1

Intervention Strategies for Seating and Positioning in the Older Adult

COLLEEN DERITIS, MA, OTR/L

Goals for today

• Identify problem areas related to positioning and document findings

• Recommend devices and positional changes to allow greater function and safe movement of the patient.

• Demonstrate understanding the role stability can play in reducing pressure ulcer risk related to seating

2

Consider throughout our course…• How well you evaluate impacts seating

• How well you evaluate impacts bed position

• Provision of proper adaptations and timeliness

• Are you adapting, compensating, or correcting?

• Patient and caregiver education

• How to document for carryover

Quick review of Measurements

SEAT WIDTH: A◦ Add an extra inch to each side to allow movement and any extra width to

allow for bulky clothing if appropriate◦ Measure widest width for windswept hips

SEAT DEPTH: B◦ Behind Hips / Popliteal Fossa ◦ Subtract two inches

SEAT HEIGHT: C◦ Popliteal Fossa / Heel

FOOT PLATE: D◦ Heel / Toe

4

3

Common Wheelchair Types

Types Width Depth Back Height Floor to Seat Height

Standard Adult

18” 16” 33 ½” to 36” 19 ½”

Narrow

Adult

16” 16” 33 ½” to 36” 19 ¾”

Bariatric Up to 34” 20” Up to 36” 17 ½” to 19 ½”

Hemi-Height

18” 16” 33 ½” to 36” 17 ½”

Reclining 18” 17” Up to 52 1/2” 21 ¾”

5

Durable Medical Equipment• Can withstand repeated use

• Primary use is medical

• Not useful to person in absence of illness or injury

• Appropriate for in home use

4

Cushion Properties Review

We want and need:

• Pressure distribution

• Stability

• Interface temperature

• Reliability

Solid base

Foam

Viscous fluid- Gel

Air flotation

Evaluation considerations

•Mat evaluation◦ Posture

◦ Movable or fixed?

• Information gathering

◦ Demographics and referral information

• Observation!

• Insurance allowance

• Current DME in use

• Technology- current and possible new need

• Rationalization for change

5

Evaluation considerations

•Pain

•ADL’so Leisure

o Education/Employment

•Cognitive/perceptual status

•Sensation

•Respiration status

•Endurance

o Tank of gas

•Sitting tolerance

•Functional mobility

Evaluation considerations

• Transfers

• Ambulation

• Environmental accessoWhere is it stored?

oEase of use

• Transportation resourcesoEase of use

• Simulation

6

Poor posture…

•Contractures

•Deformity

•Skin breakdown

•Systemic complicationso Infection

UTI

oRespiratory complications

•Fatigue

•Discomfort

•Loss of functional performance and decreased ability to perform ADL

•Quality of life compromise

•Financial complications

You are the case manager

• Advocate and Educate!

