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Request for Proposal
Improving Bathroom Utilities Design for Alzheimer’s Disease Patients

March 2nd 2014 TBA3012T1

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Abstract This report details a request for proposal for design solutions addressing the need of safe and independent shower usage by Alzheimer’s patients. The emphasis is placed on homebound patients, who extensively rely on caregivers for help in all aspects of showering, including entering and exiting the shower. A survey conducted by the Alzheimer’s Association reports that over 30% of Alzheimer’s patients required aid in the bathroom (see figure 10). In this same study, 31% of Alzheimer’s patients required help bathing, compared to the 23% of other older people. This leads to show that showering and bathing can become a hassle, and even more so for Alzheimer’s patients who have a higher risk of injuring themselves, from falls, burns and scalding or electrocution [1]. This is due to the factors of aging, and the symptoms of Alzheimer’s and its effect on cognitive ability.

Design proposals are requested such that they improve the quality of life of the patients themselves and their respective stakeholders, which is outlined in full in the report. The solution should promote independent usage of the shower or bath system, while maintaining safety as the utmost priority. The solution should balance patient privacy, with safety and injury prevention, so that caregivers and family members may be relieved or have their number of responsibilities reduced. As well, ease of use and installation should be considered to appeal to the caregivers, and additions to existing shower systems should be preferred over remodeling. Possible multifaceted solutions should have a greater effect on preventing injury in the shower [2].

References 1. Oleske DM, Wilson RS, Bernard BA, Evans DA, Terman EW, Epidemiology of injury in people with Alzheimer's disease, Journal of the American Geriatrics Society [1995, 43(7): 741-746]. 2. Oliver, D., Connelly, J. B., Victorm, C. R., Sahw, F. E., Whitehead, A., Gene, Y., Vanoli, A., Martin, F. C., & Gosney, M. A. (2007). Strategies to prevent falls and fractures in hospitals and care homes, and effect cognitive impairment: Systematic review and meta-analysis. British Medical Journal.

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Table of Contents
1. Introduction ............................................................................................................................................ 5 2. Community Definition: Moderate Alzheimer Patients in the Greater Toronto Area ............................. 5 2.1 Alzheimer’s Disease Classification ..................................................................................... 5 2.2 AD Patients as a Community .............................................................................................. 5 2.3 Challenges Faced by Moderate AD Individuals .................................................................. 6 3. The Challenge of Independent Bathing .................................................................................................. 6 3.1 Cognitive Domains in Bathing ............................................................................................ 6 3.2 Physical Domains in Bathing .............................................................................................. 6 4. The Engineering Design Problem .......................................................................................................... 7 4.1 Brief Outline ........................................................................................................................ 7 4.2 Short Term Consequences ................................................................................................... 7 4.3 Long Term Consequences ................................................................................................... 8 5. Stakeholders ........................................................................................................................................... 8 5.1 The Alzheimer’s Patients .................................................................................................... 8 5.2 Caregivers............................................................................................................................ 8 5.3 Alzheimer’s Disease Support Groups and Sponsors ........................................................... 9 5.4 Bathroom Utility Manufacturers ......................................................................................... 9 6. Engineering Requirements ................................................................................................................... 10 6.1 High-Level Objectives ...................................................................................................... 10 6.2 Detailed Objectives ........................................................................................................... 10 6.3 Detailed Requirements ...................................................................................................... 10 6.4 Summary of Requirements ................................................................................................ 11 7. Reference Designs ................................................................................................................................ 12 7.1 Walk-In Bathtubs .............................................................................................................. 12 7.2 Reclining Bath-Lift............................................................................................................ 13 7.3 Large Area Floor Sensor ................................................................................................... 13 8. References ............................................................................................................................................ 15 9. Appendix A: Stakeholder Engagement Feedback ................................................................................ 18

10. Appendix B: Reference Statistics ......................................................................................................... 19

