How the Aging Process Can Impact Seating Systems & How Providers Can Help Clients Maintain Their Independence

With age, the pundits tell us, come wisdom, experience, a well-rounded perspective and a host of other hard-won benefits.
But for seniors using seating & mobility equipment, age can also bring on a host of physical changes – naturally occurring ones that everyone experiences, as well as others tied to specific medical conditions that alter or progress over time.

All of these changes can create big challenges for providers trying to ensure that seniors maintain their mobility, independence and dignity for a lifetime. And providers can expect to see these challenges more and more frequently as more baby boomers enter their golden years.

The Science of Aging
As we age, our bodies go through a myriad of changes, many of which can impact a seating & mobility system’s fit and overall functionality.

“When thinking about the elderly and appropriate mobility prescriptions, we cannot ignore the aging process,” says Sunrise Medical’s Sharon Pratt, PT. “The aging process brings with it multiple neuromusculoskeletal, cardiopulmonary, urinary, gastrointestinal, skin, visual and hearing changes. These age-related changes in turn affect functional activities.”

In an “Aging with a Disability” presentation she’s given at rehab educational conferences, Pratt details the following results of the aging process:

Neuromusculoskeletal changes
•    Decreasing muscle mass.
•    Loss of elasticity in ligaments & tendons.
•    Narrowing intervertebral discs.
•    Decreasing bone density.
•    Deterioration of articular cartilage.
•    Decreasing effectiveness of neurotransmitters.

Cardiopulmonary changes
•    Increasing anterior-posterior chest diameter.
•    Weakening respiratory muscles.
•    Decreasing number of alveoli & thickened membranes for gas exchange.
•    Decreased cardiac output & elasticity of cardiac valves.

Urinary changes
•    Decrease in muscle tone & bladder capacity contributing to urinary frequency, urgency & stress incontinence.

Gastro-intestinal changes
•    Reduced saliva & esophageal peristalsis leading to swallowing difficulties.
•    Kyphotic posture = elevated abdominal pressure, decreased motility & bowel obstruction.
•    Hyper-extended cervical spine opens airway and therefore may increase susceptibility to aspirated pneumonia or choking.

Skin changes
•    Diminishing of sweat glands.
•    Thinning of the skin.
•    Skin health can be affected by nutrition and food intake.
The Impact on Seating Systems

So how do these changes translate into challenges for seating & mobility providers?
Lois Brown, MTP, ATP, clinical education manager at Quantum Rehab, says, for instance, “Skin loses a lot of its elasticity. It becomes very thin, so any abrasion or shear (from) sliding down in the seating system or sliding across the seating system to transfer is going to cause pressure issues.”

“Age-related skin changes include diminishing of sweat glands and thinning of the skin, which can cause an inability to regulate heat, and increased susceptibility to skin tears,” Pratt says. “Primary areas of concern are the ischials, sacrum and spinous processes. Approximately 23 percent of nursing home population have pressure ulcers/skin breakdown according to the National Pressure Ulcer Advisory Panel.”

Significant changes in body weight can also occur with aging, though Mike McCarthy, ATS, national sales manager of manual wheelchairs and cushions for

Quantum Rehab, says, “Weight gain or loss could really be associated with a given diagnosis. It’s very individually based as it pertains to seating.”
Brown adds that body weight can redistribute as we age: “A lot of the weight starts to splay outward to the side, which changes our seat width. A lot of times, there’s body weight coming forward, but it ends up changing the dynamic as far as seat size and things we need to build into the system so we can expand the seating system to accommodate those changes.”

Neuromusculoskeletal changes, Pratt notes, can cause or contribute to “decrease in movement, strength, endurance and the ability to stay upright; decreased independent weight-shift ability; and stiffening and mild flexion of joints, neck and vertebrae.”
Pratt adds, “These changes may create the typical kyphotic posture, with decreased lumbar lordosis. This posture may in turn impact the ability to sit upright unsupported, swallowing, respiration and digestion, as well as wheelchair propulsion.”

Those types of changes, Brown says, can be challenging to seating & mobility providers.
“One of most difficult things that we face is anticipating those progressive changes, whether it’s an orthopedic change that’s just via aging or whether we are dealing with someone who is progressing through their disability,” Brown points out. “So what we look for is changes in range of motion causing tight joints, and then needing to change angles on the equipment and how it’s going to fit. With changes to the spine — whether it’s a thoracic kyphosis or whether it’s a curvature of the spine, more significant scoliosis — we’re dealing with needing to accommodate seating that can change with their changes, that we can either change a mold or move a component so we can accommodate those changes and support their body to maintain their head and their trunk in an upright position.

“And then we start to talk about whether we’ve chosen a system that can also accommodate power positioning possibly, something that can bring their body behind the line of gravity and help support them upright.”

Brown says pain is another complication to consider: “People’s shoulders come more forward because of that rounded kyphosis. Their shoulders are tight, their necks are tight — there’s a lot of different pain that gets associated with these clients that already have weakness. And the joints are already not supported, so that can cause a lot of pain as well.”

