By Lindsay Milgrim, OTR/L
Occupational Therapist

For older adults, falls in the bathroom are twice as likely to result in injury than those that occur in other areas of the home, a 2014 research study found. Between physical limitations and environmental barriers, the bathroom can be full of scary obstacles that increase a person’s fear of falling. Bathing, grooming, and toileting are complex tasks that involve many factors such as balance, strength, problem-solving, and vision, among many others. But some older adults may avoid these necessary occupations out of this fear—how many have reduced their shower days to once a week?

These daily bathroom tasks, although routine and important, can add stress and anxiety to a person’s day if they feel unsafe, are not meeting their expectations, or have difficulty adequately completing them. As an occupational therapist, I try to identify the root of these challenges and help patients reengage in their daily self-care with a sense of accomplishment and joy.

7 Fall Risk Assessments for Older Adult Patient Bathrooms

A thorough safety assessment and simple home modifications can immensely reduce the risk of falls and restore your patient’s sense of independence, self-esteem, and control. First, let’s walk through how to assess their environment and identify the risk factors below.

What you will need for a bathroom assessment:

• Measuring tape to assess dimensions.
• Painter’s tape to mark areas (if needed).
• A phone or computer to record measurements or take photos.

Feeling overwhelmed or don’t know where to begin? Break down the task and assess one area at a time.

1. Accessibility. First, assess and record the width of the doorway. Can the patient enter and exit the bathroom with their device? Compare with the measurements of their device. Assess the space within the bathroom. Is there room to turn with a device? Are there obstacles in the bathroom preventing movement?
2. Clutter and Obstacles. Are there hazards on the floor like loose towels or throw rugs that lack nonskid material? Small spaces coupled with trip hazards can increase the risk of falls and fear of falling.
3. Lighting. Identify how many lights are in the bathroom, their location, and the location of switches. Adequate lighting can prevent falls caused by vision impairment, which is one of the highest risk factors for falls in the geriatric population.
4. Sink Area. Does the height or clearance of the sink area fit a manual wheelchair? Is there space to place commonly used items? Organization can limit unnecessary reaching, conserves energy, and limits obstacles during bathroom tasks. Items used daily, such as a toothbrush and hairbrush, should be placed in an easily accessible area.
5. Toilet. Measure the toilet height. Assess the patient’s ability to transfer. Typically, it is more difficult to transfer from lower surfaces and surfaces without arm support. If the toilet is too low and has no place to engage a patient’s arm strength to assist, toileting could become a fall hazard.
6. Shower and Tub. Measure the dimensions (length and width) of your patient’s shower or tub as well as the lip of the entrance (if applicable). Are there any devices in the shower? Next, assess the flooring. Is there enough or any traction? Note the type of showerhead. Is it handheld, easy to use, and producing appropriate water pressure? If a patient benefits from showering while seated, that will require a handheld showerhead in order to improve water control and placement. Is there a storage area or shelving in the shower? Are there any towel racks or grab bars?
7. Storage. Assess storage availability within the bathroom. Every item should have a “place” to limit clutter and reduce tripping hazards. Keep items off of the floor and in easy to reach places. Similar to accessibility in the first point, clutter and disorganized storage will reduce the accessibility of the bathroom.

Modifications to Improve Bathroom Safety for Older Adults

Why modify the environment? Many studies show falls are caused by a variety of risk factors, and fall reduction treatment responds best when applying a multifaceted approach. Per a 2013 study, applying this method helped decrease falls by 25% to 40%. Home modifications allow for quick, immediate changes that reduce one’s fall risk with longstanding effects.

Here are some simple modifications you and your patients can make to reduce falls in the bathroom.

Grab Bars
Grab bars are the most secure support available to assist with mobility, steadying, and standing. Towel racks are not good replacements for grab bars as they are not secured into studs in the wall and can therefore be easily pulled out.

The proper placement is essential. For the toilet, a horizontal grab bar next to the toilet is best to assist with standing and transfers. For the shower, add a horizontal bar to assist with steadying while standing and a vertical bar at the entrance to assist with entering and exiting. The height of the grab bar is similar to the height of a person’s standard walker.

