Improving wheelchair mobility.

How to address a central, and frequently overlooked, factor in residents' quality of life

Of the 1.8 million nursing home residents in the United States, more than half are incapable of independent ambulation. For these residents, wheelchair propulsion is their only means of mobility. Given their large numbers, it is unfortunate that health care providers and researchers have paid so little attention to the special needs of wheelchair-dependent nursing home residents.

There is little evidence in the literature that residents are formally assessed or evaluated for a wheelchair, much less a specific type of wheelchair. Moreover, of those assessments that are conducted, physicians and other health professionals are rarely involved in assessing a resident's specific need for a wheelchair. Few studies describe wheelchair activity among nursing home residents, and there are no published reports of intervention programs designed to improve wheelchair mobility in this population.

Perhaps part of the problem is that wheelchairs are so ubiquitous in nursing homes that, ironically, they're easy to overlook - a case of missing the trees for the forest. Yet when we consider their usefulness to nursing home residents, wheelchairs, and wheelchair mobility, seem far too important to ignore.

Wheelchair use increases mobility, not only for non-ambulatory residents, but also for some ambulatory residents who choose to use a wheelchair instead of walking due to their fear of falling.(1) Nursing home residents have also reported that wheelchair use increases their feeling of independence and sense of physical and emotional well-being.(1) The ability to independently or self-propel a wheelchair also has important social ramifications that can affect quality of life. Wheelchair mobility, for example, allows some residents to determine where they will sit and in what activities they will participate. Wheelchair mobility makes it easier for residents to get around in their rooms and to socialize with other residents. Through wheelchair mobility, residents have the freedom to make these choices without relying on nursing home staff for assistance.

Despite these benefits, a significant number of nursing home residents spend the majority of their day sitting in their wheelchairs, immobile for hours. In 1994, we conducted a study during which we observed wheelchair activity among 65 non-ambulatory residents across seven nursing homes.(2) Each resident was observed every 15 minutes for 12 hours on each of two days, for a total of 96 observations. We didn't see much, to say the least. On average, residents were observed propelling their wheelchairs on only four of the 96 observations.

The authors identified at least three explanations for this. First, many residents were so functionally impaired that they had difficulty moving their wheelchairs. For example, only 45% could wheel their chairs under their own power, but even then, none of the residents could independently unlock their chairs. This problem in unlocking wheelchairs was due to difficulties with both locating the locks and having sufficient strength to move the lock once located.

The second barrier to wheelchair mobility was problems with the wheelchairs themselves: 46% of residents were in chairs that were dysfunctional or ill-suited to the resident's size. Thus, even if residents could unlock the brakes and had sufficient strength to propel their wheelchairs, there still remained significant barriers to frequent or easy wheelchair propulsion.

Finally, we identified policy and institutional barriers to improved wheelchair mobility. Too often, nursing home providers assume that non-ambulatory means immobile, and that wheelchairs are designed only to be pushed, not self-propelled. An institutional emphasis on time-efficient care delivery exacerbates the problem: busy nursing home staff often find it more efficient to simply push a wheelchair-bound resident to his or her destination rather than take the time to prompt the resident to self-propel the chair. Over time, the resident may come to expect this type of assistance from staff and forgo any attempt at self-propulsion.

Then, too, nursing facilities may not always be able to match a resident to the most appropriate wheelchair, in part because Medicare does not pay for wheelchairs in nursing homes. Thus, facilities have only a limited supply of wheelchairs to assign to new residents at any given time.

These barriers represent the bad news. The good news is that many of these barriers can be overcome with easy-to-implement solutions.

To start, residents who need or want to use a wheelchair should be assessed by a physical or occupational therapist for the most appropriate type of wheelchair. An ill-fitting wheelchair not only can be uncomfortable and difficult to propel, but can also pose multiple health hazards. Remember: wheelchairs are not "one size fits all." In addition to the standard wheelchair, there is the hemi-wheelchair, which allows the resident to propel the chair with one leg and/or one arm; the semi-reclining wheelchair, for residents with limited trunk control; the fully-reclining wheelchair, for residents with no trunk control or who are unable to tolerate the upright position; and the amputee wheelchair, with the rear wheel set back to compensate for the loss of the lower extremity(ies).

There are other options to consider: most types of wheelchairs are available with three different seat widths: regular, narrow and extra-wide. Other options include removable arms, which make it easier to transfer residents; elevated leg rests, often used with residents who have lower extremity edema; and swing-away leg rests, which makes transferring easier for both staff and residents.

