Addressing Seating and Mobility for the Geriatric Population

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 (K0001s), 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. In place of heavy K0001s we should at least consider lightweight (K0003) wheelchairs (a few pounds lighter), although high-strength, lightweight (K0004) and ultra-lightweight (K0005) frames might be an even better option. 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. Although not available on K0001s or K0003s, these adjustments can be found on some K0004s and K0005s. 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. While K0001s and K0003s offer very limited sizes, many K0004s and all K0005s provide multiple seat and back dimensions to accommodate most any body size. 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. While the STFH of most K0001s and K0003s is limited to 18 – 19”, many K0004s and K0005s provide multiple STFHs including ultra-low “hemi” heights. 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 handrim access, (3) proper seat back and STFH dimensions, and (4) appropriate adjustments. These features are not found on basic K0001 wheelchairs and although K0003s are a few pounds lighter, most models are otherwise no different compared to a standard wheelchair. For any individual who needs the wheelchair for independent mobility on a daily basis, does not fit in standard seat sizes without compromise, has even minimal postural instability or deformity, and/or has decreased range of motion or joint pain, a K0004 or even a K0005 should be considered. 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 nonadjustable equipment so older adults have the technology necessary for the best outcomes of comfort, health and quality of life.