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Assistive Technology and Mobility Aids for the Older Patient with Disability
Conceptually, assistive technology needs to be thought of simultaneously with adaptive techniques and environmental modifications, as they are typically used in conjunction with one another. Assistive technology refers specifically to devices used to compensate for physical limitations. The term assistive technology may be used narrowly to refer to special tools used to accomplish an activity (eg, a walker), or it may include orthotics (eg, braces, splints) and prosthetics (eg, artificial limbs) as well. Adaptive techniques refer to modifications in the way an activity is carried out. For example, someone with limited shoulder range of motion might place the arms in the sleeves of a t-shirt, then put it over the head rather than the reverse; or a woman might fasten her brassiere in the front, then turn it around rather than trying to reach behind to close the brassiere.
Use of almost any assistive device will require some modification in the way the activities performed with the device are carried out. Environmental modifications are changes in the physical surroundings, such as enlargement of a doorway to allow for a wheelchair. The Americans with Disabilities Act (ADA) of 1990 focused on environmental modifications to enhance access to the workplace, public buildings, and transportation (see www.adata.org for further information).
Universal design is a term occasionally used in the context of environmental modifications that refer to architectural design to enable access for the widest possible breadth of physical abilities. Thus, generally speaking, assistive technologies and adaptive strategies compensate for extant disability by increasing an individual’s functional abilities, environmental modifications act to reduce the environmental demands on the individual, and all three together help enable people with physical limitations continue to accomplish important activities. Usage of assistive technology is increasingly common, with growth far exceeding demographic changes in the U.S. population.1 From 1980-1994, the U.S. population increased by 19.1%; however, the age-adjusted use of leg braces increased by 52.1%, walkers by 70.1%, and wheelchairs by 82.6%.2 Approximately one in four older adults use an assistive device, and one-third of those use more than one such device. Assistive technology has improved considerably in functionality, appearance, and diversity over recent years.3,4 While outcomes research on assistive technology is limited,5 existing data show that it may reduce task difficulty and reduce the need for help from another person.6-9 However, many disabled people report that they lack potentially helpful devices, and problems with devices are common.10-14 The very process by which assistive devices are acquired by older adults is part of the problem.
Difficulties besetting elderly persons trying to obtain assistive technology include difficulty obtaining information on potentially useful equipment, high cost and limited funding for assistive technology, and fraud and abuse by providers.15 To foster technology-related assistance for consumers, the “Tech Act” was enacted in 1988.16 This legislation spawned availability of information on the Internet and centers in each state to provide assistance with technology to disabled persons. (see www.resna.org/taproject/index.html/at/statecontacts.html for a state-by-state list). Useful websites include https://www.abledata.com (a listing of over 17,000 different assistive devices), https://www.wheelchairnet.org/ (a website specifically focused on wheelchairs), and https://www.resna.org/ (the website for the Rehabilitation Engineering and Assistive Technology Society of North America). Professional experts can help ensure that the device fits the patient and his or her unique needs, recommend adaptations such as a ramp that may be needed to use the device correctly, and provide training in correct use of the device. Unfortunately, many older adults obtain assistive technology without professional help. For example, elderly persons may acquire assistive devices via yard sales or hand-me-downs.
Problems with disrepair and poor fit may not be self-evident to the average person, and this may result in aids that do not meet the user’s needs. In one study, wheelchair users were more likely to report problems with their wheelchair if they obtained it on their own.10 Another study showed that patients whose homes were adapted for their wheelchair were more likely to use the wheelchair.17 Typically, physical therapists may help with fitting and proper use of mobility aids, either physical or occupational therapists may help with wheelchair prescription, and occupational therapists and/or nursing staff may help with self-care devices (eg, raised toilet seat, hydraulic lift, etc). Certified Assistive Technology Providers have added expertise in computerized and electronic aids for communication and control of the environment (see https://www.resna.org/ for a list of certified providers). Mobility aids are one of the most commonly used types of assistive technology. Among mobility aids, the cane is the most commonly used device. Canes are both light in weight and quite versatile. However, using a cane requires good upper extremity strength and provides minimal support (no more than 15-20% of the body weight can be supported by a cane).
