What are the risks for the elderly of sitting in a wheelchair?
October 22, 2015 11:08 AM   Subscribe

Unfortunately my grandmother (85) suffered a stroke which left her left arm and leg paralyzed and required that she be in a nursing home. Although she initially could still walk, she now spends most of her day in bed. I would like to try to get her to sit in a wheelchair. The nursing home, however, is against this for reasons I'm not sure make sense. What can I do?

After my grandmother had her stroke 10 years ago, she could walk (or more accurately, hop) with the help of a cane. Around 4 years ago, however, she developed a contracture in her left leg which meant she could no longer safely walk. She then settled for sitting on the side of her bed, or in a chair, or on a wheelchair which the staff pushed around.

About a year ago, she decided she wanted to spend most of her time in bed (I suspect due to depression). Although we told the staff to put her in the wheelchair on a daily basis, this didn’t end up happening because my grandmother protested whenever the staff tried. To complicate matters, my grandmother doesn’t speak English, and so the staff were unable to communicate with her (so I think kind of gave up in frustration). I don’t speak her language either, so was unable to explain to her the importance of sitting up. The staff giving up and not telling me, combined with me moving away, meant that she was allowed to stay in bed most of the day. The staff did manage to get her in a water chair/tub chair, which is basically this institutional recliner with wheels, for several hours a day. She also got some sitting exercise when she would sit up in bed as the staff used a hoist/lifter to transport her to the toilet.

I recently decided to try to help my grandmother get more mobile. My original hope was to get her a one armed drive wheelchair she could propel herself. The nursing home management, however, was really against this on the grounds that she may hit other residents (I’m not sure about the risk there, but I let it go for the time being). I then proposed that my grandmother simply sit in a wheelchair in her room. It turns out she is still able to sit on the side of her bed and in a wheelchair. On several different days, we have sat her in a transport chair for 1-2 hours at a time. She has good posture, and seemed secure. I thought, great, she can sit in a wheelchair at least for a couple hours a day to start. However, the nursing home administrator said no, she can't sit in a wheelchair/transport chair at all if I'm not there. They are saying that in order to sit in a wheelchair, she needs to be supervised (e.g. by the family, at group exercise or at dinner). Their argument is that she could slip out of the wheelchair and injure herself. There are several reasons why I am not sure of this point:

1) She appears extremely stable while sitting with good posture. Her foot is firmly on the footrest to stop her from sliding forward. She has even started to doze off while in the wheelchair while we were there and was still stable with no signs of slipping. We had an occupational therapist (OT) assess her, and he said that she looked fine. All of the nurses on duty haven’t batted an eyelid when I asked to put her in the wheelchair. When I asked the nurses if it there was a risk she would fall out, they said no (when our risk-adverse nursing home administrator talked to them, they changed their tune).

2) She was able to sit in the wheelchair unsupervised before, and there appears to be no significant physical deterioration.

3) Almost every other resident is sitting in a chair/wheelchair unsupervised. Some of them have terrible posture, are slouching, and appear to be much more of a fall risk than my grandmother. It appears inconsistent for the administration to say no here.

Although we could kind of acquiesce and tell my grandmother she can only sit in the chair during dinner, she would much prefer to be able to sit in the chair in her room while she does her everyday tasks.

I asked the OT about what to do, but he wasn’t entirely clear. On the one hand, he said there were really no great risk of her sitting in a chair, but on the other hand, he said due to her age (85), he couldn’t officially recommend that she is left unsupervised. He did seem rather uncertain about this, and we have had different physical therapist/OT's in the past who have given very contradictory advice. So, I would like to continue to consider the wheelchair issue.

The nursing home is suggesting that she just sit in the recliner/water chair in the reclined position (therefore reducing the risk of her falling forward). However, as I understand it, most of the health benefits of sitting are achieved by actually sitting up straight. Also, my grandmother doesn’t like the water chair, and complains of neck pain while sitting in it.

