Prevention of Overuse of Wheelchairs in Nursing Homes
The number of nursing home residents in the United States is projected to reach three million by the year 2030. Currently, over 80% of residents spend time sitting in a wheelchair every day. Many of these residents are overlooked for therapeutic treatment because they are perceived as being too physically disabled and/or without rehabilitation potential. Furthermore, use of wheelchairs is associated with many types of adverse outcomes and injuries, including deconditioning, pressure ulcers, skin tears, bruises, edema, nerve impingement, falls, discomfort, contractures, loss of independence and autonomy, social isolation, and decreased quality of life. There is increasing concern that wheelchairs are being overused in nursing homes. This growing trend can be curtailed by the development and implementation of a program to assess mobility, encourage ambulation, and restrict unnecessary wheelchair use. (Annals of Long-Term Care: Clinical Care and Aging 2010;18:34-38) The reduction of physical function in advancing age often leads to loss of independence, increased need for institutionalization, and premature death. As people age, they experience changes in proprioception, balance, muscle strength, and sensory function, all of which can have a negative effect on mobility and navigation around environmental hazards and barriers.1 With the increasing population of older adults age 65 and over, the number of nursing home (NH) residents in the United States is projected to reach three million by the year 2030.2 Currently, most residents are admitted directly from a hospital or from another NH with three or more admitting diagnoses.3 The most common medical conditions are cardiovascular diseases, mental and cognitive disorders, and musculoskeletal problems, all of which may contribute to mobility challenges in this population.4 For example, the effects of a stroke often result in impairment of gait, balance, proprioception, and endurance. Individuals with dementia lose their ability to plan and execute purposeful activities and may put themselves at risk of physical injury.5 Osteoarthritis and fixed spinal deformities (eg, kyphosis) frequently present challenges in assessing residents for comfortable seating and positioning, and can present a misleading picture when NH staff perceive residents as more functionally impaired than they actually are.4,6,7 This presents a problem, in that the loss of mobility can sometimes result in unnecessary dependence upon others. Some NH regulations, while intended to protect the presumably vulnerable adult population, actually limit the personal freedom of the residents. For example, most facilities have specific mealtimes and food choices, and residents are allowed visitors only during certain hours. Smoking and drinking alcohol are monitored closely, if allowed at all. With regard to safe mobility, wheelchairs may be assigned as a means of providing protection from injuries, particularly falls. While the intention is primarily protective, it may contribute to preventable decline in function. For example, wheelchair use in NHs is very common, with up to 80% of residents spending time sitting in a wheelchair every day, and many of these residents are overlooked for therapeutic treatment because they are perceived as too physically and/or functionally impaired to benefit from rehabilitation programs.8 Unfortunately, use of wheelchairs is associated with many types of adverse events and injuries that are often overlooked or unrecognized. These adverse outcomes include, but are not limited to: deconditioning, pressure ulcers, falls, discomfort, contractures, constipation, loss of independence and autonomy, social isolation, and decreased quality of life.4 Ill-fitting wheelchairs can also cause pressure ulcers, skin tears, bruises and abrasions, edema, and nerve impingement. There is a growing concern that wheelchairs are being overused in NHs. Possible explanations for this phenomenon include convenience, entitlement, assumption of need, and lack of motivation on the part of both residents and staff. Another reason may be fear of liability on the part of the NH, since injurious falls have been the central issue in many lawsuits. This practice presents both challenge and opportunity when assessing residents’ functional mobility. Rather than routinely assigning a wheelchair, providers might suggest alternative assistive mobility devices to residents who have the potential to ambulate. A new initiative, Getting Residents Out of Wheelchairs (GROW) Coalition,9 was conceived by a group of healthcare professionals to lobby against the overuse of wheelchairs in NHs. Their mission is to support the Advancing Excellence in America’s Nursing Homes campaign (http://www.nhqualitycampaign.org/) by encouraging ambulation whenever possible and decreasing the use of wheelchairs when regular chairs could be used for stationary seating. An initial approach to this