Flexibility for change The equipment must be flexible to meet further changes in body dimension and weight. Changes in width and seating angles may be required. Someone who is significantly overweight may continue gaining weight or may be attempting to lose weight. Either of these scenarios may require changes to the seating system as well as the wheelchair frame. As body shape changes, the seating angles may also need to change. For example, as abdominal tissue increases, the seat-to-back angle may need to increase to accommodate for the change. Geriatric seating Much of geriatric seating is similar to positioning other populations. However, the geriatric population requiring wheelchair seating comprises several major diagnoses, often has comorbidities, and has impaired skin integrity and healing (Jones & Rader, 2015). Most clients who are elderly have Medicare and some live in long-term care facilities, which can limit funding for necessary equipment. The geriatric population typically includes anyone over age 65. However, many people are still healthy and active until a much older age. For the purposes of this section, we will not address those clients with congenital conditions or disabilities acquired before the age of 65. Disabilities acquired after age 65 include cerebral vascular accidents (CVA or stroke); Parkinson’s disease; and various dementias, including Alzheimer’s disease. These conditions are compounded by common comorbidities, including arthritis; osteoporosis (often leading to kyphosis); diabetes (which can impair sensation and healing); and high blood pressure (Centers for Disease Control and Prevention, 2015). Goals of geriatric seating Goals of geriatric seating include pressure distribution and relief; adequate postural support; and the accommodation of common orthopedic concerns, such as kyphosis. Although these goals may sound simple and easily attainable, many elderly clients continue to use very inappropriate seating and mobility equipment, primarily because of funding limitations and lack of appropriate assessment and intervention. Geriatric considerations Skin integrity Aging decreases skin integrity; the skin becomes frail and is injured more easily (Jones, 2018). Certain medications can make the skin even more susceptible to injury. Although young children heal fairly quickly from scrapes, cuts, and bruises, the elderly population tends to heal slowly due to decreased skin integrity, possible circulatory issues, and sometimes poor nutrition. Pressure injuries are all too common among elders. Mobility may be limited, resulting in a client spending long hours in a seated position. Hygiene may not be adequate to keep the skin clean and dry. The aging process can make managing hygiene more difficult, and many people begin to bathe or shower less often. Loss of continence can also increase pressure injury risk, as the skin may be moist, and urine changes the pH of the skin, increasing fragility (Chisholm & Yip, 2018). Dementia is common in this age group and can impair a client’s ability to notice discomfort and change their position (Jones, 2018). Finally, nutrition may be decreased, particularly in clients who When a client resides in a long-term care facility, the Medicare funds go to the facility. The facility, therefore, is responsible for providing any equipment the client may need. To save money, facilities tend to use what they already have available or the least costly options. Even if the client resides at home, Medicare funding regulations may limit to certain diagnoses the type of seating interventions that can be used with a client. For example, only certain clients qualify for a pressure-relieving cushion. live alone, and this affects skin integrity. Lack of funding and competent care
Self-propulsion Self-propulsion in the recommended equipment is often difficult due to the weight of the client and equipment as well as the width of the equipment. The wheels are often too far from the client’s shoulders for efficient self-propulsion. As the wheelchair width increases to match client width, the wheels move further from midline. Although the client’s seat width requirements have increased, the shoulder girdle width is unchanged. In this situation, power mobility may be indicated. Seating interventions Impaired skin integrity makes pressure-relieving cushions important for the geriatric population. Clients who have had a CVA may have increased postural support needs on the affected side, requiring lateral trunk support and upper extremity support. Clients with kyphosis typically need the seat-to-back angle opened on the wheelchair or a tilt-in-space wheelchair to balance the head over the pelvis (preventing neck hyperextension; Figure 70). Figure 70: Manual Wheelchair with Tilt to Balance Head Over Pelvis Note . From “More on Practical Seating Considerations – Posterior Pelvic Tilt,” by S. Sherman, 2011, retrieved from http://www.clinical- corner.com/2011/05/more-on- practical-seating-considerations- posterior-pelvic-tilt. © Sunrise Medical. Reprinted with permission. Wheelchairs that offer these features are more costly and are often not part of a long-term care facility’s “fleet.” If all else fails, advocate for the client’s needs. If decision makers are not made to understand why a standard fleet wheelchair is placing a client at risk, their decisions will not change. When the person resides at home, Medicare will fund the necessary equipment directly, and it is critical to work with the wheelchair supplier to meet all documentation requirements. Aging with a disability When evaluating a client of any age, it is critical to consider the future effect of any equipment recommendations and use on the client. Equipment use not only has an immediate functional effect but can lead to anticipated – and unanticipated – implications over time. The population of the United States is aging, and as people age, they experience changes in functional abilities and are likely to develop chronic medical conditions, such as arthritis. Clients with disabilities are also aging, though often with more significant functional consequences than the general population (Taylor, 2018). Medical advances have allowed people with disabilities to live longer than in the past. The life expectancy of most individuals with acquired disabilities is 85% of those without physical disability (Kemp & Mosqueda, 2004). It is essential not only to consider short-term goals when making equipment recommendations but also to plan for long-term needs. For example, when working with a child who has abnormal muscle tone, clinicians need to anticipate growth and potential orthopedic changes. This anticipation will shape equipment recommendations, not only to provide the postural support required currently but also to reduce the risk of future orthopedic changes. When working with a client who can self- propel a manual wheelchair, clinicians need to consider not only current mobility needs but also repetitive stress injuries, which can occur after long-term manual wheelchair use. It is important to ensure that the wheelchair is configured to minimize injury to the
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Book Code: PTNC1023
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