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1. Introduction Alzheimer’s disease is the most common form of dementia, a common disease that occurs to individuals of varying age, from as young as 40 years old to 90 years of age [3]. There are currently about 87,000 incidences of dementia in the GTA and this is expected to increase to over 90,000 within the next decade [4]. Of this population, 60 to 80 percent experience Alzheimer’s disease, thus creating a prominent community in the GTA [3]. This degenerate disease damages an individual’s brain cells and neurons, creating plaques and tangles that are fatal to the nervous system [5]. Alzheimer’s patients can experience a variety of symptoms including deficiencies in mental and physical abilities and extreme changes in emotions, moods and behaviors [6, 7]. Due to these impairments the constituents of this particular community experience numerous daily household activities that can potentially become challenging and hazardous [8, 9]. This situation creates a burden that both the Alzheimer’s patients and their caregivers must bear and will be the focus of this proposal. This request for proposal will specifically request for accessories that can be implemented onto current conventional bathtubs and showers, which in turn will promote the independent usage of the bathroom for Alzheimer’s patients. The community and the problem will be further defined in the proceeding report to greater detail, along with the stakeholders. Specific requirements and reference designs that may aid in the derivation of a potential solution will be discussed for further reference.

2. Moderate Alzheimer Patients in the Greater Toronto Area 2.1 Alzheimer’s Disease Classification Alzheimer’s disease (AD) is one of the common forms of dementia. Dementia is characterized by a loss of or decline in memory and other cognitive abilities [10]. The patient will experience decline in memory and cognitive abilities. Such as coherent speech, motor activities, or to think abstractly [11]. The decline in cognitive abilities is severe enough to interfere with daily life. Depending on the severity of that interference, AD is categorized into 3 stages: mild, moderate, and advanced [12]. 2.2 AD Patients as a Community The community is defined and classified as moderate AD patients living at home within the Greater Toronto Area (GTA) [14]. To differentiate, moderate AD patient exhibit problems with cognitive abilities (memory, language, etc.) that are severe enough to impose dependency for activities of daily living (ADLs) [13]. This dependency, however, is not to the extent that the AD patients are completely reliant on their environment. This differs them from milder to severe (advanced) cases. Statistically, there are approximately 87000 cases of reported of Alzheimer’s disease within the GTA, with the majority being elders over the age of 65 [15]. Long-term care facilities cited that around 75% of AD patients are eventually admitted to a nursing home as the disease progresses [22]. The increase in difficulty in accommodating the special needs of AD patients is prominent for influencing the latter trend [16].

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2.3 Challenges Faced by Moderate AD Individuals Moderate AD patients experience noticeable cognitive, physical, and psychological changes. This leads to challenges and needs unique to them [21]. As neural damage spreads, the patients’ ability to remember new information worsens. They may find it difficult to perform ADLs that they were once able to exercise. Also, confusion, impaired judgment, or aggression could preside over the individuals with AD. As a result, unintended circumstances follow. ADLs, such as eating, walking, bathing, or dressing can become impaired. Many of these tasks require a combination of different cognitive abilities such as hand-eye coordination, balance, motor coordination, or object recognition; abilities that AD destroys. This causes the majority of AD patients to require step-by-step assistance in accomplishing such ADLs. For moderate AD patients, assistance is mostly required for performing complex and unfamiliar ADLs rather than repetitive ones such as eating or drinking. Certain repetitive tasks, with varying complexity, can be still be accomplished by moderate AD patients because it is all based upon habitual skills derived from long-term memory, while some tasks cannot be [19]. After engaging with Mrs. Wong (Appendix A), we learned that a particular activity that degrades the quality of life is for AD patients to bath or shower independently, which will be the focus of this RFP.

3. The Challenge of Independent Bathing The difficultly of independent bathing is exhibited by the community of AD patients. Bathing is a complex ADL requiring cognitive and physical abilities including balance, strength, coordination, and executive function [16]. As earlier, mentioned these abilities may become impaired as AD progresses. Moderate AD patients generally require supervision while bathing to ensure safety and comfort. Bathing as an ADL is difficult to accomplish based upon habitual skills because the patients experience challenges in both cognitive and physical domains [17]. 3.1 Cognitive Domain in Bathing The process of bathing is generally complicated by the executive dysfunction experienced by moderate AD patients [16]. The planning and execution of steps in sequence impede individuals with AD in the ADL (bathing). For instance, they may have difficulty adjusting the water temperature, or properly using the showering equipment. This impedance can consume time and effort as the patient struggles to perform the ADL. Frustration and anxiety may follow. Besides decreased efficiency, moderate AD patients have decreased perception in motor activities [18]. They may fail to perceive the texture of the shower or bathtub and risk the chance of falling. They may also be insensitive to environmental factors such as water temperature and be susceptible to scalding, and other dangers [17]. 3.2 Physical Domain in Bathing The primary physical challenge to bathing is mobility impairments due to AD and the elderly age of the patient [24]. Reduction in muscle strength and range of motion of body joints prevent the patients from independently bathing in a standing posture [23]. While bathing, moderate AD patients have a tendency for loss of balance, resulting from disturbances in central processing related to motor planning [21]. As a result, the community has a demand for shower designs that include well-positioned supports