issue is to identify three major groups of individuals in the NH according to their functional ability: (1) able to walk independently; (2) require assistance when walking; and (3) unable to walk even with assistance.5 Each group will be discussed individually below. Residents Who Are Able to Walk Independently Walking is an important activity for anyone, but perhaps even more so for NH residents. Independent walking provides an opportunity to exercise and to interact with others and the environment. Another important benefit is mastery, described as the sense people have regarding their ability to exercise control over the important circumstances of their lives.10 Autonomy is recognized as a major contributor to mental alertness and physical well-being, and studies indicate that elderly individuals report greater satisfaction and quality of life when they experience autonomy.11,12 Essential physical elements that affect quality of life and the ability to interact with one’s environment include upright trunk alignment, normal visual field, verticality, and independent mobility potential.13 Walking is also important for prevention of intercurrent infections and pressure ulcers. Residents who are unable to walk have 3.4 times higher risk of development of urinary tract infections and 6.6 times higher risk of development of pneumonia.14 It is important to implement programs that promote walking to maintain or improve functional mobility. Some progress is being made in the area of maintenance/restoration of independent mobility in NH residents. One study reported that 12 weeks of daily walking at a self-selected pace by ambulatory NH residents produced significant improvement in walk endurance capacity.15 Tolerating the risk of falling may be preferable to decreased ambulation caused by use of wheelchairs in these individuals. The Alzheimer’s Association recommends that NHs develop a care plan that promotes mobility and safety, and that residents, families, and caregivers be informed of risks associated with all mobility assistive devices and programs that promote ambulation. A range of interventions and strategies to prevent or minimize injuries can be tailored for each resident at risk of falling. Although falls in NH residents with dementia are quite common, occurring an average four times a year, 60% of these falls result in no injury, 31% in soft-tissue injury, less than 3% in a fracture, with hip fracture occurring only in 1% of the falls.1 Injuries caused by falls often can be prevented by an appropriate environmental design that allows for safe ambulation and by the use of hip protectors.17,18 Residents Who Require Assistance When Walking Recent statistics provided by the Minimum Data Set (MDS) indicate that approximately two-thirds of NH residents use wheelchairs as their primary mode of locomotion, one-fourth require physical assistance of another person to ambulate, and one-fifth are ambulatory with supervision.19 The need for physical assistance during ambulation may be due to a cognitive impairment that leads to gait disorder and/or inability of the resident to recognize objects in his/her path. Dementia induces a cautious gait that is characterized by widened base of support, decreased step length, and decreased walking speed. In later stages of dementia, residents may develop narrow-based gait (“scissoring”) and may also be afraid of becoming dizzy, and therefore unwilling to walk alone.20 Wheelchair use in this population is usually justified by two goals: improvement in mobility and increased safety. However, NH residents have been observed propelling their wheelchairs less than 4% of the time. In addition, improperly maintained or ill-fitting wheelchairs account for 16% of NH falls.21,22 Wheelchairs were originally designed to transport people from one place to another quickly and easily. They have evolved to rank among the most important therapeutic devices used in rehabilitation. However, the increased—and possibly indiscriminate—use of wheelchairs in NHs has been accompanied by an increase in many types of adverse events, including wheelchair-related tips and falls and deconditioning.19,23 The physiologic demands of propelling a wheelchair are greater than one might assume, since the typical standard wheelchair (18” wide, weighing more than 40 lb) is only 5% efficient, in that 95% of the user’s effort is wasted in the form of heat or nonproductive energy expended. One reason for this is that the small muscles of the upper extremities are not designed for the powerful movements necessary for wheelchair propulsion.24 Many wheelchair users suffer shoulder pain (35-100%) and carpal tunnel syndrome (49-73%) from the strain of pushing heavy, ill-fitting wheelchairs.25 Other injuries include radial nerve palsy, strained backs, muscle fatigue, and pressure ulcers. There is also evidence that a significant correlation exists between falls and wheelchair use in dementia units.20 It is often overlooked that functional