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Continence by design.

Rachel Long is a freelance writer based in Tampa, Florida. She was the project writer for this month's Senior Living Design supplement.

Keeping things homelike was top of mind when Parkcliffe Eldercare Community in Toledo decided to add a new 24-unit building for people with mild-stage dementia. Window treatments, furnishings, ceiling heights, and other details all lend a cozy; residential feel. But then there are the toilets, which, along with the sinks, are open to the room. The bathroom-without-walls may not be "just like home,' but the designers hadn't lost sight of their goals. Rather, the toilets were placed to promote continence; though the idea is not without some controversy--visitors are often taken aback--some experts suggest that residents with dementia are more likely to use the fixtures if they can see and get to them without trouble.

If you are about to build a new facility or renovate an existing one, consider the potential impact of design on improving urinary incontinence (UI) among residents and easing operational demands of caring for residents who have irreversible incontinence or occasional accidental urinations. As long term care's multi-billion dollar problem--costing upwards of $6 billion yearly, according to some estimates--incontinence can strain staff, compromise aesthetics, and adversely affect residents physiologically and psychologically.

Close to 70 percent of the nation's nursing home residents and about 40 percent of those living in assisted living suffer from incontinence. Many of these residents are so functionally impaired by immobility or dementia that they are unable to toilet independently no matter what you do, says UI expert John Schnelle, PhD, who directs the Borun Center for Gerontological Research in Los Angeles. But in potentially treatable cases, Schnelle says that design can play an important role. Accessibility of toilets, for example, can make a big difference in curbing urinary incontinence, he says.

Architects and interior designers who specialize in dementia care environments focus on encouraging continence by not only making bathrooms more accessible, but also making it easier for staff to prevent or clean up after incidents of incontinence, and eliminating offensive odors and stains.

"Don't assume that because of a couple of days of UI, it's time for diapers and catheters," says Alan Stevens, PhD, assistant professor and co-director of the dementia care research program at the University of Alabama, Birmingham. "Maybe we can address the environmental factors and look at why [this has occurred]. Everything is fair game. You have to individualize everything to suit the cognitive perspective of the patient. Customize it until you find what works," he advises.

Streamline for staff

Any good designer will look for ways to simplify daily routines and save steps for staff. Stevens suggests focusing on changes that benefit nursing assistants, the caregivers most frequently assisting in toileting.

Clustering keeps laundry and linens close to resident rooms, typically providing linen storage substations for every seven beds and closets for soiled laundry for every 14 beds. John Shoesmith, AIA, who specializes in elder care housing at Dieterich Mithun Residential Care Studio of Mithun Partners in Seattle, advocates placing soiled utility closets adjacent to shower and toilet rooms to improve efficiency.

Shoesmith cites one innovative installation that put an attractive cabinet for clean linen storage at the entrance to each resident room. Of course, not all budgets allow for such placement--and some fire codes, he points out, prohibit it.

Designers nix mobile hampers and their usual stench. Odorous laundry and used disposable incontinence pads must be placed in utility rooms, says Susan DiMotta, ASID, vice president and director of interiors at Perkins Eastman Architects in New York City. "The key is utilizing the rooms as designed," she adds. "And there must be enough of them to be accessible to staff."

When it comes to assisting incontinent residents, staff need to have room to maneuver. Grab bars placed 18 inches from toilets to comply with the Americans with Disabilities Act and other codes allow little space for two staff members to stand--let alone bend or turn to help a resident. One simple fix: swing-away grab bars that buy additional space for a dual assist can often be approved despite code restrictions, according to Margaret J. (Peg) Cervantes, AIA, IIDA, director of interior design at O'Donnell Wicklund Pigozzi and Peterson Architects (OWP&P) in Chicago.

Promote continence

Encouraging continence among your residents can start with something as simple as installing bathroom floor and wall surface materials that contrast with the color of the toilet. By differentiating the toilet from its surroundings--defining edges and promoting depth perception--you can help a resident's aim. A black seat against a white toilet might provide a similar effect, but beware the institutional look, warns Cervantes.

Toilet visibility ranks among major contributors to improved continence in care facilities. Many designers make sure residents can see the toilet from the bed no matter where in the room it is placed.

The bathroom-without-walls at Parkcliffe Eldercare, designed by Dorsky Hodgson + Partners in Cleveland, is another way to help residents with dementia. Other adaptations can also improve the chances for continence. "Even open doors pr multiple doors would help. We need to change the environment to reduce limitations and disorientation," notes Stevens.

Pocket doors, which can be slid out of the way into the wall, are well worth the $80 or so in additional installation costs, says Martha Child, principal of Sterling, Virginia-based Martha Child Interiors, the design division of Sunrise Assisted Living. "They can be left open and yet be concealed, but they offer privacy if needed. They allow a direct sight line to the facility," she says.