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such as grab bars and slip-resistant surfaces. Furthermore, moderate AD patients can be become engulfed while deciding between the relevant and irrelevant details present within the environment due to selection inhibition deficits and their choice reaction time. Two common factors that decrease mobility. This causes moderate AD patients to become distracted from the current ADL being performed to irrelevant matters [17].

3. The Engineering Design Problem 3.1 Brief Outline of the Problem As covered in Section 2, Alzheimer’s patients experience both cognitive and physical challenges during bathing. Their decreased cognition leaves them vulnerable and prone to accidents in many regular bath/shower facilities as they are currently designed. Currently, bathtubs and showers used by Alzheimer’s patients in senior care homes and other such facilities have few modifications from regular bathrooms. These handrails near and in the shower, as well as non-skid mats on the bathtub/shower floor. [20] However, as shown under Reference Designs, these additional features have drawbacks. Additionally, patients in the moderate stage of Alzheimer’s may require varying degrees of assistance from caregivers, which decreases their sense of dignity and independence leaving them more reluctant to perform tasks by themselves. Statistics show that about one third of family caregivers assist their AD patient with bathroom needs, including bathing. [29] This RFP addresses the following problem statement: Improve independent bathing experience for homebound moderate AD patients. 3.2 Short Term Consequences Providing an improved bathing facility in the home for AD patients would improve the quality of life of both the patients themselves and consequently their caregivers.  A bathing facility that protects the patient from their own unknowing actions will greatly reduce the frequency of accidents and injuries in the bathtub/shower. For instance, temperature control can prevent AD patients from putting scalding water on their skin as they begin to lose their perception of temperature [24]. In addition, research shows that Alzheimer’s patients are 4 to 5 times more prone to falling than regular seniors [24], and as such a safe bathing facility that addresses this is required. A bathroom design that takes into account the cognitive disabilities of AD patients such as incorrect depth perception of water [24] will substantially improve the quality of life of the patient as they will not have to face unpleasant emotions such as fear when bathing. A bathtub/shower system designed for mobility impairment will allow patients to enter and exit safely as well as move around in the bath and wash them with relative ease [20]. Having a simple shower system that is easy to use for those with cognitive impairment will reduce the amount of confusion for the patient and allow the patient to wash himself/herself properly.

 

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3.3 Long Term Consequences Many AD patients associate the thought of showering with negative emotions, as the experience may be confusing or frightening to them. Improving bathing facilities such that they have a comfortable bathing experience with a much lower frequency of accidents will increase their confidence and allow them to maintain their sense of dignity. As a result, they are likely to become less hesitant to take a bath or shower over time. This also is a benefit for caregivers as well as they will require less effort to persuade their AD patient to take a shower.

5. Stakeholders 5.1 The Alzheimer’s Patients The primary and largest stakeholders of this problem are the Alzheimer’s patients themselves. Due to the extensive effect that moderately staged Alzheimer’s has on cognitive ability, this should be the focal point of design [12]. This diminished cognitive ability leads to an amplification of everyday mistakes that could be dangerous for the patients. For example, patients may forget which tap is for hot water, and may become scalded. However the aim of this project is also to promote privacy and dignity of the patients themselves, as such, design teams must decide on the balance with safety. At the moderate stage of Alzheimer’s many patients will be able to recognize and enjoy the benefits of independently showering, and they will appreciate the increased privacy [23]. Regardless of the stage of Alzheimer’s we believe it is in the best interest of the patients and the other stakeholders that shower systems become safer for autonomous usage. 5.2 Caregivers Since the Alzheimer’s disease does not have a cure and its effects cannot be reversed, the patients require additional assistance as the symptoms become progressively severe. The disease affects an individual in such a way that menial tasks that may be simple but necessary on a daily basis, challenging and hazardous. Caregivers can include a wide range of population who assist the patients in these tasks to prevent possible problems and injuries. This community may include the nurses or volunteers at health institutions or retirement homes, as well as the patients’ relatives or families. There are more t han 15 million Americans that provide unpaid care for Alzheimer’s patients, primarily consisting of family members and relatives of the patients. In 2012, the community of unpaid caregivers provided an estimate of 17.5 billion hours of labor, resulting to a cumulative value of about $216 billion USD [1]. This community should be recognized as a significant stakeholder due to the fact that the caregivers are directly affected by the severity of the disease, which correlates to the amount of assistance the patients require. By providing a solution to the problem statement “To promote independent usage of the bathroom, to preserve dignity & self-respect for Alzheimer patients,” the caregivers will gain implicit benefits since the promotion of independence of the patients will relieve them of the concern for the patient’s well-being and safety to some degree, as well as possibly strenuous or dangerous physical labor that may be involved in the process of caregiving.

