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August 2004


It Starts in the Home

By Shoshana Shamberg, OTR/L, MS

Accessible bathroom

More than 16 years ago, my husband Aaron, a landscape architect, and I, an occupational therapist, purchased our dream home in Baltimore. The three-story colonial, built in 1917, enchanted us with its elegant stairway leading to its large columned front porch, artistically created leaded-glass windows, natural wood floors, and carved woodwork throughout the home. Winding stairways led to the upper two floors, with full bathrooms on each level, and five bedrooms for our growing family of four children and one more on the way. Five years later, our sixth child was born.

Once we moved in, however, we began to see problems in the design and layout of the home. The main floor had only a small powder room, containing very tight shower and toilet areas, barely large enough for a small adult and definitely not adequate for toilet training our little ones. The elderly couple who lived here before us had added it to have a bathroom on the first floor so they did not have to access the second floor for daily needs.

Eventually, with proposed renovations, this older home in need of upgrading would meet not only our space needs and aesthetic desires, but our functional needs as well.

ARCHITECTURAL CONCERNS
At that time, the bathrooms and kitchen were difficult to use, due to the tight spaces and older fixtures that did not work efficiently for daily functioning. Building designers of the past did not often consider ergonomics or the environmental barriers created by their elegant and beautiful architectural features. Architects traditionally did not consider functional limitations imposed by disability, varying heights of children and adults, or the effects of aging.

To renovate an existing structure for special needs is often very costly and sometimes structurally impossible to implement. Even for a healthy adult like myself, carrying heavy packages, strollers, and bicycles up and down the many stairs leading to the basement and the main floor was an overwhelming task, especially while assisting small children at the same time.

For a person with a disability, it would be impossible and dangerous. The steep, slippery interior stairs of our home were actually dangerous hazards for our children and older family members. The lighting throughout the home was inadequate, especially in stairways. Light switches were too high for the kids to reach and door knobs often difficult to grasp, occasionally leaving a traumatized child upstairs stuck in a bedroom or bathroom. Older bathtubs were too high to access, even for an adult, and individual knobbed faucet controls presented scalding dangers, and were difficult to grasp and maneuver. We were unable to invite relatives and friends with mobility impairments to our home or home office.

We dreamed of creating an accessible and adaptable home for our family, so that we could achieve the goals for ourselves that we were accomplishing for our clients.

GETTING ACCESSIBLE
Our initial introduction to the fascinating concepts of accessible design, Universal Design, and "visitability" began when Aaron worked for an engineering firm in 1988. His bosses soon realized that they would have to incorporate federal accessibility design guidelines into all of their commercial projects. The federal government would be implementing the new Americans with Disabilities Act (ADA), and compliance would begin after 1990. Therefore, their designers would need to be educated in ADAAG (Americans with Disabilities Act Accessibility Guidelines).

Aaron attended an accessible design seminar in 1989 with more than 100 design/build professionals. Much to his surprise, three occupational therapists were also attendees. He had spoken often of trying to find ways to connect his architectural design training with my medical knowledge, and I was fascinated by the idea of working with design/build professionals to enhance home safety, independent living, and community integration of people with disabilities. How to accomplish this remained yet a mystery.

I called one of the OTs who attended the design seminar to discuss the vision and possibilities of medical and design/build professionals collaborating on creating environments for people with disabilities. She encouraged me, stressing the importance of eliminating environmental barriers at home, at the job site, in educational settings, and throughout the community for successful rehabilitation and community re-entry after a traumatic accident, maintaining independent living during a progressive illness, deinstitutionalization for children and adults with lifelong disabilities, and quality of life for aging adults who may decline in functional performance. She stressed that I was on the cutting edge of a new specialty area for professionals involved in medical rehabilitation, especially OTs and PTs. She provided me with many resources and technical assistance information to study.

We were also in the process of using a new building contractor for a minor renovation to our home. This contractor, Mark, proved to be the missing link in our service delivery goals.

ABILITIES INC
Soon after this conversation, our excitement led to the formation of Abilities Inc, a design/build construction company with the collaboration of three professionals-a building contractor (Mark), a landscape designer and access consultant (Aaron), and an occupational therapist (me), who would provide functional assessments and ADL training in use of adaptive equipment and eliminating barriers in the environment for clients with functional limitations.The company eventually evolved into a consulting firm.

