left on indefinitely. Heating is another important concern, and potential burn-hazards, like radiators or towel warmers that get hot to the touch, should be removed lest they be grabbed by mistake or during a fall. Safety guards are available, and automatic shut-offs can be installed to guarantee the heating device does not stay on. More permanent, a low-temperature or wall-mounted radiator can be installed at a safe height, out of reach. More drastic - but highly effective and efficient - is an under-floor radiant heating system. Both sensors and safer heating systems are great for parents of young children, as well.

Take a look at the floor you're standing or sitting on. Is it patterned, or flecked? Shiny? Dark? Though you probably only view the floor as an aesthetic consideration, dementia drastically alters perception and thought. Flecks might be mistaken for debris on the ground (a fall hazard should the patient try to "clean it up"), and patterns can cause confusion and even fear (imagine a beautiful arabesque design turned snake pit). Even highly pronounced wood grain can trigger a bad reaction. A light, single-color floor is ideal; darker colors can be perceived as empty spaces or holes that cannot be stepped onto. Likewise, a floor that contrasts too greatly with the flooring in the adjacent room or hallway might be viewed as a step or emptiness, which could lead to a fall or lack of use. Additionally, remember that rugs can also be viewed as holes or steps, and if used on a wet floor could cause slips and falls. Avoid using rugs in the bathroom or use something that won't slip, like a teak floor mat.

To help ambulatory persons remain so longer and avoid falls, rails can be installed along hallways and walls to safeguard the path to important places like the bathroom. When a door breaks up the flow, just use a grab bar! Along with signage, tactile markers (like textured adhesive strips) attached to the rails at turns and near room entrances can help guide your loved one to the correct place.

Miscellaneous bathroom safety tips:

• When falling, anything in reach can be used to try to break the fall; remove everything that cannot withstand a person's weight, or could cause additional injury (like tub/shower soap dishes and towel bars). Rely only upon properly-installed grab bars for fall protection.
• Mirrors have the potential to cause confusion and fear. Try installing roll-up blinds or a curtain if this becomes a problem.
• Move cleaning and hygiene products to a secure location. Use open shelving in the bathroom (rather than cupboards) so that necessary items can be easily accessed.
• Cover all electrical outlets, store hair dryers and electric razors off the counter when not in use, and consider investing in an "elephant" curling iron. (They remember to turn themselves off when you forget.)
• Use foam pipe insulation or cushioning pads to cover sharp edges and corners that could prove fatal in the event of a fall.
• Consider adding a flood/leak alarm system to the bathroom. While the patient may not know how to respond to one, it should alert others in the home that something is wrong (or even neighbors, if it's loud enough!)

Bathtub & Shower Safety

Probably the most precarious spot in a bathroom for anyone, tubs and showers present a whole new dimension of risk for those with dementia. To begin with, nearly all showers have a curb that needs to be stepped over to get in; a simple task that can be overwhelming for one with dementia. Obviously, a curbless shower would be the best solution, as would a "wet room": an open, European-style bathroom in which the entire room and the fixtures in it are waterproof, with a centrally-located drain. These are major renovations, however, and not entirely practical. Less invasive but still highly effective, try putting colored tape down around the curb or tub edge to distinguish it and alert the patient of its presence. Tubs with sides that open for easy access are another excellent option.

Showers need to be large enough to accommodate the caretaker, as well as a wheelchair (a common eventuality) - another reason why a wet room is ideal: the entire room is essentially shower space! Bathtubs need ample space around them for transferring mechanisms and slings, which can be difficult since many bathroom designs place the toilet very near to the tub. Toilets, too, require space: in the front for caregiver assistance, and to the side for wheelchair transfers. Another point for curbless showers and wet rooms.

To prevent falls, grab bars need to be installed correctly (into studs), catered to the height, reach and comfort of the patient. Consulting with an occupational therapist is invaluable, and can give both patient and caretaker added peace of mind. Those with tubs should consider a tub rail to assist in getting in and out of the tub. Showers with larger tiles (3"-4") may present a slip risk; replacing them with smaller tiles creates a more stable surface, as does choosing alternative non-skid flooring. And of course, transfer seats and/or shower benches are a must: we offer a variety of attractive, high-quality, and ADA-compliant units.

