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December 2004


Age Over Matter

By Patricia Dworak, MSOT, OTR/L, ATP; Robin Folland, PTA, ATP; and Amy Kirkner, MPT, ATP

Geriatric seating, positioning, and functional mobility is an area of assistive technology that provides great rewards as well as unique challenges for the clinician. In working with the senior population, therapists deal with an individual's primary diagnosis as well as the normal physical and cognitive changes associated with aging. Clinicians need to address a multitude of factors associated with aging with a disability. Through completion of a thorough evaluation, performed by a skilled clinician, a significant impact can be made on the lives of our geriatric population, enhancing the quality of their lives.

Normal aging may involve changes in blood pressure, blood sugar, body weight, bone density, and cardiorespiratory status. Osteoarthritis, depression, anxiety, and cognitive changes may also be seen in this population. Additionally, older individuals present with an increased incidence of joint replacements, decreased endurance, increased risk of diabetes, increased risk of pressure ulcers, and decreased vascular function.

As individuals age, they experience normal musculoskeletal changes, which may cause them to move more slowly. A deterioration in physical strength, fine and gross motor control/coordination, endurance, range of motion, and muscle tone may be seen throughout the body, with lower extremity strength declining first. Loss of cartilage in the spine coupled with the common diagnosis of osteoporosis in older adults can lead to vertebral disc collapse and vertebral fractures. Decreased lung capacity may be noted due to the lungs becoming more rigid with age, thus causing a decline in respiratory status. Additionally, older adults experience a change in metabolism as they age, leading to an increased chance of gaining body weight, which makes mobility more difficult. They may also have cognitive changes and/or sensory changes involving perception, vision, hearing, and tactile sensation.1

It is of utmost importance to keep the geriatric population mobile and functional. With decreased mobility and any of the above listed complications, there is significant increased risk of developing further medical complications. Should the elderly be bedridden, they are at an increased risk of developing pneumonia more quickly than healthy young adults. In addition to the risk of elevated blood sugars and an increased incidence of diabetes, they are at increased risk of pressure ulcers particularly if they are bedridden. The elderly population must maintain their mobility and function to prevent any additional medical complications, which would be more difficult for them to overcome. Being mobile will maximize their endurance and decrease the risk of pneumonia, osteoporosis, pressure ulcers, further deconditioning, and blood clots. It will give them the greatest opportunity to fully interact cognitively and physically with their environment. Being mobile thus promotes independence and an optimal quality of life.

SEATING CHOICES
The most significant consideration when seating elderly clients is accommodating the postural changes that often accompany aging. One of the postural changes seen, particularly in elderly women, is an increased incidence of thoracic kyphosis or dowager's hump. Often, this is associated with osteoporosis and is the result of stress fractures throughout the spine, which cause significant pain, decreased function, and decreased sitting tolerance. It is essential that these individuals be provided with a seating system that provides them with enough support, pressure relief, cushioning, and comfort to help protect against stress fractures and to accommodate, yet not promote, increased kyphosis. The seat cushion choice is also very important for the elderly. Particularly for those who have diabetes and decreased sensation, their cushion will prevent loss of skin integrity and prevent episodes of skin breakdown. Pressure ulcers can result in development of further medical complications and great cost in medical care.

CUSHIONS AND LEGRESTS
In choosing a cushion for the wheelchair, it is essential to consider the weight of the wheelchair in combination with the cushion. Some cushions are heavier than others, and it is important to choose a cushion that will allow for essential energy conservation while performing daily wheelchair propulsion as well as ensuring the individual's skin care needs are met. One must also consider the client's ability to care for the cushion and maintain it. Can they adjust air or gel, or do they need one that is maintenance-free such as foam?

Another feature of the wheelchair that is critical to consider is legrests. It is essential to have legrests that will swing in or out to provide safety during transfers. This is particularly important due to decreased vision and functional mobility changes. Legrests need to be able to swing in or out of the way completely so as to provide a safe and clutter-free environment to promote safe transfers in and out of the wheelchair. If legrests are in the way, it places the individual at risk of falling, with a higher chance of fractures or dislocations, thus causing further medical complications.

MEETING INDIVIDUAL NEEDS
In addition, it is important to determine which mobility device would best meet the individual's needs. The determination as to whether a client is going to receive a manual wheelchair versus a power wheelchair is critical in order to get the system to successfully be accepted and interfaced with their level of function, their environment, their transportation, and their lifestyle. An extensive history needs to be taken, which includes an assessment of the client's living situation. Are they living alone in a home or in a personal care home? Are they going to be moving in with a family member or are they looking for admission into a nursing home? Are they willing to make modifications to their current home to ensure accessibility?

