Positioning can make the difference.

Too often society's perception of the institutionalized elderly has been that of a non-functional individual slumped in a sling back wheelchair, limbs contracted, with non-focused eyes gazing at the floor. While this perception may be reinforced by observation in many long-term care facilities, it is inaccurate to assume that poor posture is a result of normal aging or a necessary by-product of institutionalization.

Unfortunately, these observations are further reinforced by society's perception of growing old. We as a society have associated the term "old" with deterioration, while in fact it comes from the Latin root "alo," meaning to nourish and, more generally, to strengthen, increase and advance forward.

As rehabilitation clinicians, our general focus in working with the elderly has been to emphasize positive vs. negative, ability vs. disability, strengths vs. weaknesses. In connection with this, seating and positioning in the elderly become critical concerns, as the nursing home population becomes increasingly more physically dependent and cognitively impaired.

Our facility has made seating intervention a priority for several reasons. The psychosocial benefits of intervention start with perception. It has been shown that society judges people based on their appearance. Unfortunately, nursing home personnel, family members and the community as a whole are no different: They judge the institutionalized elderly's cognitive and physical abilities by their appearances.

The psychosocial benefits of therapeutic seating go beyond mere perception. The benefits include residents' increased awarenes of their environment, enhanced communication, and improved socialization. Further benefits often extend into maximizing functional levels with increasing mobility and enhanced level of independence. Seating intervention can also improve cardiovascular, pulmonary and gastrointestinal function. Proper positioning can provide uniform pressure distribution, with a potential decrease in the incidence of pressure sores. Lastly, our facility has achieved significant success in restraint reduction, with a major component of the process being seating intervention.

These successful results are dependent on individualized assessments and interventions. Individualization is impossible with the use only of standard wheelchairs and gerichairs. The anatomical dimensions of our residents do not fit the physical dimensions of conventional equipment. In a sample of 75 of our residents we found that the average measurements of seat width, depth, seat height, and arm height were significantly different from standard wheelchair and gerichair dimensions (see chart).

With this in mind, intervention can span the gamut from low-tech to high-tech equipment. Low-tech includes catalogue-ordered parts and facility-fabricated adaptations. From bolsters to solid seat inserts, these offer quick, inexpensive means of adapting the traditional seating devices. High-tech equipment includes individually molded seat and backs, as well as individualized orthotic support systems. High-tech offers greater potential for individualization, but with a far greater cost and time frame for fabrication.

Any intervention in a multi-caregiver setting must be linked to extensive education. Primary caregivers must understand the reasons for interventions, as well as the techniques for application of equipment. It is essential that all caregivers consistently adhere to the plan formulated by the rehabilitative team--physician, nursing staff, rehabilitation staff and orthotist and/or seating vendor--in order to maximize the benefits of this approach. Furthermore, the community at large needs to be educated as to the purpose and advantages of seating intervention. All staff, family, volunteers, and able residents must be made knowledgeable partners in the seating process.

For many of our residents the positioning device in which they are seated creates their primary environment. This environment contributes to the resident's self-concept. It needs to represent an image of wellness and independence while supporting weakened musculature, contributing to a decrease in the use of restraints and acting as an adjunct to decubitis prevention programs. This primary environment will influence the overall function and attitude of the resident, and contribute to a positive staff perception and the community's positive concept of the resident.

The overall intervention in seating must highlight one's philosophy of care. In our case this is to maximize our residents' functional abilities and interaction with their surroundings while making the primary environment a partner in caregiving.

Mr. M

Mr. M is a 90-year-old male admitted to our facility with diagnoses of CVA with right hemiplegia. He presented to our seating clinic positioned in a gerichair, as his increased trunk extensor tone makes it impossible to maintain his position in a standard wheel chair. His size and trunk extensor tone would cause his continuous sliding out of a standard wheelchair.

Although alert, his CVA had left him globally aphasic and non-ambulatory. His position in the gerichair limited his eye contact with his environment and made oral feeding impossible. His straining to make eye contact increased his abnormal tone. Furthermore, his wife was unable to propel his gerichair, increasing her frustration during visits.

The team recommendation was for high-tech intervention. When positioned properly in a segmental seating system, he was able to make eye contact with people and his environment. The system promoted proper alignment of his trunk and extremities, while enabling him to tolerate a small amount of oral feeding. His wife was able to propel the system. Proper positioning improved Mr. M's image, his family's perceptions and the ability to interact with those closest to him.

Mr. S

79-year old- Mr. S was admitted to our facility with a diagnosis of Alzheimer's and Paget's diseases. His family and caregivers assured us that his level of communication was low. His increased tone and trunk extensor regidity make sitting in a standard wheelchair difficult for him.

The gerichair alternative did nothing to control his tone, while contributing to misalignment. His eye contact and contact with his environment were severely limited in the gerichair. His positioning portrayed illness and the community reacted accordingly.

With-the low tech intervention of a firm seat and firm back his image was changed. He looked relatively well. His family and caregivers were amazed. Even more amazing to all was his increased level of communication. He was able to look at and appreacite magazines and even discuss some thoughts concerning the Reagan Presidency. His dementia could not be reversed, but his ability to interact with those around him was maximized.

Mrs. M

Mrs. M was a 79-year-old woman admitted to our facility with a myriad of diagnoses, including Parkinson's disease and osteoporosis, with compression fractures of lumbar vertebrae. In her home she had become used to being viewed as a "sick" person, one to be surrounded by the comforter-like softness of the wheelchair cover, one to be cared for -- a debilitated person.

Even though she was alert, oriented and physically capable of a high level of function, her wheelchair limited her potential. The wheelchair seat height and arm rest height prevented her from independently coming to stand. She was unable to feed herself because the armrests increased the excursion distance to the table. She was even unable to properl her own wheelchair. Furthermore, the sling back and sling seat added to her increasing kyphosis and hip internal rotation. The wheelchair was limiting her abilities while increasing her disabilities.

With a relatively high-tech intervention of a molded seat and back coupled with an appropriate wheelchair frame, her level of function improved dramatically. She was able to self-feed, propel her wheelchair, transfer and walk short distances. Just as significantly, she portrayed an image of wellness. With this, not only her self-image but also her wardrobe changed. No more house dresses -- now she would wear fashionable outfits with trendy tennis shoes. The seating system had changed her function, image and attitude.