Typically, canes are used to reduce pain from an arthritic joint or to improve balance. A cane can transmit sensory input from the floor to the arms, which can help people with sensory deficits in the feet and legs or who are visually impaired. Canes are most useful when the gait problem is unilateral and/or mild. People who need bilateral canes may find a walker works just as well and may be easier to use. One exception is someone with excellent arm strength who needs to surmount stairs, for whom bilateral canes or forearm crutches are a good option. Improper fit or incorrect usage of a cane may increase the risk of falls. A cane should be used in the hand opposite to the impaired leg. This takes advantage of the normal opposition between the arm and the leg while walking, and it helps maintain the patient’s center of gravity over his or her base of support when using the cane. The handle of the cane should come up to the ulnar styloid with the arm fully extended, resulting in a 15-20 degree angle at the elbow when holding the cane in the hand.
Consideration may be given to patient preference in determining proper cane length, as existing evidence does not show a significant difference in outcomes such as energy expenditure with differences in handle height of 2.5 cm above or below the ulnar styloid.18 Use of a pistol grip-type handle, instead of a curved handle, may help increase the support gained from the cane. The height of the cane can be adjusted either by cutting a wooden cane or by a ratchet in the stem of an aluminum cane. All canes should have a rubber tip to provide better grip on the floor, and it should be replaced periodically when worn. Crutches are seldom used for geriatric patients. This is because of the risk of harm if used by someone without sufficient arm strength, including those with carpal tunnel syndrome and musculotendinous and/or neuropathic injury to the shoulder.
There are several gait patterns that can be used with crutches (eg, swing through, opposition), some of which may be difficult to learn, especially for someone with delirium, dementia, or an acute illiness. If an incorrect gait pattern is used, the patient is at increased risk of falling, and the crutches may not provide the correct support. On the other hand, crutches have the advantage of versatility for use on stairs, in narrow confines, and full body weight can be supported with crutches. Thus, crutches may be a fine choice for temporary usage by cognitively intact patients with good arm strength. People who will be using crutches for a prolonged period of time may benefit from forearm crutches, as they may be less traumatic to the wrist and shoulder than standard underarm crutches. Experts agree that weight should not be placed on the axillary pads (armpits) because of the potential for complications from neurovascular compression, and therefore there should be about 2 inches between the top of the crutch and the armpit. However, recommendations for optimal handle placement vary. A recent investigation with forearm crutches found that variation in handle height of up to 2.5 cm. above or below the ulnar styloid did not affect oxygen cost, walking speed, or perceived exertion; the authors recommended consideration of patient preferences.18
Walkers are used to treat gait problems due to bilateral lower extremity weakness, incoordination, or when greater body weight support is needed than can be provided with a cane. In addition, a walker may decrease pain from spinal stenosis or vertebral osteoporosis. A 2-wheeled (front-wheel) walker is the most commonly used type of walker. A walker with no wheels at all (a 4-point or pick-up walker) requires more arm strength and energy to use than the front-wheeled walker, and it is more complicated to use correctly yet offers little additional stability over a 2-wheeled walker.19 In general, 2-wheeled walkers are used instead of 4-wheeled walkers because they are more stable; however, there are several notable exceptions. A standard 4-wheeled walker can be helpful for patients with parkinsonism, as the tendency of the 4-wheeled walker to roll forward makes it is particularly easy to start walking and may help to counteract the tendency of patients with parkinsonism to fall backward.