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5.3 Alzheimer’s Disease Support Groups and Sponsors Within the GTA, Alzheimer disease support groups and organizations play a significant role in providing support, information and education to people with dementia, their families, and caregivers [28]. Organizations such as the Alzheimer Society of Toronto (AST) not only increase the public awareness on dementia-related topics but they also promote research, and advocate for services that respect the dignity of Alzheimer patients [28]. Research initiatives such as the ASRP (Alzheimer Society Research Program), has funded over $40 million in grants and awards since its inception in 1989 and is currently facilitated by the AST [29]. It provides biomedical research opportunities for both PhDs and MDs that aim to develop technologies to enhance quality of life, care and safety for people affected [28]. In our research process, we were able to contact members working with the Alzheimer Society of Toronto and acquire recommendations for possible improvements on the quality of life for Alzheimer ’s patients. 5.4 Bathroom Utility Manufacturers It would be in the best interest of bathroom utility manufacturers to produce more utilities oriented toward Alzheimer’s patients, seeing as Alzheimer’s is the most common type of dementia and about 11% of the population, aged 65 and older have Alzheimer’s disease with an estimated total of 5.2 million in 2013 [42]. As it is a degenerative disease, the stage where washroom assistance is required is inevitable, and at that stage specialized utilities will prevent accidents and injuries as well as greatly aid patients in using the bathroom more independently. Bathroom utility manufacturers would profit from producing the necessary items that would improve the quality of life of Alzheimer’s patients and their caregivers, which is unfortunately a growing community.

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6. Engineering Requirements 6.1 High-Level Objectives 1. To improve independent bathing experience for moderate AD patients 2. To preserve dignity and self-respect, and increase the quality of life for AD patients. 6.2 Detailed Objectives 1. To design and propose a solution that increases the independence of moderate AD patients when using bathroom utilities. 2. The solution should accommodate multilateral needs in cognitive, and physical domains. 6.3 Detailed Requirements Design for Illumination To provide sufficient bathing illumination that reduces glares and increase safety [30]. Design for Simplicity To propose a solution that reduces the time of control tasks involved with bathing such as adjusting water temperature, initializing the shower equipment, etc. [30] Design for Safety To propose a solution that does not affect the physical stability of AD patients, i.e. does not increase cognitive demands while performing the primary task [31]. Design for Strength Reduction in handgrip strength in usage of the solution or device that require actions such as pushing, pulling, lifting, twisting, and pressing [33]. Design for Sensitivity To prevent misperception of object surface characteristics that may pose environmental dangers such as scalding or slipping [34]. Design for Accessibility To propose a solution that is available to the largest set of users possible within the scoped community; as defined by the problem statement, the solution must promote independent usage of bathrooms by Alzheimer’s patients. Design for Cost To propose a solution with cost that is within the community’s budget, and not divergent from the cost of pre-existing products that strive to solve a similar problem or potential competing solutions.

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6.4 Summary of Requirements Requirements Explanation Metric Reduction of high intensity light concentration and to even out the light in the environment. The complexity of the task involved. Cd/m2 (Candela per Square Meter) Criteria Gradient The lower the intensity the better. Must at least maintain a level of illumination of 100 cd/m2 [30]. Constraints

Design for Illumination

Design for Simplicity

The time required accomplishing the task.

The smaller the time interval the better.

Must not increase the difficulty in operating or using the solution. Should not introduce factors that induce physical instability. Force required must in task not exceed 20 Kg IGS [32]. N.A.