• Research

• Show evidence/best practice standards

• Credentials

• Consider appeals

• Need knowledge◦ What’s available◦ Frames

◦ Wheels

◦ Safety

7

Wheelchair modifications

• BrakesoPush on

oPull on

oExtender

• FootplatesoFixed

oSwing away

oElevating leg rests

• Castor size and position

• Camber

• Seat angle

• ArmrestsoFull or desk

oHeight adjustable

oDetachable

oFlip up

•Tires• Pneumatic

• Width

•Wheels• Size

• Hand rims

• Spokes

To recline or not to recline

Tilt-in-space Reclining

◦ Changes back angle

8

Prescriptive seating for wheeled mobility- Diane Ward- 1984

•Domains of Fit◦ Health and Physical Fit

Human orientation

Skeletal Alignment

Postural

Soft tissue integrity

Physiological function

◦ Functional fit

◦ Socio-Economic Fit

◦ Environmental Fit

Seating system features• Comfort

• Operate independently

• Stability of cushion

•Material

•Maintenance

• Follow through and compliance

•Weight

•Warranty

9

Patient complaints related to sitting

• Discomfort◦ Buttock

◦ Spine

◦ Results in low sitting tolerance and possibly bedrest

◦ Effects quality of life

• Poor posture◦ Stress on intervertebral disks

◦ Lumbar area

◦ Kyphotic lumbar posture

Identification of patient’s mobility level•Non-mobile and dependent

◦ Safety risk

◦ Without ability to walk or wheel self

•Mobile, non-ambulatory

• Ambulatory but with special needs

• Ambulatory

10

Activity level considerations

• Ambulatory or supervised ambulatory◦ Seating easy for

transfers

• Less mobile

◦ Contoured support

◦ Accommodate poor trunk strength and balance

◦ Transfer

Rehabilitation Planning

• Restore

• Compensate

• Adapt

11

Type of Deformities

• Fixedo Respect

o Accommodate

o Structural

• Flexibleo Correct it

o Functional

o Positional

Adaptation possibilities

• Lap trays

• Cushions/Wedges

• Arm bolsters

• Elevating leg rests

• Firm seating surface

• Dycem

12

Common problems related to mobility devices

•Width

• Height

• Backrests, armrests, footrests

• Upholstery laxity

•Wrong equipment

Seating Problem-Asymmetrical Posture

• Determine if it’s due to:◦ Diagnosis

◦ Current positioning

◦ Combination

•May be exacerbated by sling upholstery

13

Seating recommendationAsymmetrical Posture

• Goal- promote stability and symmetry

• Firm, level base of support

Seating Problem-Patient sliding and cannot propel

PROBLEM

•Sliding out of the wheelchair

•Unable to reach floor- self propel wheelchair

RATIONALE

•Sitting height too high to allow self propulsion

•Some people feel wedge may help keep in position

14

Seating recommendation-Patient sliding and poor propulsion

• Recommendations with goal of optimizing flexible postures and mobility◦ Lower seat to floor height

Hemi-height wheelchair

◦ Drop seat

Adaptation possibilities

•Wedge cushions◦ May be considered a restraint

◦ Height in front limits propulsion and transfers

◦ May require frequent repositioning

◦ Check available hip range via mat eval

◦ Purpose is to hold pelvis to back of chair

Decreases hip-back angle

When pt does not have this they sit in different angle

Posterior pelvic tilt

Flattened lumbar region

Increased thoracic kyphosis

15

Adaptation possibilities

•Physical problems which may result from the cushion◦ Back pain

◦ Poor circulation

◦ Respiratory difficulty

◦ Increased pressure

Seating Problem-Patient leaning laterally

PROBLEM

•Patient not able to sit up straight

•Eye gaze changes

•Patient can slide

RATIONALE

•Patient needs a device to hold them in place

•Will prevent lean

16

Seating Problem-Patient leaning laterally

•Recommendation:oLateral support

oSolid contour seat

oRecline trunk

oContoured back

Adaptation possibilities

• Lap trays◦ Used in some facilities to prevent sliding or

leaning

◦ Designed for UE support

◦ Writing

◦ May also be considered a restraint

•Consider a half lap tray

17

Seating Problem-Poor ability to maintain positioning

PROBLEM

•Cannot hold hips back

RATIONALE

• Leg rests can hold the hips back by raising the leg

• Feet can prevent sliding

Seating Problem-Poor ability to maintain positioning

• Recommendation◦ Older people cannot sit in the position forced by

leg rests

◦ Mat evaluation◦ May not even tolerate regular foot plates

◦ Tight hamstring muscles

18

Adaptation possibilities

• Leg rests◦ Tight hamstrings will pull people into posterior tilt when

elevated

◦ Remove them

Good for self propulsion

Removes skin tear risk

Reduces falls

When on, they add 20lbs weight

Does not do anything for edema control

Pressure UlcerNPUAP- 2014

◦ “…localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or

pressure in combination with shear.”