A recent innovation is a 4-wheeled walker with bicycle-type brakes located on the handles and a platform seat (sometimes called a rollator). Rollators are less stable and more expensive than a standard 2-wheeled walker. However, a rollator may be an excellent choice for patients with limited endurance due to cardiopulmonary disease; such patients usually have the coordination and balance needed to operate this type of walker safely, and the seat allows for rest breaks. A Merry Walker™ is a 4-wheeled folding walker/chair combination with a padded seat and steel frame that is bottom weighted so that the patient is protected from falling (see https://www.merrywalker.com). The Merry Walker is most appropriate for an institutional setting with wide doorways. A final variation is the 3-wheeled walker. Three-wheeled walkers have greater maneuverability than 4-wheeled walkers,20 but they do not offer the seating advantages possible with a 4-wheeled walker, and they lack the stability of a 2-wheeled walker. Three-wheeled walkers are particularly helpful for people who need more support than a cane and have to maneuver through narrow spaces (eg, someone who lives in a trailer). Platform arm rest attachments for walkers can be used for patients with arthritis, to help distribute forces evenly over the forearm, decreasing stress to hands and wrists; however, they do increase the overall weight and bulk of the walker. Like a cane, the handles of the walker should be at the level of the ulnar styloid with the arm extended. The patient should walk within the base of support afforded by the walker, rather than having the walker too far ahead. Care should be taken when rising and sitting back down to avoid placing weight unequally on one side of the walker so that it tips over.
Wheelchairs are used when gait problems are too severe to safely use a walker or cane, or when the patient is non-weight-bearing altogether. The most commonly used wheelchair is a folding manual wheelchair with a sling seat and removable foot and arm rests. While cost savings may be achieved by use of nonremovable foot and arm rests, these increase the difficulty of transferring in and out of the chair. Fixed foot rests are a fall hazard. Elevating leg rests and reclining back rests are additional options that may help some patients, but at some additional financial cost. A wheelchair can be used without foot rests to allow patients to use their feet to help propel the wheelchair, in which case the height of the wheelchair seat should be lower than normal. Lightweight wheelchairs are more expensive than standard manual wheelchairs, but they may have better durability, they may be easier to maneuver, and they may have more options available to customize the chair to the patient.21
Transport wheelchairs are wheelchairs with 4 small wheels, so they cannot be self-propelled. Some transport chairs are lighter in weight and smaller than standard wheelchairs, making them particularly useful for transport on and off an airplane or in and out of a car. Alternatively, taking the arm and leg rests off of a standard wheelchair can make it lighter to lift into a car, or a wheelchair lift may be attached to a car. Sling seats may create back discomfort and can make it difficult to change position, increasing the risk of pressure sores. A seat cushion should always be used with a sling seat. Special air and gel cushions are available to reduce risk of pressure sores in patients with limited ability to shift their weight. Specialized seating can be fabricated for patients with postural problems or deformity to improve comfort, independence, and safety with seated activities (eg, eating). Anti-tippers or “anti-tip bars” are devices attached to the rear posts at the base of the wheelchairs, but they are optional on many wheelchairs. In general, anti-tippers are a good safety precaution and should be requested if not present. Problems with poorly fitting wheelchairs and disrepair are common.
Wheelchairs should be inspected visually for wear and tear. When the sling seat or back wears, the bowing may reduce the ability of the patient to shift weight while seated, and therefore increase risk of pressure sores as well as increasing discomfort. Brakes should fit firmly. Brake extension handles can be added to accommodate patients who have residual hemiparesis/hemiplegia due to CVA. The foot and arm rests should support the extremities in anatomically correct positions. Motorized wheelchairs and scooters are increasingly common. Motorized wheelchairs and scooters are larger than manual wheelchairs, so they are most helpful for people who have difficulty with community mobility rather than in-home mobility. Problems with motorized wheelchairs/scooters include high cost, need for additional equipment to transport the chair, and the potential for deconditioning. Obtaining third-party reimbursement for motorized wheelchairs or scooters can be quite difficult.22
Recently, Medicare has cracked down on fraud in the provision of powered mobility devices, recovering over $84 million in fraudulent claims; providers should be sure to personally verify and clearly document the medical necessity for powered mobility devices when prescribing such a device.23 A special wheelchair lift for the patient’s vehicle may be needed to transport the motorized wheelchair/ scooter to the locations where it will be used (eg, the store, the doctor’s office). The lift is purchased separately and must be purchased with the specific wheelchair in mind, as lifts and wheelchairs are not interchangeable, and not all cars can be adapted to accommodate all wheelchair lifts. One concern that both patients and clinicians may have about using a wheelchair, especially a motorized chair, is the idea of “use it or lose it.” There are no good data to answer this concern, but there is no evidence that wheelchairs are overused.17 The clinician and patient must trade off the potential of increased participation in activities that a motorized wheelchair/scooter might allow versus the cost and the potential for deconditioning that might occur with overuse. Motorized wheelchairs and scooters are fit similarly to manual wheelchairs.