Design for Safety

Prevention of fall due to loss of balance.

The presence of stability installments (grab bars, handle, etc.).

The more installment the better. The more accessible the better. The lower the force required the better.

Design for Strength

The strength required for task completion.

Kg (Isometric Grip Strength, IGS) [35] Presence of frictional characteristics of surface texture. Number of applicable groups within the specified community.

Design for Sensitivity

Should provide extra texture to offset the perceptual loss.

The more sensitive to the user the better.

Design for Accessibility

Solution must be applicable to a wide range of constituents of the community.

The larger the amount of applicable groups the better.

The applicable groups must be inclusive in the community defined in this RFP. Within the consumer’s budget as well as the cost of other competing solutions.

Design for Cost

Cost should be within reasonable range.

CAD or USD (Canadian Dollar or US Dollar)

The less the cost is, the better.

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7. Reference Designs 7. 1 Walk-In Bathtubs One of the potential solutions for slip and fall prevention is removing the procedure of standing in the bathtub or stepping inside it. Removal of these features introduces the idea of walking into the bathtub through implementation of a door and a seat inside of the bathtub. These are commonly addressed as a walk-in bathtub [39], and the model that will be observed in this document will be a walk-in bathtub provided by Carefree Fig 1. Walk-In Bathtub Model [40] Bathing Canada Inc. The company features numerous models but listed below are some of the key features the bathtubs have in common. Key Features  Durability and Maintenance Steel support frames provide stable and durable structure. The main structure of the tub is manufactured with combination of fiberglass for strength and stability. Finished with high quality gel coat, the structure requires minimal maintenance. Additionally, the stainless steel door hinge and the marinequality rubber door seal assures a durable and secure method of leak prevention.  User-Friendliness The entry point of the tub is very low level and requires minimal assistance as the door opens inwards, allowing the user to easily enter and sit down. The user does not have to remain standing while closing the door, or reposition their legs when exiting.  Safety Installments All models have slip-resistant floors and surfaces installed. The seat is 17.5” tall, providing a comfortable height for ease of user-interface. Scalding can be prevented due to the pre-set temperature that can be assigned during installation. With a grab bar for additional security and fast drainage system, the walk-in bathtub provides a safe user experience. Although the walk-in bathtub is a viable solution in many of the aspects discussed previously in this document, this particular reference design fails to meet the constraint of cost
Fig 3. Grab Bar Installment [40] Fig 2. Diagram of the Framing [40]

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efficiency, as a walk-in bathtub costs at an average of $3,500 USD [41]. 7.2 Reclining Bath-Lift How This Helps The reclining bath lift is a seat which allows the patient to be lowered into the tub and allows the backrest to be reclined at various angles, thus aiding the patient from a seated position to lying down and vice versa. [42] At its full height, the height of the seat matches that of a standard bathtub. The seat contains a pad (blue circle in the third image) that swivels around, allowing the patient to sit on the seat from outside the tub, then turn and bring their legs inside. Stabilizers on the bottom of the lift frame allow the lift to be secured to the bottom of the tub. Giving the Alzheimer’s patients a seat in the bathtub may reduce their fear of the depth of water as their depth perception becomes impaired. Deficiencies In The Design The system is operated using a simple remote, although the patient may not be capable of using it, which would therefore require caregiver supervision.

Figure 4. Bath-Lift Model: Bath Mode [42] 7.3 Large Area Floor Sensor

Figure 5. Bath-Lift Model: Lift Mode [42]

The textile floor sensor is a pressure-activated device used to notify caregivers or nurses if patient has fallen on the floor. The device comes in a variety of textile materials to match the existing floor of the bathroom and shower, and are 100% enclosed in PVC for water protection [38]. When a pressure threshold is passed, indicating a fall, it can remotely alert the caregiver, who does not need to be in proximity of the bathroom. These devices are a safeguard towards injury due to falls in the bathroom. Alzheimer’s patients are especially susceptible to injury either through neglect or failing sense of logic. A study conducted by the Faculty of Health Sciences at the University of Ottawa found that almost 15% of the 550 seniors participating in the study experienced falls related to bath or shower transfers [36]. As