Transportation is an area that also needs to be evaluated. Who will be loading and unloading this mobility device for attending physician appointments and medical tests? Does the power wheelchair disassemble or not? Is the client capable of doing it themselves or do they require help? Is a family member going to be assisting with loading the equipment? The weight of the wheelchair, vehicle type, size of trunk, and lift accessibility all need to be evaluated and considered when making the decision between a manual wheelchair versus a power wheelchair. Lifestyle and activity level of the individual are very critical in determining which wheelchair will meet their needs. Are they going to be using this wheelchair in the community attending church, volunteering, working? Are they going to use public transportation and/or travel? Are they semiretired? All of these factors need to be taken into consideration to ensure that the wheelchair will most appropriately and successfully be integrated into the client's life. Psychological issues and adjustment are significant areas that are sometimes overlooked in choosing a wheelchair. How will this individual and their family accept a mobility device? What style, appearance, and color must be chosen in order to maximize the occurrence of a successful integration into the client's life?

These factors, along with the possibility of a decline in cognition, become very important to assess when an older individual is being evaluated for a manual or power wheelchair. Intact sensory skills such as hearing, vision, perception, and tactile sensation are very important with regard to ensuring safety while utilizing a manual or power wheelchair. Cognitive factors to consider with an older individual being evaluated may include assessing safety awareness, problem-solving skills, and ability to learn how to safely and effectively operate a manual or power wheelchair and all its features. Strength, endurance, active range of motion, and fine and gross motor control/coordination, including hand dexterity and grasp, are very important. A deficit in any or all of these areas may necessitate the individual utilizing powered mobility over manual mobility. The diagnoses older adults most commonly suffer from are coronary artery disease, cancer, Alzheimer's disease, cerebral vascular accidents, arthritis, and osteoporosis.2 The resultant deficits due to these diagnoses result in manual or powered mobility becoming a near necessity for this population.

EDUCATING CAREGIVERS
When choosing a wheelchair for an elderly client, one should also take into account if another person will be pushing the wheelchair and whether the wheelchair can be easily utilized by an attendant. Ease of transportability within the living environment as well as out in the community for physician and medical appointments needs to be considered. The client's environment also needs to be looked at thoroughly. Funding and co-pay responsibilities must be evaluated and determined prior to the ordering of the wheelchair to find out if funding is available and if the client will have any additional co-pays.

The care provider needs to be educated and listen to the client in order to choose the mobility device that will be best accepted by the client and their family. This will help to ensure a successful integration of this equipment into the client's home and lifestyle as well as their family. Education is critical with the geriatric population in order to ensure that they fully understand how to operate, maintain, and safely use the mobility device. There may be some memory deficits, and this requires repetition of instructions and/or information conveyed in a manner that is easily understandable for this clientele and their families. When all of this information is compiled via evaluation and follow-up, taking into consideration all of the changes that happen with normal aging, there can be a very successful integration of a mobility device into a senior's life. This will maximize their quality of life, cognitive stimulation, and participation in their environment. Matching the appropriate mobility devices to our seniors' needs will produce a positive experience in which the end product will be a very rich asset that allows them to enjoy their remaining years.

Patricia Dworak, MSOT, OTR/L, ATP, is a staff therapist; Robin Folland, PTA, ATP, is a staff PTA; and Amy Kirkner, MPT, ATP, is a staff therapist and the wheelchair clinic coordinator at Good Shepherd Home and Rehabilitation Hospital, Allentown, Pa.

REFERENCES
  1. Biological Research for Animals and People. Aging and genetics. Probing deeper. Normal changes in aging. Available at: www.biorap.org. Accessed October 7, 2004.
  2. Biological Research for Animals and People. Aging and genetics. Probing deeper. Diseases of aging. Available at: www.biorap.org. Accessed October 7, 2004.

ADDITIONAL READING
  • Cook AM, Hussey SM. Assistive Technologies: Principles and Practice. 2nd ed. St Louis: Mosby Inc; 2002:333-334.
  • Llorens LA. Performance tasks and roles throughout the life span. In: Christiansen C, Baum C, eds. Occupational Therapy: Overcoming Human Performance Deficits. New York: McGraw-Hill Inc; 1991:59-63.

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