11/2/2017. Individualized Seating and Wheeled Mobility for the Older Adult

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1 for the Older Adult Course Objectives Upon completion of this course the participant will be able to: Recognize the need for individualized seating and wheeled mobility Understand seating as it relates to physiological function Identify wheelchair users in need of intervention Implement effective methods to reduce physical restraints Individualized seating means identifying the client s body contours, range of motion, and orientation in space and implementing a seating system that best positions and supports the person for comfort and function Jones and Rader (2000) Age-Associated Changes Decreased body fat Thinner, more fragile skin Visual Bladder and kidney; frequency and urgency Cardiovascular Respiratory Sarcopenia Limited joint range Osteopenia Fried et al (2001) 5 6 Co-morbidities Diseases Cardiac Respiratory Neurological And/or Diabetes Osteoarthritis Obesity Osteoporosis Frailty Decrease reserve and resistance. Fried et al (2001) 1

2 Fried et al (2001) 7 Frailty Syndrome Three or more of the following: Unintentional weight loss Self-reported exhaustion Weakness Slow walking speed Low physical activity Fried et al (2001) Conditions contributing to Frailty Chronic conditions Changes in the musculoskeletal system Changes in the neuroendocrine system Nutritional deficits Immunological deficits Mental changes Depression Fried et al (2001) Person Centered Care Needs, wants and desires Improvements can occur in: Posture: Respiration Digestion Elimination Vision 11 Improvements can occur in: Comfort/Wheelchair Tolerance: Primary interest 2

3 Amount of time spent in wheelchair 12 Improvements can occur in: Skin condition Distribute pressure Improvements can occur in: Ability to Care for Self Socialization Comfort Quality of Life Current practice is changing: Knowledgeable and updated about: Individualize needs Products available and correct use Current issues, rules and regulations (>40% physical restraint use to < 2%) Jones & Rader (2015) 15 What happens when chairs do not fit? Discomfort/pain Inhibited mobility Poor posture Decrease function Pressure ulcers Requejo et al (2015) 16 Standard Wheelchairs What issues do you see here? 3

4 17 Standard Wheelchairs Heavy (>35lbs without leg rests) Sling seating Little to no adjustability arm rest axle plate Parts not maintained No foot plates 18 Solid seat wheelchair Find the desirable features in this chair? Wicker Wheelchair What are the desirable features in this chair? Solid seat Breathable Moldable Mobility ease Footplate position Adjustable backrest Wheelchairs and parts: Geri-chairs Not maintained Standard wheelchair 1. What do you see? 2. Why were these items chosen? 4

5 3. What should never be used? Shaw (1993) 22 Standard wheelchair Poor attempt to Provide comfort Reduce leaning Reduce sliding Improve skin condition Observations that should trigger seating assessment: Leaning or sliding in wheelchair/ chair Use of tie on restraints Use of geri chair as restraint Crying and yelling Agitation and restlessness Seat belts over abdomen Use of tray tables, lap pillows Skin problems from seated surface areas Rader et al (2001) Physical Restraint What is a physical restraint? Why are restraints used? What does a physical restraint look like? What are the benefits? 25 Physical Restraints: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual: Can not easily remove Restricts movement Restricts normal access to own body 5

6 26 Physical Restraints OBRA of 1987 Physical restraint 27 Physical Restraints 28 1 Risks of Physical Restraints Physical 2 Cardiac Overload Bone Loss Edema Skin Trauma Contractures Pressure Ulcers Malnutrition Infections Psychological Agitation Aggression Depression Confusion Social Isolation Traumatic Memories Evans & Strumpf (1989), (1990). Williams & Finch (1997). Miles Restrained Lap buddy : is it really the person s friend? Used to keep in uncomfortable chair? Used to hold up trunk and upper extremity weight? Keep them from doing what they want to do? Give them place to gently rest their arms? 6

7 Usually it is a very bad quick fix Vest restraint Pommel Restraint Belt Restraint Physical Restraints: The individual: Can not easily remove Restricts movement Restricts normal access to own body Circle of restraint use OBRA Case Study example: Individualized assessment: Mat assessment Goals Equipment Final fit Caregiver training Maintenance Caring for self Improved Socialization Improved Comfort and Quality of Life Improvements can occur in: Efficient use of limited energy and endurance Light weight equipment Adjustability of rear wheels and casters Push assist mechanism Power mobility 7

