Maintaining MobilityBy Carol Daus
Assistive equipment helps the geriatric population stay active and independent.
Today's seniors have never been more on the go. Between postponing retirement and participating in sports and activities once relegated to the young, most people over the age of 65 are living much more active lives than their parents did. Given this trend, it is clear that mobility plays a critical role for the geriatric population. Yet by their 70s and 80s, many seniors develop certain disabilities or chronic medical conditions that can seriously impact their ability to stay active. Fortunately, because of advances in mobility aids, a wide array of products are available to help the elderly live as independently and actively as possible. In addition, a great number of resources from Web sites to funding programs can now help seniors in their quest for more fulfilling lives.
William Mann, PhD, OTR, FAOTA, chairman, program director, and professor of the occupational therapy department at the University of Buffalo and the director or the Center for Assistive Technology, Buffalo, NY, stresses that enormous advancements in assistive technology have not only made these products more safe and reliable for the elderly, they have also helped enhance mobility for many individuals.
The cane is the most widely used assistive device, and in the United States alone, more than 4 million people use them. Canes support up to 25% of a person's weight and may prevent falls. The two types of canes available are single-point canes and quad canes. A single-point cane provides minimal support during ambulation and is appropriate for people who have slightly decreased balance, poor endurance, poor coordination, or muscular weakness.
A quad cane is a cane with four points in contact with the ground. It is available with either a wide or small base. The quad cane is more stable than the single-point cane. People with significant muscle weakness in both the arm and leg on one side of the body, which often happens following a stroke or brain injury, may benefit from the use of a quad cane.
According to Mann, the different materials used in the shaft of the cane can change its weight and feel. Traditional wood is relatively heavy while aluminum is much lighter. "We are also seeing newer, lightweight materials like carbon fiber," he says.
Almost 2 million people in the United States rely on walkers for their mobility needs. Since their introduction more than 200 years ago, walkers have changed dramatically. Originally designed as temporary rehab equipment, walkers have been modified for use in the home and features have been added like wheels, seats, and brakes, along with convenient accessories such as detachable baskets, trays, and walker bags.
Wheelchairs are typically used by seniors with impaired mobility and reduced strength. Wheelchairs often become a necessity due to chronic conditions like arthritis, stroke, or a fractured hip. Today, older Americans use more wheelchairs than any other age group.
During the past 20 years, enormous changes have been made in wheelchair design and construction. "The sad part is that many people are not aware of all the different types of wheelchairs that are available because they end up purchasing one at their local drugstore, which has a limited supply, or a relative lends them one," Mann says. "This is unfortunate since it may be set at the wrong height or is too heavy." Poorly fitting chairs can cause bruises, pressure ulcers, poor posture, and other problems.
Laura Gitlin, PhD, director of community and home care, research division of the College of Health Professions, Thomas Jefferson University, Philadelphia, concurs that assistive equipment should not be purchased for an elderly patient without consultation from an occupational or physical therapist. "It is easier to make recommendations about equipment and safety concerns, but when it comes to making the actual choice of a particular piece of adaptive equipment, a rehab professional is necessary," Gitlin says. "There are just too many variables between a patient's diagnosis and individualized needs." Matching the right piece of equipment to a person's needs requires skilled intervention and an interdisciplinary approach.
Three-wheeled mobility systems, also known as scooters, are becoming increasingly popular among the elderly. Scooters are useful for individuals who can walk short distances but need help for long distances. Most scooters have rear wheel drive and front wheel steering. According to Mann, even though scooters have been around for a long time, they have undergone some of the biggest improvements. "The power of the batteries and the speed at which they recharge are the most important changes we have seen with this technology," Mann says. Specifically, power seats, flip-back arms, adjustable bases, gear drive systems that provide 40 miles to a charge, and attractive colors are enhancements found in today's scooters.
Many elderly patients like scooters since they provide a very comfortable ride because they absorb shock. Most can achieve speeds of up to four miles per hour. Scooters are steered with a handlebar, steering wheel, joystick, or push-button controls. Some scooters disassemble easily for transportation in the trunk of a vehicle. "The elderly particularly need to pay attention to how heavy a scooters is if they, or someone else, will have to lift it in and out of a car," Mann says. "The best gauge is to determine if you can lift the largest, heaviest part when the chair is disassembled."