The need for toilet visibility extends to public corridors as well. Open doors allow easier, quicker access, in addition to providing the advantage of allowing residents to see readily the bathroom interiors.

The right signs also help residents find toilets--in private rooms as well as public spaces. Shoesmith and Elizabeth T. MacPherson, IIDA, of Dieterich Mithun Residential Care Studio, have developed an outhouse symbol for dementia patients who remember the outhouses of their youth better than modern-day plumbing fixtures. An illiterate resident with dementia was helped by a picture sign on his bathroom door. After the change, he began to void independently again, reports Stevens. Keep in mind that where you place a sign is important as well: "Eye level" may be too high for residents in wheelchairs.

It's also vital to have an ample supply of accessible, easy-to-spot toilets. "Many times, there aren't enough bathrooms, especially in older facilities," says Cervantes. "[Improving the ratio] is our biggest obstacle in renovation. We find we're even reducing the number of beds for additions such as larger program and activity spaces, and certainly we're adding plenty of washrooms immediately adjacent."

Err on the safe side, suggests Shoesmith: "Put four bathrooms in good places where they'll be seen, then add four more." Placing bathrooms in the same locations on each floor allows you to stack your plumbing and save money during construction.

The flip side of encouraging people to void where they should is discouraging them from going where they should not. According to Stevens, design "don'ts" include fountains and other water features, vents and registers at or near floor level ("men urinate down vents"), and mirrors in the bathrooms of dementia residents. Mirrored reflections can work against continence, since a person with dementia who has lost the ability to recognize himself may see "another man" in the bathroom mirror and become agitated.

Keep it homelike

Good design can also help ensure that the cases of incontinence you can't prevent don't affect quality of life for residents or visitors. "You lose the visual, aesthetic, residential quality when you walk into [a facility] and it doesn't smell good," says architect David Dillard, principal of Three Architecture in Dallas.

The ideal solution starts with effective air handling systems. To draw odors out of soiled linen storage areas and bathrooms, "you need to make sure air is moving in the right direction," says architect Shoesmith.

Also essential are durable interior finishes and treatments that block odor-causing moisture and can be easily cleaned and thoroughly disinfected. Odor problems in interior finishes such as carpeting and upholstery begin when urine penetrates the surface. Technological improvements in backings and barrier treatments have created moisture-resistant and moisture-proof textiles and floor coverings that help control odors while maintaining a residential feel. "There are amazing things available today," says architect MacPherson.

For fabrics, shiny and slick is out. Specification choices range from vinyls to cloth-like impermeable upholstery (first printed, now available in wovens), as well as topical coatings or special backings.

"Everybody has graduated from the laminated look," agrees Martha Child. Unwilling to be restricted to fabrics that come pre-treated, Child often selects textiles on purely aesthetic grounds and then has them treated with a new flexible sealant. A caveat: That kind of customization doesn't come cheap; treating every piece of material in a typical project could add $10,000 or more to the budget.

There's more choice in attractive, incontinence-friendly carpet as well. Improved moisture-proof carpet backing, which promotes a residential look, allows carpet to be used almost anywhere. Though moisture-proofing adds $3 to $4 per square yard to the cost of carpeting, the process is essential. Once urine seeps into the latex backing of unprotected carpet, the smell is there to stay.

Where there was until recently only a limited selection of solution-dyed monotones and heathers, there are now appealing prints and an expanding pallette. The biggest advance in carpet aesthetics for long term care and health care settings stems from the development of more flexible backings that are moisture-proof but that permit the stretching necessary during installation to match larger-scale patterns, notes DiMotta. Designer Martha Child is working with manufacturers to develop new colors of the durable, solution-dyed carpets.

For bathrooms, acrylic resinous flooring is a significant advance. The poured flooring creates a seal at the floor-wall joint, preventing moisture seepage and related odors.

Selecting the appropriate furniture construction is also key. "Senior-friendly furniture" is a must, says MacPherson. Chair and sofa arms, high seats, and firm support can aid mobile persons in getting up and making it to the bathroom. Chairs with spaces between seats and backs allow thorough cleaning and prevent moisture build-up.

And don't forget aesthetics. It's common knowledge that making your facility homelike makes life pleasant for residents and staff and helps in your marketing efforts. But it may also help hold down incontinence. According to OWP&P's Cervantes, "Studies prove that institutional looks encourage institutional, dependent behaviors-almost encouraging [preventable] incontinence."
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Author:Long, Rachel
Publication:Contemporary Long Term Care
Article Type:Brief Article
Geographic Code:1USA
Date:Aug 1, 1999
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