I’M TOO OLD FOR THIS

I’M TOO OLD FOR THIS! … AREN’T I?

Meeting the Ever-Changing Seating and Mobility Needs of the Aging Population

Sheila Buck B.Sc.(OT)Reg.(Ont.), ATP

When prescribing seating and mobility devices, the support surface and chair design must address physical, perceptual, cognitive and social needs. However, in order to allow the person to then become functional and complete tasks a number of other factors must be accounted for. These include the task purpose, visual, motor and time requirements, environmental stimuli, location and accessibility. In the theory of occupation, the person’s needs, desires, ability to make decisions and explore values must be considered. The occupation must be considered for it’s need for detail, pace and ability to change task and this is also affected by the environment that determines communication and flexibility for function. A secure and comfortable seated position must be created in order for a functional movement to begin, however, adjustability must then be incorporated to allow changes in function and environment over time. These changes occur more quickly in the geriatric population as the aging factor becomes more evident. As a result, often the elderly person "gives up" and assumes that they can no longer complete the function. Assistive technology needs to be provided that will adjust to these changes to allow the elderly to continue to function in areas of identified need or want with in their level of performance.

Specific issues and concerns for postural changes in the elderly include:

Asymmetrical postures: It is essential to determine whether this is secondary to the client’s diagnosis or current positioning, e.g., sling upholstery, hemiparesis with reduced tone on one side, or a combination of both.

Kyphotic posture: One of the most common postures observed when passing through long-term care facilities. Assessment findings would reveal, posterior pelvic tilt, loss of normal lumbar curve, rounded shoulders, thoracic kyphosis, and lower cervical flexion with upper cervical extension. This is created by the effects of gravity, loss of muscular tone, poor seating systems or inappropriate heights for foot propulsion

Multiple Diagnoses: Often times we are not seeing a client who has just a CVA, or a fractured hip, instead, we may find a combination of a fractured hip with total hip replacement, plus Alzheimer’s, +/- dementia as well as osteoporosis. The seating system must include objectives of providing comfort, function, prevention and maintenance with predicted changes over time.

Incontinence: Commonly an issue with the elderly population, this, combined with inactivity, decreased nutrition and hydration, decreased elasticity of the skin tissue and muscle atrophy, is another contributor to the increased risk of skin breakdown with our elderly clients.

The direct benefits of seating the elderly in adjustable seating and mobility systems are:

Redced need for restraints – adjustable systems accommodate a variety of postures and provide comfort
Improved function – maximizing support and mobility and adjusting as changes occur
Reduced nursing care – decreased need for repositioning
Improved sitting tolerance from increased comfort
Prevention/delay of structural deformities
Improved respiratory function
Improved swallowing
Improved cardiac output
Decreased risk of skin breakdown
Improved visual field
Increased social contact
Improved gastrointestinal function
Normalized muscle tone
Increased independence, mobility and/or ADL

Factors to be considered when providing seating to clients in a long-term care setting, especially when increasing the likelihood of adjustable parts include:

Ease of maintenance	Ease of transfers
Foldability (often space is restricted)	Safety for the client and the staff
Ease of instructions for use	Cost to the family or caregiver
Education of all caregivers	Ability to recycle

The seating system must provide stability, alignment and comfort in an effort to maximize function with minimum pathology as well as addressing the caregiver/facility needs. This equipment must also address the increased frequency of changes that may be required as the aging process occurs. Our needs change not only over the years, but also throughout the day. Leisure sitting postures are more supportive and tend towards increased comfort and supine positions. Work and play postures are more upright providing a good stable base but bringing the body forward into a functional "ready" position. We must then consider that aging with a disability is also a dynamic, on going process requiring constant changes in seated posture and mobility devices. These changes will occur not only as a result of physical changes related to the disease or diagnosis, but also due to changes in function, want, need, and environmental access.