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such the necessity for such devices is evident. As well, the manufacturer of this product states, “The SensFloor system is suitable for public buildings and has already been used in care homes for Alzheimer patients.” [38], and thus this product can be easily transferred to homebound patients as well. How This Helps The floor sensor adds a layer of privacy to the patient’s usage of the bathroom, and in combination with other shower accessories this can relief the caregivers of any insecurities about the safety of their loved ones. For less severe stages of Alzheimer’s this product may completely relieve the caregiver the need to monitor patients entering and exiting the shower or bath. As well this sensor mat has upgrades to provide live pressure monitoring and is 100% washable. Deficiencies In The Design The sensor only detects pressure changes and does not actually inform caregivers of the real situation or condition of the patient. As such it does not prevent possible falls, it only alerts caregivers of falls after they happen, therefore it does not improve the safety of independent shower usage [37]. Also the caregiver will not be directly with the at-risk patient and thus this increases the response time needed to help the patient.

Fig 6. Pressure-Fall Detector [38]

Fig 7. Actual Installation in a home-setting [39]

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References 3. (2014). 2013 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association. U.S. [Online]. Available: http://www.alz.org/downloads/facts_figures_2013.pdf. [Assessed January 6 2014]. 4. Hopkins. Robert. “DEMENTIA PROJECTIONS FOR THE COUNTIES, REGIONAL MUNICIPALITIES, AND CENSUS DIVISIONS OF ONTARIO” Alzheimer Society of Canada. Internet: http://www.alzheimertoronto.org/pdf/brochures/Hopkins2010.pdf. [Assessed January 10 2014]. 5. What is Alzheimer’s?, Alzheimer’s Association, [Online], http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp (Accessed: 15 February 2014) 6. Statistics, Alzheimer Society Toronto, [Online], http://www.alzheimertoronto.org/ad_Statistics.htm (Accessed: 15 February 2014) 7. “What is Alzheimer’s Disease?”, Alzheimer Society of Toronto, [Online], http://www.alzheimertoronto.org/ad_whatIsAD.htm (Accessed: 15 February 2014) 8. Home Safety Tips: Preparing for Alzheimer’s Caregiving, Mayo Clinic, [Online], http://www.mayoclinic.org/home-safety-tips/art-20046785?pg=2 (Accessed: 15 February 2014) 9. Identifying Alzheimer’s Bathroom Safety Issues, Alzheimer’s-in-your-home, [Online], http://www.alzheimers-in-your-home.com/alzheimers-bathroom-safety.html (Accessed: 15 February 2014) 10. "Alzheimer Society of Toronto - What Is Dementia?" Alzheimer Society of Toronto - What Is Dementia? [Online]. Available: http://www.alzheimertoronto.org/ad_whatIsDementia.htm. [Assessed 8 Feb. 2014]. 11. "Types of Dementia." Alzheimer's Association. [Online]. Available: http://www.alz.org/dementia/types-of-dementia.asp. [Assessed 12 Feb. 2014]. 12. "Stages of Alzheimer's Disease." Alzheimer's Association. [Online]. Available: http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage4. [Assessed 10 Feb. 2014]. 13. "Caring for a Person with Alzheimer's Disease." National Institute on Aging. [Online]. Available: http://www.nia.nih.gov/alzheimers/publication/caring-person-alzheimers-disease. [Assessed 9 Feb. 2014]. 14. "Map of Greater Toronto Area." Wikipedia. Wikimedia Foundation, n.d. [Online]. Available: http://en.wikipedia.org/wiki/File%3AGreater_toronto_area_map.svg. [Assessed 7 Feb. 2014]. 15. "Definitions in English." Need: Definition of Need in Oxford Dictionary (British & World English). [Online]. Available: <http://www.oxforddictionaries.com/definition/english/need? q=need>. [Assessed 15 Feb. 2014]. 16. Brawley, E. C. "Environmental Design for Alzheimer's Disease: A Quality of Life Issue."Aging & Mental Health 5.Sup001 (2001): 79-83. 17. Schultz, Albert B. "Mobility Impairment in the Elderly: Challenges for Biomechanics Research." Journal of Biomechanics 25.5 (1992): 519-28.