As our consultation services grew nationally, Aaron and I felt that our skills could be shared with other professionals to encourage greater awareness of this collaboration. In 1993, this led to an internationally recognized training program on Universal Design and Accessibility Consultation by Abilities staff. I had trained with some of the top experts in the accessible design fields, with both medical and design/build professionals. Today, as the American Occupational Therapy Association (AOTA) representative to the American National Standards Institute's Accessible Design Committee, I am involved in creating the major accessible design guideline used internationally by both government agencies and private sector professionals to design and build our public and private spaces.

Abilities has trained thousands of professionals and consumers internationally over the last 12 years and has worked with AOTA to develop professional standards for accessibility consultation services and training programs.

VISITABILITY
Although the concept of Universal Design is decades old, accessibility features have taken years of advocacy to be incorporated into our daily lives. In 1996, Eleanor Smith, the founder of Concrete Change, created a concept called visitability. This concept focuses on minimal, accessible design features in all construction, which are useable by people with and without disabilities.

In the last few years, many states and local jurisdictions have made visitability the basis for all new construction, due to powerful work by consumers and disability advocates. Its impact is quietly being felt by millions on our society as more and more communities are creating minimal access in housing projects and public spaces, to enable people with disabilities to "visit" their friends, relatives, and neighbors and all people to "age in place."

Visitability can be accomplished at the same price, or with a minimal increase in costs, as a traditionally designed home. It is simple to implement:
  1. one no-step entrance,
  2. wide enough doorways on the main floor so a person can access such areas as the living room, dining room and one bathroom to toilet in, so visiting can be accomplished,
  3. light switches located within reach of someone in a wheelchair in the bathroom, and
  4. the ability to get into a room with an accessible toilet and sink and close the door safely for privacy.

Aaron and I decided to create an accessible first-floor living space with visitability and adaptability in mind. We want a home where our disabled friends and relatives can visit easily via a no-step entrance created by a ramped back porch and entrance into our home, an accessible bathroom on the main floor, and a room that can be converted to a guest room or bedroom, if a family member becomes disabled or wants to visit and cannot access the upper bedroom levels. We moved the laundry room to the first floor from the basement, which provides a complete one-floor living space if needed. We are now planning the next phase, an adaptable, universally designed kitchen. When the renovations are done, a complete, one-floor accessible living space will be completed.

The renovated bathroom space is small, but by creating a shower room, where there are no thresholds between the shower area and the rest of the bathroom, a small spacious bathroom was constructed with a tile floor graded for proper drainage. The pedestal sink is accessible with an open bottom. Faucet controls are levered and easy to maneuver. A handheld shower, on an adjustable height track, provides easy and safe bathing while standing or seated in a shower chair. Wheelchair maneuverability is more than adequate for the toilet, sink, and shower, and a pocket door eliminates unnecessary barriers and is easy to open and close.

There are no thresholds or barriers throughout the spacious, uncluttered living room and dining room. Hardwood floors provide an excellent floor surface for wheelchairs and walker mobility. Doorways are wide enough to provide access throughout the first floor. A stair glide can be installed to the second floor, but is not really needed with this adaptable layout and first-floor design.

Our beautiful home is no longer an inefficient environment with barriers to comfortable daily living. It is an environment that eliminates unnecessary obstacles and is useable comfortably and safely for persons with and without functional limitations. Our emerging "visitable" home provides access for all who wish to visit, greater efficiency and comfort for our family, a safe environment for all ages, and the possibility of aging in place as we approach our golden years.

Bathroom Basics

The following is a partial list of common bathroom problems limiting safety and comfort, as well as suggestions for simple modifications:

PROBLEM:  Glass shower doors can be hazardous because they limit the access space in and out of the tub or shower. Often they are used for stability, but with a strong pull or push, they may pop out of their track and shatter, or become a heavy load on top of a person who has fallen.
SOLUTION:  Replace with lighter, shatter-proof doors on a sturdy track system or remove completely and use a shower curtain or folding plastic doors. Create a shower room with an open space for the shower and graded floor for drainage.

PROBLEM:  Faucets and door knobs are difficult to turn, and water temperature is hard to control. Light switches are difficult to see and use.
SOLUTION:  Install levered handles, single mix controls, and a water temperature control device to prevent scalding and to maintain constant water temperature. Water heaters may be turned down to 115 degrees to avoid scalding throughout the house. Automatically controlled faucets may be useful for a person with limited upper body strength and movement. Install lighted toggle switches with color contrasting covers at heights to meet the needs of your customer.