A wheelchair is much more than four wheels! Improper seating, positioning and mobility devices can result in the aging population not realizing their potential, because they have not been provided with the opportunity to prove a difference in functioning as they age and change. This can create a withdrawal from society and needless suffering. Human beings are adaptive. When a system no longer accommodates changes in function, physical stature or psychosocial needs, the human body will likely adapt to the equipment, resulting in further deformities of postural realignment, in order to provide the necessary posture for function. In providing seating and mobility devices, we therefore must assess the need proactively for change. Adaptability in equipment design, prescription and timeliness of reassessment is necessary to accommodate to changes in the normal aging process, in order to preserve function and posture, and to promote a sense of well being and quality of life.

Areas of adjustability in seating and mobility products that need to be addressed are:

wheel size and position on the chair for maximum reach, maneuverability, function – center of gravity positioning and propulsion (arm vs. feet)
chair back angle and adjustability (recline) for changing back contours, hip angles, pelvic restrictions
chair back height adjustment for changing trunk stability requirements
chair seat angle adjustability (tilt) for repositioning, trunk stability, function, pressure relief, comfort
arm height adjustment for changing cushion needs, sitting posture affected by spinal

changes(kyphosis)

seat cushion adjustability - angles and contours to maintain trunk stability and pelvic alignment especially with foot propulsion and transfers – materials for pressure relief
modular back adjustability - angles and contours to maintain alignment for interaction and function as kyphotic and scoliotic postures change with gravity, muscle and bone density changes - materials for pressure relief
footrest hanger angles for changes in environment, muscle tone – hamstring tightness and inability to maintain 60 degrees of knee flexion from arthritic changes
footplate adjustability for changes in tone, hamstring tightness and bony changes from arthritic changes
power mobility controllers and switches - decreased sensitivity and throw to accommodate changes in strength and range of motion

These areas must be continually reassessed to monitor correct fit as changes occur. Providing seating and mobility products with adjustable parts will only work if the system continues to be reassessed as the client ages. Who is responsible for determining the need for reassessment? It must be done in a timely manner to allow changes to be made before the body adapts to the incorrect positioning. Clients and caregivers must take responsibility for noting changes in chair usage and function. Service technicians should identify abnormal wear patterns. Physicians need to identify for the client/caregiver potential changes in physical/medical status. Finally, the therapist must educate the client/caregivers on the need for ongoing reassessment through out the initial assessment phase.

The following are some considerations which should be made for the prescription of equipment as clients age:

as strength decreases, alternate methods of propulsion must be assessed. Don’t assume dependence! Wheel base, wheel size and center of gravity can also be adjusted to improve mobility
light weight mobility decreases energy consumption and allows for the ability to attempt other tasks – also consider power or power add-ons
easy and frequent repositioning assists in easing pain. Dynamic tilt allows repositioning, but do not forget to assess how it may affect function, and who is trained on the use of such
interaction with others can be increased through adjustable seat angles, back angles and ease of maneuverability
body image and self esteem are affected by the cosmesis of the device. Consider cushion covers, too many parts, high tech vs. low tech
sitting tolerance as it is affected by comfortable seating vs. corrective seating. Consider height adjustable arms, ability for foot movement, trunk mobility and leisure sitting
joints require active range to prevent stiffness. Seating should not be so restrictive as to eliminate the ability to reposition all body joints as able.

By considering that humans are dynamic, and aging is a continual, ongoing process, reassessment, refitting and adjustability with in systems can allow a client to more easily travel through life’s many hills and valleys. This will allow for a full and complete life without restrictions imposed by their equipment.

References:

1. Diane E. Ward M.Ed., O.T.R. Prescriptive Seating for Wheeled Mobility: Vol. 1 Theory, Application and Terminology. Kansas City, MO. Health Wealth International; 1994

Trefler, Hobson, Johnson Taylor, Monahan, Shaw. Seating and Mobility for Persons with Physical Disabilities

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