Guest Author: Pat Quigley, PhD, APRN, CRRN, FAAN, FAANP, FARN, is a falls prevention expert. More detail can be found at the end of this article.
Takeaway:
Prioritizing fall prevention matters for all of us because our risk of falling and being injured increases as we age. Those changes make falls more likely to lead to serious outcomes, including hip fractures and head injuries.
Complexity of Toileting
Toileting involves: Getting to and from the bathroom, on and off the toilet, undressing and redressing, urinary and fecal elimination, self-cleaning, and personal hygiene. All of these become even more complex for people having urinary problems, such as incontinence, bladder accidents, or bowel problems such as diarrhea. Sometimes medications like diuretics increase urinary frequency for the first 2-3 hrs. after administration, or cause muscle weakness, gait and balance problems, and/or coordination problems. Many of these lead to the need for physical help in order safety perform the tasks listed.
Understanding “Safe” When It Comes to Toileting
We asked patients treated in our clinic to draw a picture of their bathroom, entrance in and out of the bathroom, location of the toilet near the sink/shower/tub, presence and location of grab bars, which most did NOT have. I know from experience that the lack of grab bars is a major safety risk, because most of our patients needed grab bars to hold onto as they safely lowered onto the toilet, and safely pushed up from toilet to stand and transfer away from the toilet. Importantly, grab bars need to be securely mounted to the wall and appropriately positioned for the height, reach and strength of the person who is using them.
In our experience, conversing about toileting helped patients to realize that their desire for independence resulted in their overestimating their ability to safely toilet. These were awkward conversations – difficult but essential for fall prevention.
I know many persons, whose functional abilities have decreased but who are unwilling to admit that it has become too difficult for them to get into and out of the bathroom, or to access the toilet. Yet, this is the very reality that must be addressed to reduce each patient’s fall-risk.
Recognizing this creates opportunities to learn that help can be provided by primary care providers, rehabilitation specialists or occupational therapists. These are clinically trained people who will conduct home environmental safety assessment and recommend durable medical equipment (I.e., grab bars, raised toilet seats, non-skid flooring) that will modify environments in ways that reduce the risk of falling yet optimize whatever standing and sitting strength a person still has.
Still, there comes a time when using even that special equipment is no longer safe. This is usually when people keep trying to get to the bathroom and onto the toilet safely and in time to avoid an accident but begin to be too late This is when people are most likely to fall.
Bedside Commodes
This is the time when other types of special equipment become the most appropriate. For example, a Bedside Commode (BSC) was the second most frequently recommended home device that we ordered into our Falls Clinic, second only to walking devices (the correct walker or cane). Insurance would pay for 1 bedside commode; an Occupational Therapist would conduct a home evaluation to set up the bedside commode either in the bathroom to make sure it fit, and if not, at the patient’s bedside. The Occupational Therapist would train the patient, family and caregivers on transfer, sitting and rising skills to safely transfer onto and off of the commode from standing or seated position, complete personal hygiene, including undressing and redressing. These are skilled services that ensure each patient, family and caregiver feels competent and safe to manage modified toileting using a bedside commode, including how to maintain cleanliness of the commode.
For some persons, use of a bedside commode is temporary. For others, bedside commodes may be needed permanently, such as persons living with stroke or spinal cord injury who do not have an adapted bathroom modified for their disability. There are a variety of BSCs available on the market with very different features, each designed to support a specific type of need. The result is that there is no one single model that safely meets the needs of all patients. A given model may work for someone who can stand up, turn and pivot and sit back down – but not for someone who can only slide from one surface to another. This becomes a problem in hospitals and nursing homes that purchase only one type of bedside commode.
My Great Aunt Marty was an example of someone who could/could not stand/pivot. At 89 years of age, she fractured her pelvis from a fall. My husband and I cared for her over the course of 2 wonderful months. By then, she was independent enough to return to her home. Her story is shared in the blog article: When a Traditional Bedside Commode Didn’t Work.
Together we learn more.
About the Author
Patricia A. Quigley, PhD, APRN, CRRN, FAAN, FAANP, FARN
Nurse Consultant
Pat Quigley, PhD, APRN, CRRN, FAAN, FAANP, FARN, is a falls prevention expert whose work is referenced throughout this microsite. As a rehabilitation advanced practice nurse, she has specialized in fall and fall injury prevention focused on vulnerable, high-risk, elderly, and frail persons across settings of care throughout the United States and internationally.
Personal Statement
Let me briefly introduce myself to you. I’m thankful to be 72 years old, still going for 100! I’m married, living in Florida, the Sunshine State, for 53 years, in the same home for 35 years. I am celebrating my 51st year as a nurse, living the dream of my life — a practitioner, educator, publisher, scholar, and scientist.
Speaking From Experience:
For 3 decades, I have written about fall and injury risk factors for both general and special populations including persons living with disabling and debilitating conditions, chronic diseases, and traumatic injuries. In each case, we found a unique set of fall and injury risk factors that required individualized interventions to minimize or eliminate those risks. These individualized plans of care also consider the environment in which patients live, seek and receive healthcare, realizing that as we age, our environment may need to be adapted to meet our needs.
I worked with clinical team members for years running a Fall Prevention Clinic treating adults referred to us because they either had concerns or fear of falling, were falling, and/or had already experienced fall-related injuries. During each person’s clinic visit, my team and I completed a 2-hour assessment to understand their functional independence and limitations. This assessment included toileting -the most private topic that patients were usually reluctant to talk about.
That’s because toileting is a very personal part of daily life. Most people think talking about it means that they are losing control, that admitting to it means they will be seen as unable to take care of themselves anymore. Yet, it is so important in the context of fall prevention: where someone toilets is the most important factor we consider because falls that happen in bathrooms are dangerous and can result in grave, life threatening injuries.