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18. Northridge, M. E., M. C. Nevitt, J. L. Kelsey, and B. Link. "Home Hazards and Falls in the Elderly: The Role of Health and Functional Status." American Journal of Public Health 85.4 (1995): 509-15. 19. Bathrooms and bathing, Dementia-Friendly Environments- A guide for residential care, [online] January 2014, http://www.health.vic.gov.au/dementia/changes/bathrooms.htm (Accessed: 8 February 2014) 20. Managing toilet problems and incontinence, Alzheimer’s Society: Leading the fight against dementia, [online] 2014, http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=136 (Accessed: 8 February 2014) 21. Romano Del Nord, “Detailed design” in Architecture for Alzheimer Disease, Florence: Alinea, 2003, pp. 204-205 22. Hygiene, Fight Alzheimer’s Save Australia, [online] 2010, http://www.fightdementia.org.au/services/hygiene.aspx (Accessed: 8 February 2014) 23. L. Souren and E. Franssen, “Stage III: partial take-over” in Alzheimer’s disease: Broken Connections, Amsterdam: Taylor & Francis, pp. 162, 2005 24. Mark L. Warner, “Fears” in The Complete Guide to Alzheimer’s Proofing Your Home, USA: Ageless Design, pp.110, 2000 25. Alzheimer’s Home Care: Tips for Managing Bathroom Activities, Everyday Health, [online] 2014, http://www.everydayhealth.com/alzheimers/alzheimers-disease-and-bathroom-activities.aspx (Accessed: 9 February 2014) 26. Daily Living – Home Safety, Alzheimer Society Toronto, [online], http://www.everydayhealth.com/alzheimers/alzheimers-disease-and-bathroom-activities.aspx (Accessed: 9 February 2014) 27. Alzheimer’s Disease Facts and Figures, Alzheimer’s Disease and Detection, [online] 2014, http://www.alz.org/downloads/facts_figures_2013.pdf (Accessed: 9 February 2014) 28. “Alzheimer Society of Canada: About Dementia” [Online]. Available: http://www.alzheimer.ca/en/About- dementia/Dementias [January 9 2014]. 29. “Statistics”. Alzheimer Society Toronto. [Online]. Available: http://www.alzheimertoronto.org/ad_Statistics.htm. [January 10 2014]. 30. Salvendy, Gavriel. Handbook of Human Factors and Ergonomics. Hoboken, N.J: Wiley, 2006. 31. Thaler, David S. "Design for an Aging Brain." Neurobiology of Aging 23.1 (2002): 13-15. 32. Lunaheredia, E., G. Martinpena, and J. Ruizgaliana. "Handgrip Dynamometry in Healthy Adults." Clinical Nutrition 24.2 (2005): 250-58. Scholars Portal Journals. Elsevier. [Online]. Available: http://journals2.scholarsportal.info.myaccess.library.utoronto.ca/pdf/02615614/v24i0002/250_hdiha.xml. [Assessed 6 Feb. 2014].

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33. Bassey, E. Joan. "Measurement of Muscle Strength and Power." Muscle & Nerve 20.S5 (1997): 4446. Scholars Journal Portal. [Online]. Available: http://journals1.scholarsportal.info.myaccess.library.utoronto.ca/pdf/0148639x/v20is5_n/44_momsap.xml . [Assessed 14 Feb. 2014] 34. Mital, Anil, and Shrawan Kumar. "Human Muscle Strength Definitions, Measurement, and Usage: Part I – Guidelines for the Practitioner." International Journal of Industrial Ergonomics 22.1-2 (1998): 101-21. Scholar Portal Journals. [Online]. Available: http://journals1.scholarsportal.info.myaccess.library.utoronto.ca/pdf/01698141/v22i12/101_hmsdmapigftp.xml. [Assessed 14 Feb. 2014]. 35. Vianna, Lauro C., Ricardo B. Oliveira, and Claudio Gil S. Araújo. "Age-Related Decline in Handgrip Strength Differs According to Gender." The Journal of Strength and Conditioning Research 21.4 (2007): 1310. U of T Libraries. [Online]. Available: http://search.proquest.com.myaccess.library.utoronto.ca/docview/213061686. [Assessed 14 Feb. 2014]. 36. F.Aminzadeh, N.Edwards, D.Lockettand, R.Nair. Utilization of bathroom safety devices, patterns of bathing and toileting and bathroom falls in a sample of community living older adults, Technology and Disability 13 (2000), 95–103. 37. Sahota O, Drummond A, Kendrick D, Grainge MJ, Vass C, Sach T, Gladman J, Avis M. REFINE (Reducing Falls in In-Patient Elderly) using bed and bedside chair pressure sensors linked to radio-pagers in acute hospital care: a randomized controlled trial, Department of Health Care of Older People, Nottingham University Hospitals NHS Trust, UK (2013). 38. Toilet Sensor. Digital image. Curbell Medical. N.p., 13 Feb. 2014. [Online]. Available: http://www.curbellmedical.com/products/fall-management/toilet-seat-sensor. [Accessed: February 2014]. 39. Neidich; Andre J., “Side Door for Walk-in Tub,” U.S Patent 20080109954, May 15, 2008. 40. Main Features, Carefree Bathing Cana Inc., [Online]. Available: http://www.carefreebathing.ca/walkinbathtubs.html [Accessed: 15 February 2014] 41. The Home Depot Walk-in Bathtub Catalogue, The Home Depot, [Online]. Available: http://www.homedepot.com/b/Bath-Bath-Tubs-Showers-Whirlpool-Tubs-Bath-Tubs-Walk-in-Tubs/N5yc1vZbz9m [Accessed: 12 February 2014]. 42. Minivator Reclining Bath Lift, Hoist and Shower Chair Co Ltd, [online] 2009, http://www.hsccltd.co.uk/bath-lift.asp (Accessed: 9 February 2014) 43. Outlet Shortener. Digital Image. [Online]. Available: http://www.amazon.com/Safety-1st-48308Outlet-Shortener/dp/B000HKVG9C/. [Accessed: 12 February 2014].