8 40 41 Individualized: Lightweight, adjustable and mobile For the Older Adult The freedom to move about to maintain independence and to pursue happiness is critical for elders facing aging and illness changes Ken Brummel-Smith, MD 42 Mat Assessment Need the person out of the wheelchair Assess in supine Pelvis Trunk Hips Knees Ankle Assess in sitting Postural control 43 Mat Assessment The mat assessment is the most important step prior to application of a seating and mobility interface Common Problems for older adults: 1. Lack of pelvic mobility: posterior pelvic tilt 2. Poor hip range beyond 90 degrees; often less 3. Knee contractures 4. Kyphosis and/or scoliosis 44 Mat Assessment The mat assessment is the most important step prior to application of a seating and mobility interface Mat assessment will provide information for size, shape, angle and body contours, to determine selection and modification of a seating and wheeled mobility system for 8

9 an individual older adult 45 Poor Choice for Sliding 1. May not have hip range 2. Forces pelvis into more posterior pelvic tilt 3. Increases further sliding 4. Poor positioning 5. Increases pain 46 Quick fixes can make sliding out of chair worse and cause pain Examples of quick fixes: Using a wedge cushion Elevating the footrest 47 Chair Mobility (quick fix) What causes Sliding out from seated surface What causes Sliding out from seated surface Posterior pelvic tilt What causes Sliding out from seated surface Posterior pelvic tilt Tight Hamstrings 9

10 What causes Sliding out from seated surface Posterior pelvic tilt Tight Hamstrings Discomfort What causes Sliding out from seated surface Posterior pelvic tilt Tight Hamstrings Discomfort Weakness What causes Sliding out from seated surface Posterior pelvic tilt Tight Hamstrings Discomfort Weakness Behaviors Other How to reducing sliding and determine correct equipment selection? Individualize from mat assessment findings Use key points of control Basic cushion contour Posterior Pelvic Support Check seated surface and mobility interface: Width Length (depth) Usually longer Seat to floor height Thigh support 10

11 Foot support Short-term Positioning Belt Short-term Positioning Belt for an Older Adult Correct Incorrect 63 Tight hamstrings are common: 1. Posterior thigh muscles (hamstrings) cross both the hip and knee joints and affect pelvic position. 2. To reduce sliding: hamstrings need to be on slack or shortened. 3. Poor foot placement lengthens hamstrings; pulling pelvis into posterior pelvic tilt 64 Tight hamstrings and wedge cushion 1. Forces pelvis into more posterior pelvic tilt 2. Increases further sliding 3. Poor positioning 4. Increases pain Geri-chair: Before Standard Wheelchair: After trial accommodation Lack of Hamstring Length Standard Wheelchair: After trial accommodation Foot propulsion: 1. Can not reach floor 2. Sliding out of chair to reach floor Check seated surface and mobility interface: Width Length (depth) Maybe longer 11

12 Seat to floor height thigh support Foot support Accommodate for hip contracture or one leg propulsion Cushion to accommodate spine Tilt-in-space chair for level eye gaze Upper Thoracic Kyphosis Tilt for Eye Gaze/Position A typical person in a Geri-chair: dependent in all ADLs Assessed and Fitted An individualized wheelchair: Able to feed self, assist with transfers, brush teeth with cuing, move short distances in w/c by self, interactive and social 77 References Brault, M. Current population report. In: Americans with disability s: Washington, DC: US census bureau; Pp Evans, L. Strumpf, N. (1989). Tying down the elderly. A review of the literature on physical restraint. Journal of American Geriatric Society Evans, L. Strumpf, N. (1990). Myths about elder restraint. Image J Nursing Sch (22) p Fried L., Tangen, C. Walston, J., Neman, A., Hirsch, C., Gottdiener, J et al Cardiovascular health study collaborative research (2001). Frailty and older adults: evidence for a phenotype. Journal of Gerontology: Series A. Biological Sciences in Medical Sciences, (56) PP Jones, D., Rader, J. (2015). Seating and wheeled mobility for older adults living in nursing homes. What has changed clinically in the past 20 years? Topics in Geriatric Rehabilitation. Vol 31 no. 1, pp Karmarker, A., Dicianno, B., Graham, J., Cooper, R., Kelleher, A., Cooper, R. (2012). Factors associated with provision of wheelchairs in older adults. Assistive Technology 24:

13 Miles, S., Irvine, P. (1992). Deaths caused by physical restraints. Gerontologist (30) Pp Deborah Jones, PT DPT, GCS, CEEAA, ATP Contact information: Deborah.jones@providence.org 13