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Robin Tuffley image
Robin Tuffley, Marketing Manager for Closomat

The content for the original core document by Closomat – ‘Occupational Analysis: Activity analysis of toileting’ – was developed by Occupational Therapists Sarah Baxendale and Carolyn Leach, which can be downloaded from Closomat’s website: https://www.closomat.co.uk/images/downloads/campaigner-resources/OT_TA.pdf

Here, Robin Tuffley, Closomat Marketing Manager, has translated the original document into an article for AT Today.


Toileting is one of the most intimate personal activities of daily living a person needs to engage in. When living with an illness or disability, a person’s occupational participation and performance when toileting can be impacted.

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Therefore, solutions that may help by promoting independence whilst maintaining dignity and privacy need to be considered.

Alter the approach to the task or adapt the environment

“Using a client centred approach through occupations enable the service user to participate in activities of everyday life. This is achieved by working collaboratively with the service user, family and carers to enhance their ability to engage in occupations they need to, want to, and expected to do. This can be done by modifying the occupation or the environment to better support their occupational engagement” (WFOT, 2012).

If we undertake an activity analysis of an individual using a toilet, it is obvious that the user must coordinate a complex combination of physical and cognitive tasks.

Overt and covert steps involved prior to using the toilet

The first step in the process of using a toilet is body awareness. The user will understand the resulting sensations of needing to eliminate their bladder and/or bowel.

The ability to picture actions (symbolic thought), plan (problem solve) and our memory begin to develop around one years old – around the time we traditionally begin to learn how to use a potty.

The user will be able to recall, from memory, the correct sequence involved in using the toilet.

The body’s motor system (nerves and muscles) control movement. For the user to carry out the required movements, messages are sent to the brain (motor cortex). From there, these messages travel to the brainstem, spinal cord, nerve cells and finally to the relevant muscles.

A body has three planes of movement: sagittal (forwards/backwards), frontal (side to side) and horizontal (rotation).

The user will stand and walk to the bathroom, navigating objects such as stairs and doors along the way via gross motor skills:

  • Flexion, extension in the sagittal plane
  • Abduction/adduction in the frontal plane
  • Medial and lateral rotation in the horizontal plane

The user will coordinate their body’s movements. These movements assist the user to stand, walk and sit when using the toilet.

The user’s muscle tone will be high enough to withstand gravity but low enough to allow selective movements. Additionally, the vestibular system will help maintain their balance throughout all gross movements.

Gross motor skills:

  • Coordination
  • Balance

The user will navigate the environment without bumping into objects and will be able to reach successfully for objects such as door handles. They will be able to recall from memory the location of the bathroom or be able to follow signage.

Fine motor skills:

The user can navigate holding tools in a particular orientation for their functional use (unfastening buttons, pulling clothing up and down). They know where their body is in relation to the space and they can deal with sequencing.

Overt and covert steps to use the toilet

  • Gross and fine motor skills
  • Co-ordination of muscle and balance
  • Object recognition
  • Balance
  • Visual
  • Sequencing

The user will identify the toilet as opposed to other fixtures (e.g. washbasin) and walk over. The user will position themselves with the toilet behind them, lower clothing items and seat themselves into the correct seated position on the toilet pan. They will allow their muscles time to relax in order to begin the process of voiding.

Overt and covert steps involved after using the toilet

  • Gross and fine motor skills
  • Co-ordination
  • Muscle tone
  • Balance
  • Visual
  • Tactile
  • Sequencing

The user will locate the toilet paper, take the required number of sheets and wipe, then place the tissue down into the toilet pan.

Socio-cultural considerations

Toilet talk can be taboo. The word “toilet” can be considered in some cultures as dirty, whereas asking to use the restroom or bathroom is considered more appropriate. People will admit to struggling to get up from a chair but would be reluctant to make the same admission about a toilet.

Consideration must to be taken into account that every country has its own social and cultural norms when it comes to toileting and each user has their own habits, values and routines (LaVine, 2018).

Evidence base

According to the NHS (2018), falls are a common occurrence in those aged over 65 or in those with a long-term health condition. It also highlights that falls are most likely to happen in areas such as the bathroom.

Falls have been linked to a loss of confidence, a person becoming withdrawn and a loss of independence, and the estimated cost of falls to the NHS is £2.3 billion per year (NICE, 2013; The Kings Fund, 2013).

Furthermore, the average projected cost of a fall per person is £189,222 with one in three people over the age of 65 being at risk of a fall (Kings Fund, 2013).

Once a person has fallen, they are more likely to fall again within the same year and the hospitalisation costs of a fall are not as high as the aftercare and subsequent treatment of the fall (Kings Fund, 2013).

Reducing or eliminating care cost through the provision of equipment

A care package costs approximately £15 per hour – that’s nearly £11,000 per year if you have a carer for 14 hours a week to assist with toileting; if you need full-time care during the day, costs start at £30,000 per year (Money Advice Service, 2018).

Social costs of illness

There is a growing interest in incorporating informal care in cost-of-illness studies as a relevant part of the economic impact of some diseases with the average hourly unit cost being £11.43 per hour. (Oliva-Moreno, Trapero-Bertran, Peña-Longobardo del Pozo-Rubio, 2017).

Equipment vs carer

A wash & dry toilet with a toilet lifter can reduce or even eliminate the need for care intervention. The combination enables the individual to use the toilet, safely transfer on and off, and be assured of being clean after.

A toilet lifter provides the benefits from rise & recline chairs for a toilet. It automatically, and in a controlled manner, lowers and raises the user over the toilet, maintaining their centre of balance. Some versions deliver tilting to ease the user to standing and vertical which require a degree of lower limb strength.

The wash function of the toilet can address dermatological issues. The douche washes the anus and rectum, thoroughly removing faecal and urinary residue without the abrasion inherent in cleaning with paper or wipes. It ensures residue between skin folds is removed. The drying function ensures the skin is left dry without residual dampness.

Cost-effectiveness analysis

  • Closomat Palma Vita wash & dry toilet and Aerolet toilet lifter provide a one-off cost at £5,735 for both.
  • A ten-year service and maintenance (one-year warranty then nine years at £195 per unit) plan for the Closomat Palma Vita and Aerolet costs £3,510.
  • A care package covering 14 hours per week at £15 per hour costs £109,200 over ten years.

Thus, over a ten-year period (more than the typical duration of long-term care (https://www.mylifesite.net/blog/post/so-ill-probably-need-long-term-care-but-for-how-long)), based on these assumptions, a Closomat Palma Vita and Aerolet would save social care budgets £99,690.

Based on the same assumptions, the Closomat Palma Vita and Aerolet cost versus a 14-hour care package would pay for itself in under nine months.

For more information on the technical specifications or to request a free no-obligation quotation, please visit: www.closomat.co.uk

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