Patients must have the cognitive and visual skills to safely operate a motorized vehicle. Minor to moderate problems with upper extremity coordination may be able to be accommodated through specialized controls. In some states, one may need to be seen by a rehabiltiation specialist in order to have Medicare approval for a motorized mobility aid such as a scooter. Expert assessment can be very helpful in selecting the optimal chair, particularly for people with special seating needs or progressive conditions (eg, amyotrophic lateral dystrophy). Not all physical or occupational therapists have expertise in motorized mobility aids or specialized seating, and vendors may have a particular interest in selling particular types of devices, so investigation may be needed to locate the right expert. There are a variety of new innovations in wheelchair design. The “manual assist” wheelchair uses a small battery to supplement the wheelchair user’s own efforts. It requires less cardiac work to propel the manual assist wheelchair than a standard manual wheelchair, yet it has the dimensions of a standard manual wheelchair.24
Both manual and motorized wheelchairs are available now that can change position from seated to standing. The utility of the sit-to-stand capability for the average wheelchair user is unknown, and they cost considerably more than a standard wheelchair. The IBOT is a motorized wheelchair capable of standing and climbing curbs and stairs, but the patient must have good sitting balance and good cognition; specialized training is needed to use the IBOT. Examples of the manual assist wheelchair and the IBOT can be found at https://www.innow.org. Guidance from someone with expertise in wheelchairs is useful the first time a patient is prescribed a wheelchair, but it is particularly important for patients who are at risk of pressure sores, who have postural problems or difficulty with sitting balance, who will use the wheelchair most or all of the time, or if a motorized wheelchair or scooter is being considered. Not all physical and occupational therapists have expertise with wheelchair prescription, but they should be able to recommend a provider with the appropriate expertise.
Finances and environmental access can be a problem for mobility aid users. The entry into the home and the bathroom are particularly prone to problems. Helpful information on environmental modifications can be found at the websites for the Center for Design and Environmental Access and the Center for Universal Design. Reimbursement for mobility aids is available through Medicaid and Medicare, but neither pays for home modifications. To qualify for reimbursement under Medicare, the mobility aid must be medically necessary, and only one mobility aid is covered per condition.25 A new mobility aid may be justified if the patient’s condition has changed significantly, and replacements can be obtained once every 5 years. Coverage is provided for the least costly mobility aid to treat a given condition.
Specialized mobility aids may not be covered at all, added medical justification may be needed, and/or payment limited to what would have been provided for the standard device. Authorization from Medicare should be obtained prior to purchase of devices other than a standard-type cane, crutches, walker, or wheelchair. Medicaid also provides coverage for medically necessary durable medical equipment, including mobility aids. Approval from Medicaid should always be obtained prior to purchasing the item. Additional information on Medicare or Medicaid reimbursement can be found at www.cms.gov. This work was supported in part by the Paul Beeson Faculty Scholar Program from the American Federation for Aging Research. This work also was supported in part by the National Institutes of Health, National Institute on Aging, Duke University Claude D. Pepper Older Americans Independence Center, Grant #2P60AG11268.