mobility may be improved by physical exercise. Brief walks and repeated chair stands four times a day improved walking and standing endurance in frail, deconditioned, cognitively impaired NH residents.26 The combination of assisted walking with conversation was shown to slow down decline in functional mobility in residents with Alzheimer’s disease.27 To date, little attention has been paid to alternative assistive devices that could replace wheelchairs for some residents. One example of an alternative device is a wheeled walker (eg, Merry Walker®; Figure 1) that surrounds the user on all sides and has a built-in seat and optional safety strap between the legs to prevent falls. In one pilot study, use of the Merry Walker resulted in improved mobility, decreased daytime sleep, improved mood, increased engagement, and no injuries.28 Another alternative device for mobility is the U-Step walker (Figure 2), a wheeled upright walker with U shape to step into, and hand brakes that automatically engage whenever the walker is not in motion, unlike current styles with brakes that the user must squeeze to engage. This walker also has an optional laser beam at the bottom that can be turned on and used as a visual cue for individuals with festinating gait (eg, those with Parkinson’s disease) to step over. Wheelchair use for this population should be limited to transportation to dining or activity rooms. When residents reach their destination, they can be transferred to regular chairs or other seating arrangements. Regular seating arrangements not only improve the atmosphere of dining and activity rooms but also increase residents’ self-esteem. Individuals Who Are Unable to Walk Even with Assistance Certain medical conditions preclude the ability to ambulate, even with assistance (eg, amputations, fixed contractures, multiple sclerosis, spinal cord injuries, progression of dementia). This frequently creates difficulties in NHs when attempting to balance the desire for independence, comfort, and personal safety of residents. Some residents are unable to walk even with assistance but are able to use a wheelchair for primary ambulation (eg, paraplegics). However, individuals with advanced dementia usually cannot propel a wheelchair, yet are often placed in a wheelchair for most of the day. For elderly NH residents who must use a wheelchair for mobility, the chair becomes an extension of, and an integral part of, their daily life, their environment, and their identity. Adaptive (or individualized) wheelchair seating, is defined here as the matching of construction, size, and function of a wheelchair with the function, safety, comfort, size, and/or disability of an individual user.4 Prescription of the most appropriate wheelchair with proper adjustment and training in safe use are critical elements in rehabilitation.23 Deficient/inappropriate wheelchairs are generally a direct result of a lack of awareness and knowledge regarding elderly seating needs, but cost may also be prohibitive in the long-term care setting.4 A wheelchair that is properly fitted to the user is the single most important factor in reducing adverse events, including repetitive strain injuries.25 In a single-subject intervention study of 13 elderly NH residents who used a wheelchair for mobility, subjects were given formal seating evaluations and provided a new individualized custom wheelchair. Pre- and posttest results indicated that all subjects benefited from the new seating systems by demonstrating improved posture, more efficient mobility, increased functional independence, and improved quality of life.6 Cognitive function may be negatively affected by poor positioning, especially when the user’s eyes are directed up toward the ceiling, which can promote shortened neck tendons, confusion, and isolation.29 A person with kyphosis of the spine assigned a wheelchair that is too wide or that has armrests placed too high will have his/her visual field directed toward the floor, causing the shoulders and trunk to round forward due to gravity, and the person will suffer similar consequences.30 Poorly positioned residents as described above often present a misleading picture and may be perceived by onlookers as unable or unwilling to participate in social interaction.13 Improper wheelchair positioning (eg, chair too wide, armrests too high, blocking the elbows) can often inhibit the use of one’s arms and hands, rendering the individual unable to eat and/or propel independently. Lack of trunk support can elicit leaning, sliding, and hyperextension or hyperflexion of the head and neck, and can add to the residents’ dependency on caregivers and staff. Frequent repositioning of residents presents risks to both the individual and staff, and exposes both to unnecessary injury. Given the opportunity to be placed in a more appropriate seating system, however, the same resident may show dramatic improvement in function, sometimes immediately. Further, increased patient comfort can lead