In their book Positioning in a Wheelchair: A Guide for Professional Care Givers of the Disabled Adult,(3) Mayall and Desharnais recommend that wheelchair assessments take into account the patient's diagnosis and prognosis, age, cognitive function, perceptual function, physical ability, level of independence in activities of daily living, transfer ability and modality and mobility. Other factors to consider include body weight, sensory status, presence of edema, skin integrity, leisure interests and lifestyle, patient usage of the wheelchair, amount of time spent daily in the wheelchair, and the patient's financial resources.

Obtaining this information is worthwhile, because wheelchairs these days can be customized to better fit a particular individual. To help with this, a variety of products are available, including several types of specially designed seat and back cushions, ankle positioning aids, leg-rest panels, foot supports, headrests and head supports. Medicare pays for only certain limited seating aids, primarily when trunk control is affected. If the nursing facility does not have appropriate items available, and Medicare will not pay for them, the resident or the resident's family may decide to purchase the items, on grounds that these special aids are more affordable than a new wheelchair.

In some cases, you may be able to devise your own wheelchair aids. For example, after repeatedly noting how difficult it was for residents to operate their wheelchair brakes, we began using inexpensive PVC pipes as brake extenders so that residents could more easily reach their brakes. The extension also gave residents additional leverage to operate the brakes.

Once a wheelchair has been assigned and customized to a particular resident, make sure the chair stays with that resident. One nursing facility numbers each wheelchair and then records in a file who has been assigned that wheelchair and what type of wheelchair it is. On the back of each wheelchair is the name tag for the assigned resident.

Don't assume that residents know how to use their wheelchairs. Show them. Demonstrate how to operate the brakes and foot pedals, where to place their hands and legs, how to use their hands and/or legs to propel the chair, and how to get up from and sit back down in the wheelchair. Then ask them to demonstrate their knowledge, i.e., they should show you how they propel their wheelchair, how they stand up from the chair and how they sit down.

Pay special attention to residents' safety behaviors, such as whether the resident locks his or her wheelchair and moves the foot pedals before standing. Be sure to correct any unsafe behaviors. Also, periodically reassess a resident's wheelchair skills and safety judgment, for these may change over time.

You should also regularly check wheelchairs for defects and, if found, promptly repair them. If you keep a file on each wheelchair, add a record of the results of your equipment assessment and any repairs done.

To increase wheelchair mobility, provide residents with organized practice in wheelchair propulsion, similar to how ambulatory residents are given walking exercise. This intervention has been shown to result in increases in wheelchair speed, endurance and handgrip strength.(4,5) For more practice, residents should be encouraged and prompted to propel their wheelchairs to meals, social activities, physical and occupational therapy sessions, and so forth.

In summary, because wheelchair mobility appears to be an integral part of life in a nursing home for a substantial number of residents and, if applied, can help a resident feel more independent and self-sufficient, it is well worth staff's focused attention. Minimally, nursing homes should formally assess residents upon admission for wheelchair ability and any special wheelchair device needs. In addition, a significant number of barriers could be addressed simply through better wheelchair maintenance (e.g., repairing defective brakes).

With respect to future research, the large number of residents dependent upon wheelchairs for mobility, in combination with the social ramifications of such mobility, define a fruitful area for intervention that may have a significant impact on nursing home residents' quality of life. But improvements can be undertaken now, before the research results come in.

References

1. Pawlson LG, Goodwin M, Keith K. Wheelchair use by ambulatory nursing home residents. Journal of the American Geriatrics Society 1986; 34:860-864.

2. Simmons SF, Schnelle JF, MacRae PG, et al. Wheelchairs as mobility restraints: Predictors of wheelchair activity in nonambulatory nursing home residents. Journal of the American Geriatrics Society 1995; 43:384-388.

3. Mayall JK, Desharnais G. Positioning in a Wheelchair: A Guide for Professional Care Givers of the Disabled Adult. New York, NY: McGraw-Hill, Inc., Medical Publishing Group, 1990.

4. Schnelle JF, MacRae PG, Ouslander JG, et al. Functional incidental training, mobility performance, and incontinence care with nursing home residents. Journal of the American Geriatrics Society 1995; 43(12):1356-62.

5. Schnelle JF, MacRae PG, Giacobassi K, et al. Exercise with physically restrained nursing home residents: Maximizing benefits of restraint reduction. Journal of the American Geriatrics Society, in press.

Sandra Simmons, MA is a National Institute on Aging pre-doctoral fellow at the Pennsylvania State University Gerontology Center. Anna Rahman, MSW is dissemination coordinator for the UCLA Claude D. Pepper Older Americans Independence Center and Pearl Dietz, PT is director of Rehabilitation Services at the Country Villa-Westwood nursing facility, both in Los Angeles, CA.