Reducing the Risk of Scald or Burn Injuries

Water temperature also plays a key role in slips and falls: how many times have you been "thermally-shocked" by a blast of hot or cold water in the shower? For those of sound mind and body, this is usually nothing more than an annoyance. For those with dementia (young children, as well), it can lead to serious trouble. Slipping and falling from the sudden shock of a temperature change is not rare, and in the course of a fall, neither is reaching for whatever is at hand, including faucet handles. It is entirely possible for a person to inadvertently turn the hot water handle while trying to break a fall, and in the ensuing pain and confusion not be able to recognize it, resulting in severe burns. The best way to prevent such a scenario is to install a thermostatic mixing valve on the water heater outlet. These valves permit only water at a specific set temperature to enter the home's plumbing. Thermostatic or pressure-balanced valves can also be installed at the shower itself, guaranteeing that whatever happens, the water being delivered will not be harmful. Some systems come complete with a safety valve, handshower, shower, and other accessories.

Quick Tip: Do not rely on the water heater's temperature setting to mitigate scalding risk. As a result of their design, temperatures fluctuate within the heater tank, and the outlet water temperature vary wildly. Turning the temperature down can also create a breeding ground for bacteria.

Preference and comfort will dictate the type of showerhead used. Rainshower - or downpour - heads are generally not recommended, since they are positioned directly over the showerer, potentially causing confusion and anxiety for the dementia-sufferer. Handshowers are the usual go-to, since they offer caregivers (and patients) enhanced maneuverability and easy access to hard-to-reach areas; they can also be helpful in cleaning up accidents.

As for the shower doors, make sure they're plastic: doors are easily shattered during a fall. Opaque or frosted doors provide greater privacy, and reduce reflections, allowing the patient to bathe in peace. Curtains, while acceptable, do present a risk in case of a fall since they offer no support (another reason why grab bars are so important). If curtains are used, choose ones made of a breathable fabric: should a fall occur and the curtains be dragged down, they will not present a serious suffocation risk (unlike most plastics). Designs with an open upper portion maintain privacy while giving caregivers the ability to check in unobtrusively.

Toilet Safety

Toilets are another common place for falls. As with the shower, grab bars here are indispensable: place one on both sides of the toilet, if possible. If the bathroom is shared, folding bars are an excellent option to accommodate everyone in the home. You can even replace the toilet paper holder with a dual-purpose grab bar (an especially prudent move, given the holder's proximity to the toilet and the high probability that it will be grabbed during a fall).

If a remodel is being done, it's helpful to have the toilet facing the door, or at least be readily visible through it, so that patients can recognize the room and caregivers can monitor them. Extended-height toilets make sitting and standing much easier, as do wall-mounted toilets that can be installed at the perfect individual height (they also make bathroom cleaning a breeze, since there's nothing but space below the bowl). You may also want to consider purchasing a toilet with a bidet, or installing a standalone unit that fits like a seat on the existing toilet. These not only assist in cleaning, but can also help relieve symptoms of constipation and other common conditions like hemorrhoids.

Though eventually, the patient's bathroom visits will likely require the caregiver, it may pay off to put up simple instructions - using words and pictures - for wiping, flushing, and handwashing. It may also be a good idea to move any vases, potted plants, or trash bins away from the toilet or even out of the room, as these can be mistaken for toilets or urinals. Some patients forget what to do with soiled paper, and can even resort to stuffing it into pockets or leaving it on the floor. In these situations, a trash bin with a plastic liner is probably a good idea.

As mentioned, contrast between walls and fixtures is key in helping patients with differentiation and identification. This applies to toilets, as well: seats should be a different color than the tank/bowl (which should contrast with the wall behind). If you have a white sink, consider painting the walls a different color, and/or placing colored stickers in the basin to distinguish it from the floor beneath. Sink basins should be large, and have an overflow (smaller sinks require a greater degree of precision in use). Since dementia-sufferers often lose mobility, removing cabinetry beneath the sink and installing an offset drain/p-trap to eventually accommodate a wheelchair is an excellent idea.

Nothing can make caring for someone with dementia easy, and the plight of the patient is an unthinkably difficult and tragic one. Making the bathroom as safe a place as it can be may be challenging and even expensive, but is a necessary move to ensure a higher quality of life, and help postpone the need for institutional care.