Older wheelchair users can face
additional challenges due to the effects of aging, which include neurological,
musculoskeletal, gastrointestinal, cardiopulmonary, skin, urological and
cognitive changes. All of these can contribute to seating and mobility issues,
especially if there is an underlying disease or injury.
One goal for the geriatric
population is to maintain safe and independent mobility for as long as
possible. Although decreases in strength, endurance, joint health,
cardiopulmonary function and balance may prohibit safe and functional
ambulation, many older individuals could functionally self-propel a manual
wheelchair with the appropriate features. Unfortunately, it is not unusual to
see them struggling to propel basic standard wheelchairs, which are heavy and
have few options and adjustments. These wheelchairs require much effort to
propel and may be uncomfortable, ill-fitting, and promote poor posture with
prolonged sitting. It is time we look beyond this standard equipment to
alternatives that have the features necessary to allow independent mobility for
this often fragile population.
The weight of the wheelchair is a
critical feature for anyone trying to propel since self-propulsion involves
using the smaller arm muscles to move the wheelchair weight plus the
individual’s body weight. Although weight seems to be a primary consideration
for our younger population, it is often ignored with older individuals, despite
the fact that they may have even less strength and endurance.
Another important factor is how well
the wheelchair supports/facilitates proper positioning to prevent deformity and
facilitate function, respiration, swallowing, skin protection and efficient
propulsion (access to the hand rim). Unfortunately, many elderly individuals
have trouble maintaining good posture due to weakness and fatigue. For some,
there is a tendency to slide into a slouched position, while others are already
fixed in this curved posture. The tendency to slide is compounded by the fact
that the 90-degree angle between the seat rails and the back posts of most
wheelchairs does not match their rounded anatomical shape. The difficulty in
maintaining an upright position may also be due to the vertical orientation of
the wheelchair itself. Adjusting the back posts to create a small amount of
recline in the back support could help to accommodate the individual’s shape,
while adding a small degree of tilt in the frame could decrease the effort
required to sit upright—both of which could have a significant impact on
posture, physiological function and propulsion.
Seat and back dimensions can also
affect propulsion and posture. For the smaller individual, a back height that
is too tall and/or a seat that is too wide can interfere with sufficient access
to the hand rim for efficient (easy) propulsion. A seat that is too wide can
also allow the individual to lean/move into asymmetric postures. For the taller
individual, a seat that is not long enough will provide insufficient support to
the pelvis and legs, causing poor positioning and increased pressure.
For individuals who propel with one
or both feet, efficient propulsion is possible only if the heel(s) can be
placed flat on the ground. If the seat-to-floor-height (STFH) of the wheelchair
is too high, the individual must slide down in the seat, which creates poor
posture, or propel with the toes, which is slow and energy-consuming.
In summary, to increase mobility,
reduce fatigue, promote good posture, protect joint health and prevent pain for
our older manual wheelchair users, we should provide products with: (1) the
lightest weight possible, (2) optimal hand rim access, (3) proper seat back and
STFH dimensions, and (4) appropriate adjustments. Standard wheelchairs should only be used for
short time periods over very short distances or for temporary use.
Power
of Mobility
The benefits of independent mobility
include increased time out of bed, improved skin integrity, improved
cardiopulmonary health, decreased attendant care, increased socialization and
motivation and improved quality of life. At some point however, many older
adults struggle or are unable to ambulate or propel any wheelchair. To keep
them as independently mobile for as long as possible, power mobility should be
considered.
Unfortunately despite the benefits,
power is frequently overlooked for this population. In some cases, this is due
to lack of a proper clinical evaluation and assessment of need. In other cases
the individual, caregivers and/or facility staff are reluctant due to unfounded
safety concerns and/or lack of familiarity with available options and
technology. However, today’s power wheelchairs can be programmed and configured
to allow safe and independent mobility for nearly anyone, from the very young
to the very old, as long as they possess sufficient cognition, judgment, vision
and motivation, as well as a functional body part to operate the control.
To choose the most appropriate power
wheelchair, we must consider postural needs, activity level and daily environments
of the individual. As with manual mobility, we should look beyond standard
equipment when appropriate, particularly when choosing between standard
captain’s seating vs. rehab seating. Captain’s seating is appropriate only for
individuals who can fit in standard seat sizes, are at little to no risk of
skin breakdown and are able to maintain good upright posture with minimal
support and contour. For more complex requirements for posture, function or
skin protection, rehab seating should be considered.
Dependent
Mobility
Typical mobility choices for those
who are dependent include armchair recliners or “geri-chairs.” We must
consider, however, that these options provide no specific postural support or
skin protection, cannot accommodate postural deformities, allow minimal weight
shifts and fit average body dimensions. Unfortunately, there are many older
individuals relegated to this type of seating despite their more complex
needs/risks. In some cases, these needs might be better met by one of the
manual wheelchairs described above with appropriate sizing, options and
adjustments. For others, a manual recliner or tilt-in-space might be needed to
provide weight shifts and a resting position for skin protection, comfort and
reduction of fatigue. In these cases a tilt-in-space is often preferred, since
recliners are less effective in maintaining posture, cannot accommodate
hip/knee joint limitations and can cause shearing with recline and return.
Our equipment goals for the elderly
are to provide the simplest, most cost-effective solution that will optimize
the person’s posture, function, skin integrity and mobility. This means looking
beyond standard-issue non-adjustable equipment so older adults have the
technology necessary for the best outcomes of comfort, health and quality of
life.
---------
Article adapted from Home Care magazine.