Pratt concurs that pain is a significant problem for this client group: “It is noted that over 70 percent of older adults have pain problems. Pain can impair mobility and participation in activities and can increase dependence on assistance for activities of daily living. Inflamed joints need to be protected, limited joint ranges and unique shapes accommodated, and pressure points reduced or eliminated.”

Answering the Clinical Challenges of Aging
Fortunately, despite the litany of challenges brought about by aging — for clients new to seating &?mobility, as well as clients who are rehab equipment veterans — there are also answers and ways to compensate.

“Kyphosis can add pressure issues in the spinal area, so that we start to look at the curvature,” Brown says. “If we don’t make a modular system where we can change to accommodate the orthopedic deformity that comes from that either kyphosis or the scoliosis, you end up with a pressure point on either side of the spine where the rib cage begins to protrude. So sometimes when we say ‘seating pressures,’ we just think of the ischial tuberosities and the pelvis, but we really need to look through the whole system to see how it’s going to need to be changed as their spinal column changes as well.”

McCarthy concurs: “Having been a former supplier, I think that is one of the things that is commonly missed. There is so much focus being put on the seating components, i.e., the ischial tuberosities, that a lot of folks miss the back supports. And we’ll use the kyphosis as an example: Pressure management is a huge issue with kyphosis. Kyphosis in most cases will tend to increase pressure at the apex of that curve, which would force us to make changes to that back system.”

Kyphosis, McCarthy adds, “is not something that will stop. So you really need to look at the long term (to) prevent skin-integrity issues as the kyphosis progresses.”

“Manual or power tilt is a way that we typically try to bring people’s bodies back and, if they can, increase the contact against the back, which is going to disperse pressure,” Brown explains. “Not only do we use a curved back that can accommodate their new shape, but also try to use gravity-assisted positioning through power tilt or recline or manual tilt or recline to accomplish that.”

Wheelchair backs can help disperse pressure as well, particularly if the backs feature a construction to facilitate “enough depth and dimensions of the materials to allow that curvature to sort of immerse into that back. You have a little bit of give, so the layers of foam will allow that curvature to drop into that system.”
Meanwhile, other seniors who, as Brown describes, may be “just getting inherently weaker” may have more difficulty getting in and out of their wheelchairs.

“Now you’re going to look at their ability to weight-shift themselves,” Brown says. “Maybe they’re not standing anymore to transfer; maybe they’re doing a side-to-side transfer. So now you’re looking at somebody who can’t unweight their bottom and can’t unweight themselves.”
In those cases, making height adjustments to the seating systems may help.

“You might be looking at a different seat-to-floor height,” Brown says. “Is the height of the seat going to change so it helps them? Maybe they can stand, but (the seating system) needs to be a little bit higher now. They’re not good enough in their legs to completely stand upright, but if you raise the seat-to-floor height, that’s a way to get them up. Or adding a seat elevator would help them to stand and transfer. Or just change that (seating system) height so they can make a level transfer.”

Brown also suggests determining whether swapping out other components could give senior clients a bit of extra help.
“Where are the armrests placed so they can get a better push to help them support themselves?” she notes. “So you might have gone with a short arm initially so they could get under tables, but now they do need a longer arm because it’s more important that they can push up from the front of the chair.”

And when building a seating & mobility system, assess whether today’s new generations of electronics can provide additional functionalities and support services. For instance, could your client benefit from reminders — visual or auditory — to perform pressure relief or to take medications? Seniors who have vision problems may also benefit from electronic displays that are easier to read in various types of light, or displays that use larger, illustrated icons instead of small lettering.

“Maybe they’ve been using a power chair and they’ve been able to sort of maneuver through the buttons or see the display,” Brown says of clients who’ve been in mobility systems for awhile. “Now they need something that’s larger and colorful and brighter that would allow them to continue to see the commands and how they need to navigate through the electronics. Maybe it has some auditory feedback, because now their hearing is starting to dissipate. So you may be able to put in an auditory command, so they know they’ve changed from seating to driving or to a different function. You start to look at things that are in the system that can accommodate their skin, their orthopedic issues, their transfer issues, their vision, their hearing.”

For clients who self-propel their manual wheelchairs, Pratt says, “To preserve energy and skin integrity and to maintain functional independence, I believe that more lightweight wheelchairs with adjustable axle plates, 90° front hangers, and adjustable footplate angles need to be considered. The wheelchair being prescribed should be as narrow as possible (considering all trends in weight change) for efficient propulsion with easy opportunity for achieving appropriate seat-to-floor height.”

Asking All the Questions that Need to Be Asked
For all the functionality and modularity and potential solutions it can offer, even the best of today’s seating technology cannot, of course, replace the human connection between a client and a trusted rehab provider. Ultimately, that assistive technology cannot help until the provider (as well as the rest of the seating & mobility team) can figure out exactly what the client needs.

Which, of course, is often easier said than done.
Asked to talk about the challenges that arise due to aging, McCarthy says, “I think that one of the biggest challenges from a clinician or a supplier standpoint is making sure that you not only ask the right questions, but that you ask all the questions.