19

Factors

• Extrinsic◦ Excessive pressure*

◦ Friction*

◦ Shear*

◦ Forces

◦ Heat *

◦ Moisture*

• Intrinsic◦ Immobility*

◦ Sensory loss

◦ Age

◦ Decreased nutrition

Friction

•Damage due to skin sliding against supportive surface

•Burn

•Rubbing against sheets

20

Shear“distortion of tissue caused by forces working against tissue in parallel motion”

21

Stage 1: Non-blanchableErythema

•Intact skin

•Redness of localized area over bony prominence

•Painful, firm, soft, warmer or cooler

Stage 2:Partial Thickness Skin Loss

•Loss of dermis

•Shallow open ulcer

•Red pink wound bed

•No slough

**bruising deep tissue injury

22

Stage 3: Full Thickness Skin Loss

•Subcutaneous fat may be visible

•Bone, tendon or muscle not exposed

•Slough possible

•May include undermining and tunneling

Stage 4: Full Thickness Tissue Loss

•Exposed bone, tendon or muscle

•Slough or eschar

•Undermining and tunneling

23

Unstageable: Depth Unknown

•Full thickness tissue loss

•Base of ulcer covered in slough

•Cannot determine depth

Suspected Deep Tissue Injury: Depth Unknown

•Purple/maroon discolored skin

•Blood filled blister

24

Risk Factors

• Skin Assessment – Braden Scale- 1988◦ Lower score, higher risk

• Sensory perception

•Moisture

• Activity

• Nutrition

•Mobilization and repositioning ability

• Friction and shear

25

Bed positioning considerations

26

Skin Integrity

• Greatest risks◦ Shoulder blades

◦ Spine

◦ Back of upper and lower arm

◦ Coccyx, trochanter, ischials

◦ Heels and metatarsals

27

Mattress and Bed Supports

Consider:

◦ Level of immobility/inactivity

◦ Need for shear reduction

◦ Weight

◦ Risk for further breakdown

◦ Present ulcers

◦ Compatibility with pt’s environment

Heel Ulcer Prevention

• Free of the surface of the bed

• Suspension devices◦ Elevate

◦ Offload

28

Clinical Condition Considerations

• AKA-◦ Stability, pressure relief, decreased hip flexion

• Brain Injury-◦ Normalize tone, pressure relief, comfort and symmetry

• CVA-◦ Promote stability and summetry

◦ Seat to floor ht for propulsion

◦ Pressure relief

◦ Ease of equipment management caregivers

Things to consider with immobility

•Tilt

•Recline

•Cushion

•Seat pan/sling

•Sacral sitting

•Armrests

•Trunk support

•Footrests

•Covers on cushions

29

Wheelchair documentation

•Name

•MD name/NPI

•Detail of what you need

•All options

•Must be signed

•Date of face to face- within 6 months

•Date of order

•Mobility limitation

•Height/weight

•Length of need

•Technology in use

•User’s goals

https://www.cgsmedicare.com/jc/mr/pdf/mr_checklist_manual_wheelchair.pdf

Mobility Limitation

• Prevents patient from completing mobility related ADL (toileting, feeding, dressing, grooming, bathing)

•Willingness to use device

• Cannot be addressed by use of walker or cane

•Will be used regularly

• Has UE and cognitive function for safe propulsion

• At risk for death due to the attempts

• Time frame considerations

30

CMS signature

April 22, 2010

•Provider needs to be identified.

•Electronic signature

•Reviewed before submission

https://www.cgsmedicare.com/jc/mr/pdf/mr_checklist_manual_wheelchair.pdf

Home Assessment

• Adequate access between rooms

•Maneuvering space and surfaces

• Physical layout

• Document in the medical record

31

Documentation

• Assume “I know nothing…”

• Insurance does not want to pay

• Time consuming process

• Coordination required

• Appeals are normal

•Medical Necessity-◦ Move around residence

◦ Unable to propel adequately standard weight chair

◦ Confined to home

Medical Necessity

• National Health Law Project (www.healthlaw.org)◦ Prevent the onset or worsening of illness, condition,

disability

◦ To establish a diagnosis

◦ Provide palliative, curative, or restorative treatment for physical and/or mental health conditions

32

Supportive documentation

• Specifically justify parts and why needed.

• Elevating leg rests considerations

• Discuss alternatives you may have tried◦ Why won’t it work?

Any questions???cderitisotr@aol.com

Thank you!