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Appendix A: Engagement with Stakeholder For this RFP, our team was able to contact members working with the Alzheimer Society of Toronto (AST). We were able to book an appointment with Mrs. Dali Wong, a staff member at the West Park HealthCare Center, who has had first-hand experience in nursing and treating Alzheimer’s patients. We discussed challenges and other experiences that the patients faced that would or have affected their quality of life. From that dialogue we summarized the key points into potential challenges that may be solved and framed as a series of engineering design problems, which are listed below. Stakeholder Engagement Feedback: Topics & Challenges & Potential Problems After our appointment with Mrs. Wong there were 5 – 6 problems that she said the staff frequently encountered or the Alzheimer patients frequently experienced. 1. Inability for self-supported movements: The patients usually have difficulty maneuvering out of bed, the current design of the adjustable bed is incapable of supporting the patients so that they can stand up still without inflicting pain or damage to their body. When the patient wakes up, a caregiver has to be called using the electronics installed on their bed to assist with the movements of the patients. a. Potential Challenge: To design an automatic and adjustable bed system for Alzheimer Patients, etc. 2. The tendency of object misplacement: The patients typically have trouble managing their own personal belonging such as keys, glasses, etc., When the patient is unable to quickly locate or trace a misplaced item, they usually develop an emotional response to the people in their surroundings, such as anger, or false accusations, which can create a burden in the people of their surroundings. a. Potential Challenge: Based on how this problem is framed, it can be scoped to relate to moderate Alzheimer patients, such as “improving object and valuable management for Alzheimer patients”. 3. Getting Lost Due to Wandering: Certain Alzheimer patients can develop a habit of constant wandering, as a result they can get lost very easily once gone from home. A potential challenge may be to redesign a lock-system that specifically targets families with Alzheimer patients as previously discussed in SF Library last week during team meeting. Mrs. Wong mentioned that the difficulty is to make them return to home as the origin for this being an issue. 4. Difficulty in feeding, eating, and getting to the washroom: The feeding part of this topic refers to the mental process of “forgetting to eat food” when the patient is hungry, unless someone (in the carehome, its usually a nurse) is to take the initiative to start and feed them so the patients “remembers” to eat the food given. It may sound ridiculous, but according to the staff members, some patients do actually experience this and can be a serious damage to their health. In terms of the second part, a common mobility problem for Alzheimer patients is for them getting to the bathroom. 5. Possible Design Of An Alzheimer-Centered Showering System. One fact that Mrs. Wong mentioned was that it is always difficult to get Alzheimer patients for a shower. There is always a serious concern regarding to the safety of having an Alzheimer (regardless of severity) to shower on their own since a faculty member must always accompany them to prevent fall and confusion.

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Appendix B: Reference Statistics

Fig 8. Proportion of Alzheimer’s Patients and Caregivers

Fig 9. Handgrip dynamometry values for seniors, stratified by age.