The ADA recommends placement at 33-36 inches above the floor in public bathrooms, but an advantage to being a clinician is using our judgment to recommend the best height for our patients. Some folks may require lower or higher placement depending on their height.

Flooring
Changes in surfaces can create a trip hazard, especially if they are not secured or have no traction. That means no unnecessary throw rugs. I typically only recommend non-skid bath mats placed at the exit of the shower. There is not much need for them anywhere else in the bathroom.

Educate your patient to never step on a loose towel. It is a trip hazard waiting to happen—a similar idea to slipping on a banana peel that we’ve all seen in cartoons.

Add a non-skid surface to the shower floor or non-skid bath mat. I like adhesive strips when a shower chair is warranted. A bath mat works well if no seat is required and can suction to the floor. This improves traction when wet.

Toilet
To improve a patient’s ability to transfer from the toilet, add a raised toilet seat with arms. Be aware that there are different shapes of toilet—round and oval—so ensure you select the proper device to fit the patient’s toilet.

Place a horizontal grab bar next to the toilet to assist with transfers and standing tasks. A 3-in-1 commode over the toilet is another good option and is considered durable medical equipment, meaning Medicare does cover part of the cost when medically necessary and if a person is unable to leave their bedroom. It is low cost and multi-functional. It can be placed at the bedside, or over a toilet sans bucket as a way to provide arm support and increased height for a toilet transfer.

Shower or Tub
Adequate seating and better accessibility are always good ideas. But with so many options, which is best? They each have unique benefits, drawbacks, and usefulness.

• Tub transfer benches. A great option for someone who cannot safely enter or exit their bathtub shower while standing. No grab bars are needed!
• Shower chairs with arms. Best for showers with optimal space and for someone who uses their upper extremities to assist with transfers.
• Shower stools. These are best for small shower spaces, for those with improved ability to complete transfers and those with endurance deficits requiring seated rest breaks. They are also easily removable for those sharing a shower with others and can be stored away.
• Rolling shower wheelchairs. Best for those who are non-ambulatory and use a wheelchair. Requires a walk-in shower setup. Other accessibility considerations for your patients could be to add a towel rack closer to the shower or tub for easy access and to dry off prior to exiting. Does bar soap keep falling? Place it in a stocking tied to a grab bar.
• Change the showerhead to a handheld device. These are much more conducive to an older adult’s range of motion limitations and assists with bathing while seated.

Add Storage and Reduce Clutter
Keep items in easy to reach locations to limit overhead and below waist reaching. Add a shower caddy to keep items together. Remember, less clutter means fewer falls! Make sure every item has a place.

If space is tight, there are great options for over the toilet shelving units to keep items from collecting on the floor. Organizing similar items in bins or clear containers placed on shelves allows for easy retrieval when necessary. Sometimes, I recommend labeling the bins or containers as well to assist those with short-term memory impairment. Lastly, ensure electrical cords and towels are out of pathways.

Accessibility
If a walker or wheelchair can’t fit through the doorway, you have a few viable options:

• Remove the door completely, which is a good option for a master bathroom situation.
• Add a privacy curtain if the door must be removed.
• Change the hinges on the door to an “offset” configuration, which could add 2 inches of width to your entrance.

Lighting
There are few simple ways you can manage fall risk in your patient’s bathroom with simple updates to the space’s lighting:

• Add a nightlight or motion sensor light.
• Install a “clapper” if there is inadequate overhead light. They are usually battery-powered and are easily installed wherever necessary.
• Increase the bulb wattage if the lights are too dim.

Prevention is key when it comes to falls in the bathroom. These environmental modifications can help your patient complete their daily tasks safer and with less fear. As occupational therapists working in people’s homes, we can educate our patients on the benefits of a safer environment to improve their overall wellbeing and sense of independence.

For many older adults, accepting these changes or the need for “medical” devices can be an overwhelming feeling. I love to remind my patients that being proactive about their own safety can only enrich their life. A collaborative, patient-centered approach to treatment will reap the best results and get you on your way to reducing falls, one bathroom at a time!