Regardless of what type of assistive equipment an elderly patient needs, rehab professionals stress that there are a number of social and psychological issues that must be addressed to ensure that the equipment meets its objectives. "When a PT or OT first meets an elderly patient in the rehab environment, in many instances that represents the first time that individual has experienced an acute change in his health and functional status," Gitlin says. "Whether it is a hip fracture, stroke or chronic condition, the rehab professional needs to be sensitive to the fact that the change in this patient's health has great significance in how he redefines who he is and what he is capable of doing."
Gitlin has also found in her research that assistive equipment has both positive and negative aspects for most geriatric patients. Obviously the positive aspect is that the equipment can help enable patients to live independently and resume functions that were performed before the change in health status. The negative is that the piece of equipment is symbolic of the fact that now there is a change in their health or function," Gitlin says. The patient's mixed emotions play an important tool in the rehabilitation process, and it is essential to address these feelings prior to the patient's discharge.
Although Gitlin believes that many improvements have been made is assistive equipment, which has made the devices less intimidating for the elderly, she still believes that manufacturers should pay more attention to user needs and desires. She cites the case of a piece of assistive equipment a manufacturer gave her and her staff to evaluate. "We had our own opinions about the product, but what was most interesting was that when we shared it with potential users, they came up with 20 to 50 other recommendations that never would have occurred to us, since we personally do not have a need for the product," Gitlin says.
Mann agrees that the best assistive equipment typically comes about when end users are involved in the research and development phase. With funding from the National Institute on Disability and Rehabilitation Research and the Administration on Aging, Mann established the first Rehabilitation Engineering Research Center (RERC) on Aging. One component of RERC's research has been its consumer assessment study, which solicits information from individuals who use assistive devices. This study involves more than 300 home-based older persons and approximately 100 seniors living in nursing homes to learn how various equipment helps with functional tasks.
For many seniors who need assistive equipment, funding is a serious problem. Cuts in Medicare resulting from the Balanced Budget Act if 1997 have especially impacted the elderly. At the same time, research is starting to reveal how an investment in assistive equipment can actually lower health care costs in the long run. According to research conducted by Mann, if the frail elderly are given the mobility equipment they need, they end up suffering from fewer falls and also have fewer or shorter hospitalizations. "We also learned that when the elderly have assistive devices in the home, they develop more motivation and have a greater sense of control," Mann says.
In an informal study, Gitlin studied the perceptions of low-income seniors who were given bathroom assistive equipment. Until then, they had never used this type of equipment in their homes. "The reported benefits were overwhelming," Gitlin says. "They stated they needed less assistance from caregivers, could perform bathroom functions more independently, and felt a sense of normalcy and well-being," she adds. The value of this type of research is that it clearly documents the real cost benefits of assistive technology.
One bright spot is that Congress in 1988 enacted the Technology-Related Assistance for Individuals for Disabilities Act, Public Law 100-407, also known as the Tech Bill. This law provides funding to each state to find ways to overcome barriers through the creation of statewide, consumer responsiveness systems.
Mann also points out that there are innovative programs designed to help the frail elderly obtain various assistive equipment even though they cannot afford it. San Francisco-based On Lok Senior Health Services, formed in response to community concern for frail elders, opened its first day health center in 1972. The program helps provide assistive equipment to low income seniors. In 1986, congressional legislation authorized On Lok to move beyond a demonstration project and achieve permanence as a model program. Additional legislation allowed On Lok to launch PACE, Program of All-inclusive Care for the Elderly, a nationwide effort to replicate On Lok's model of care across the country.
The PACE model was signed into legislation by President Clinton in August 1997 as an option for all 50 states. Currently, 70 organizations in 30 states are in some phase of PACE development.
Programs like On Lok and PACE are a step in the right direction, but overall reimbursement doe assistive technology is still very restrictive. "It is very shortsighted to think that the cost of this equipment is too high to justify proper reimbursement," Mann says. "If you give the elderly the tools they need to live more productive, fulfilling lives, there is no doubt that costs will be saved due to fewer hospitalizations and complications." For additional information, contact: National PACE Organization, (415) 749-2680, www.natlpaceassn.org; On Lok Senior Health, (888) 88-ON-LOK; ABLE-DATA, www.abledata.com; RESNA, (703) 524-6686, www.resna.org.