to increased sitting tolerance and more positive interaction with staff.6 Postural assessment, prescription, training, and maintenance are all critical elements in the provision of wheelchairs in this population, and may be enhanced through increased awareness and education. Programs Reducing Inappropriate Use of Wheelchairs Some progress is being made in the area of independent mobility in NH residents. One NH, Norridge Healthcare and Rehabilitation Center in Norridge, IL, is actively addressing this issue by instituting the following: requiring a comprehensive mobility evaluation by physical therapy and a specific plan with timelines on transitioning wheelchair users who qualify for a less restrictive device (eg, Merry Walker), while pursuing independent ambulation. Seventy-six residents were followed for one year, and, overall, 86% improved. After completion of the study, 8% of subjects were walking independently (including one who had used a wheelchair for more than 4 years), 15% were walking with a walker, 17% were walking with assistance of another person, 42% were able to transfer from wheelchair to bed/toilet independently, and 14% were either unable to transfer or refused involvement in the program. This NH now has disincentivized wheelchair use by discontinuing the preferred placement of wheelchairs at the front of the room during special functions, and also by planning quarterly outings where wheelchairs cannot be accommodated. Any resident who is able to walk, with or without assistance, is required to walk to dining and other activities. This change alone requires a minimum walking activity three times per day. The staff reportedly has seen dramatic changes, and there has been a significant increase in resident and family satisfaction. Residents who have progressed out of wheelchairs are encouraging other residents and explaining to them how much better life can be having their autonomy back. Although requiring an increase in person-hours in the beginning phase, this program has ultimately resulted in dramatically reduced staffing hours/efforts. The success of this initiative has led to the requirement that this program be instituted in six other NHs managed by the organization. Even with customized wheelchairs, quality of life for residents with advanced and terminal dementia may not be adequately addressed. When they are unable to participate in activity programs, they are often placed in a corridor close to a nursing station and left alone. One alternative is a special program for residents who do not benefit from regular activities, such as Namaste Care.31 This program, which does not require increased staffing, includes a special room for these residents where a staff member is always present, and it provides both physical and sensory stimulation. The residents are transferred from standard wheelchairs into comfortable reclining chairs that can be tilted back to accommodate the need for frequent napping, as well as repositioning to decrease the risk of pressure ulcers. The quiet and peaceful environment of the Namaste room has been well-received and appreciated by both staff and families of participating residents. Comparison of MDS findings before and after introduction of this program showed increased interest in residents who had been withdrawn or socially impaired, decreased agitation and delirium indicators, and decreased use of antianxiety medications.32 Conclusion There appears to be substantive evidence that wheelchairs are overused in NHs. While a few studies have demonstrated the benefits of individualized wheelchair seating, there is no published research that specifically tracked outcomes related to use of alternative mobility technology in this setting. By providing clinics or programs to objectively evaluate functional mobility, NHs can draw their residents into the decision-making process by offering alternatives to wheelchairs when choosing assistive mobility devices. Carefully monitored trials can be conducted, allowing each resident to exercise autonomy and to explore his/her ability to restore, enhance, or maintain ambulation. Through this initiative, NHs can increase the safety, function, and quality of life for their residents. The well-documented benefits of preserving ambulation and independence for as long as possible are more than adequate reasons to support efforts to do just that. The authors report no relevant financial relationships. Dr. Gavin-Dreschnack is Health Science Specialist, HSR&D/RR&D Center of Excellence Maximizing Rehabilitation Outcomes, James A. Haley VAMC, Tampa, FL; Dr. Volicer is at the School of Aging Studies, University of South Florida, Tampa; and Ms. Morris is a Registered Nurse and Licensed Nursing Home Administrator in Chicago, IL. References 1. Talbot LA, Musiol EK, Witham EK, Metter EJ. Falls in young, middle-aged and older community dwelling adults: Perceived cause, environmental factors and injury. 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