PROBLEM:  It is difficult to get up and down from the toilet; sometimes I lose my balance.
SOLUTION:  An 18-inch-high toilet enables a person in a wheelchair to transfer easily or an average-height to tall person to get up and down easily. An elevated toilet seat or commode can be placed over the existing toilet (most are 15 inches high). Toilet support rails or grab bars can be easily installed to assist with support when transferring or sitting. Proper bathroom layout to maximize ease in transferring and safety is crucial and should be implemented when building a new bathroom or major modification. A bidet can be installed easily to a standard or high-rise toilet to assist in hygiene. Most have a warm water wash and air-dry control.

PROBLEM:  Dizziness or weakness when standing in the shower or difficulty getting up and down in the tub or toilet. Lack of adequate support to maintain balance and stability.
SOLUTION:  A tub seat or retractable shower chair can provide crucial stability, while using a handheld shower for thorough cleaning. A transfer bench can assist in transfers when extra support is needed. Attractive grab bars may be installed next to sink, tub, and toilet at heights and orientation according to the specific needs of the individual. Attractive showers and bathtub units can be installed that are designed to maximize independence.

PROBLEM:  Inadequate lighting can make shaving or makeup preparation difficult. Finding the light switch in the dark is frustrating.
SOLUTION:  Increase illumination two to three times with nonglare fluorescent or frosted bulbs. A retractable mirror is a simple adaptation. Night lights, lighted rocker or pressure-sensitive switches, and easily accessible switch locations can make entering a dark bathroom safer. Open bottom cabinets enable a person to place a chair or wheelchair close to the sink or mirror.

PROBLEM:  Tight spaces in bathrooms make it difficult for an older person or a person using a wheelchair to maneuver safely to access the toilet or bathtub.
SOLUTION:  Widen the doorway (36 inches minimum). Remove the bathtub and create a wheel-in shower room with open access to the toilet and shower. A moveable shower curtain can shield the rest of the room from water spraying during showering and a floor drain makes it easy to clean this room. Other products that offer comfort and maximize independence and safety include: whirlpool baths, bidets, self-flushing toilets, and adjustable countertops and mirrors.

PROBLEM:  The bathroom floors are slippery.
SOLUTION:  A padded linoleum floor or matte finished tiles can be a safer assist. If using bathroom rugs, they should be low, tight pile glued to the floor. All bathroom rugs should be secured to the floor and removed when not in use. Be careful of curled edges.

PROBLEM:  The tub cannot be accessed by wheelchair or walker due to smallness of space in bathroom.
SOLUTION:  A wheel-in shower room can be designed and constructed to increase access room in many bathrooms, depending on the configuration, level of structural modification required or possible, and the space size. The tub can be removed completely, or a prefabricated accessible tub/shower installed. Proper drainage and configuration are crucial.

PROBLEM:  Standing up in the shower or getting up/down, in/out of the tub is very precarious due to poor balance, mobility, and/or low endurance.
SOLUTION:  A sturdy tub seat with a back, a transfer bench, a tub with a door, a handheld shower, grab bar systems, tub rails, etc are all helpful.

PROBLEM:  Bathroom safety is an important issue and is often overlooked.
SOLUTIONS:  An emergency call system may be a lifesaver in case of a bathroom accident. Nonskid or cushioned flooring can reduce serious injury from a fall. Movement-sensitive lighting for nighttime access can increase orientation when drowsy. Proper training in the use of all bathroom equipment is crucial.

PROBLEM:  Most accidents happen in the kitchen and the bathroom. Persons with Alzheimer's disease who are left alone for any length of time or who get up or wander at night are especially at risk.
SOLUTION:  A simple and spatially stable environment enhances safety. Eliminate clutter and stimuli. Keep all medications out of reach or locked up. Remove area rugs and eliminate locks on bathroom doors. Remove wastebaskets and any other receptacles that may be mistaken for the toilet. Select a toilet seat in a color that contrasts with the toilet bowl. Paint hot water taps bright red or adjust the thermostat on the hot water heater to a lower level to prevent scalds or install antiscald devices on faucets or automatic faucets/hand dryers.

Shoshana Shamberg, OTR/L, MS, is an accessibility consultant and president of Abilities OT Services Inc, Baltimore.

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