“Kind of a preface to this answer would be ‘Be prepared for change.’ With that being said, providers and clinicians will have all the information that they need to effectively prescribe seating for a client. If a client has been diagnosed with a progressive disease that will effectively eliminate ambulation and/or the ability to weight-shift over time, a cushion designed for pressure relief and comfort could be specified initially. As the client progresses and the sitting balance is compromised or lower-extremity deformities begin to occur, the clinician may specify an adjustable cushion.”

Clients, unfortunately, are not always willing or able to self-assess or to accurately describe their changing situations to their seating & mobility teams. Therefore, careful observation is crucial to a good assessment, Brown says.

“Most of the time, you can observe someone in their chair for the beginning part of the evaluation, and you can see their habits,” Brown says. “I have clients who sort of ‘hook’ onto an armrest, and they are really holding themselves from falling over. Then you can start to say, ‘Are you having trouble keeping yourself upright without being in a tilted or reclined position?’ And you start to notice things that they’re doing habitually, which are their attempts to stay upright and midline. You start to make those observations, the provider and the therapist equally, sort of just observing the patient in the chair as you start the evaluation.

You see what their typical habits are. It leads you to the real issue and the problems you need to address.
“(If) someone’s propping their hands on their knees, that means they feel that they’re going to fall forward. As you get more kyphotic and rounded in that spine, it brings your trunk and your head forward, and as you start to (lean) forward, you start to feel like you’re falling. So instead of using an external chest strap or putting on different components, we really like to try to bring their back behind that gravity line and help them feel more safe in the system.”

Another insider’s tip: Compare the client’s behavior at the start of the evaluation to his or her behavior as the evaluation is winding down to determine if there are any differences.

“Time is ticking now, and you’re going through the hour or so of the evaluation,” Brown points out. “Watch them toward the end as well to see how they respond to what you tried — or are they continuing to fatigue and gravity’s bringing them further down and further forward? (If so) you know that you need something more invasive to try to give them a longer-term solution.”

Be aware that clients may not be aware that they’re compensating for positioning difficulties, especially if they’ve been doing so for awhile.
“I do have a patient who was hooking that arm, and that was so typical for him that I don’t think he realized that there would be a solution that would make him feel more stable and more upright without using so much effort,” Brown says.

And sometimes when clients indicate they have difficulty maintaining proper positioning, all is not as it seems.
“If they are typically sliding down in their seat, and we say, ‘You did not get yourself into the seat properly,’ and then they keep sliding, they’re sliding because when they do that, they can get their head more upright,” Brown says as an example. “And they can actually have a line of sight with their family members or the activities they’re doing, so they’re sliding for a reason. Everybody wants to try to maintain their head in an active, upright position to interact with the environment. So you need to look at ‘Oh, Mary, you’re not always sitting in your seat right; please sit back’ and say, ‘Well, what do we need to do to change that seating environment so she can sit back and feel supported, but still look upwards in front of her?’”

Helping Clients to Adapt to the Aging Process
In addition to all the physical considerations a provider needs to address, Brown says clients may also be having trouble coming to terms with the changes they’re experiencing due to age. This situation requires not only thoughtful diplomacy and emotional support on the provider’s part, but also some occasional detective work to figure out where the problem lies.

“What I typically find is that people are always waiting too long or don’t at all initiate a call when they can no longer effectively use the drive controls or electronics that have been given to them to operate the chair,” Brown says. “And it’s hard for them to admit they’ve gone beyond that functional level, or even to know how to get back to the provider and back into the system of how they were evaluated. So I always look to the providers to be aware if someone comes in for a repair issue, and they say, ‘My chair’s not driving right.’ Asking all of the questions means if you don’t find the chair to be an issue operationally, then you need to look toward the user to see if maybe they’re now beyond the originally prescribed joystick handle or the electronics that were not adjusted to help them to be able to continue to drive.

“So we’re looking at the providers to be part of the feedback loop to send clients back to the physician or back to their wheelchair clinic, and bringing the provider back in and meeting as a team to reassess where this patient is in their stage of change, whether it’s aging or progression for whatever reason.”

Clients may find that either the natural aging process or the progression of their condition has caused them to “outgrow” some technologies or product types, Brown says. A client who may have successfully used a consumer power chair with a captain’s seat may now need rehab seating because “that (spinal) curvature is progressing, and you do need to give them a shape and layers of foam that the curve can fit into. And their skin is getting thinner, and maybe there are more incontinence issues, and so you want to be able to protect them and protect their skin.” Or arthritis or the natural aging process may cause tightness in the joints and resulting pain.

Nevertheless, Brown says the current generation of seniors is culturally prone to making do, instead of assertively seeking improvements and communicating that desire to their rehab team or physicians.

“They feel lucky to have what they have,” Brown says. “(They say) ‘I’ve lived with it that way for such a long time, that’s OK.’”
In those cases, providers can be the bearers of very good news: that better solutions are frequently available.

“Everybody needs to take a piece of recognizing that there are ways that we can react to their (aging) changes by changing the seating, changing the programming, by changing the way they enter or use the system,” Brown says. “There are plenty of things we can do. We just need to get everybody asking all those questions all the time and then working to put the story together.”