I suppose my question is should I just let it go and give up? To the reasonable observer, there is no evidence that she is going to fall out of the wheelchair. In fact, if she hadn’t had her hiatus where she chose to stay in bed, I don’t think anyone would’ve questioned whether she could sit in a wheelchair. The nursing home is quite risk-averse, probably for liability reasons, but I feel sometimes this can go too far.

However, in the interests of safety, I wonder if there any common risks to the elderly sitting in wheelchairs in the locked position indoors, or in chairs in general? I know that the safest option is to keep her in bed all day, but if the risk of her sitting in a wheelchair is reasonable, I think that’s something that we should do.

I will try to assuage the nursing home's fears by having a long trial period, but I wonder if at the end of the day, everything looks fine, can we insist that they help her sit in the chair? Or is it up to them?
posted by strekker to Health & Fitness (15 answers total)
I believe the biggest risk would be for falls--not just from the wheelchair, but during transfers and toileting. Falls are a huge deal with elderly populations and can often lead to death. How is your grandmother cognitively? If she were in a chair, would she know that she cannot transfer on her own?
What is the Long Term Care Home's approach to falls prevention? Do they have crash mats? Low beds? lap belts? I would look into this and maybe talk to their falls prevention expert to develop a plan that's specific to your grandmother.
I would also weigh the falls risk against the risk of deconditioning - staying in bed all day isn't ideal either. She could develop bed sores, her muscles could deteriorate, and it could be much harder for her to mobilize after being bed-ridden.
My advice to you is to keep being an active advocate for your grandmother. Whatever plan you and the staff come up with, make sure you visit frequently and unnanounced to ensure that they are honoring your grandmother's care plan. Good luck!!
posted by Dressed to Kill at 11:29 AM on October 22, 2015 [5 favorites]

The language barrier here is a huge complicating factor. I strongly suggest you resolve that (by using Language Line or another member of your family or something as translator) before you try fighting for her to sit. Right now she has essentially no power, which means that unless you basically move in with her you're not likely to have her sitting up no matter what any agreement says.

And yes, the problem with regard to safety is mostly about falling. A soft helmet and a harness should be sufficient to control for that.

(The staff may also be afraid of having a mobile patient they can't communicate with. Immobilized and in bed, it arguably doesn't matter what the patient thinks. This kind of thing is why government funded healthcare providers are required to get a translator.)
posted by SMPA at 11:59 AM on October 22, 2015 [4 favorites]

This page gives the legal information about language assistance rights in US federally-funded healthcare settings. Other Anglophone countries have similar laws, and at least some US states and localities offer further protection.
posted by SMPA at 12:05 PM on October 22, 2015

Oh, also, in the US again, there are various rights pertaining to a "least restrictive setting" and "guaranteed access" that might apply to your grandmother as a disabled person. Nursing homes can't just lock everyone up in tiny rooms on the grounds of convenience, basically; they also can't keep people who "seem to be really sick" out of the cafeteria just because it might depress the other patients, and so forth. There are a ton of precedents out there pertaining specifically to nursing homes; you'd want to talk to a disability-rights attorney in your state. The immediate takeaway is that no, they can't arbitrarily decide that your mother is now and will always be bedridden. It's all highly fact-dependent, so their in-depth reasoning and evidence really matters.

BTW I've never seen a family-vs-facility legal battle end up with the patient happily getting their needs met in that same facility. I'm sure it must happen, it just doesn't seem all that common to me (I read a lot of disability rights stuff, mostly written by lawyers.) Anyway, to win this fight your grandmother might have to move.
posted by SMPA at 12:15 PM on October 22, 2015 [1 favorite]

www.carie.org Is a good resource and you can run this scenario by them.
posted by PeaPod at 12:16 PM on October 22, 2015

Have you tried wheelchair seatbelts? Perhaps that would assuage some of the nursing home's worries.

As for the power wheelchair: I'm sorry to say, I can see their point of view on this one. My own grandmother managed to crash (to the point of totally destroying) two manual wheelchairs --- heaven knows how much more dangerous she'd have been in a power chair.
posted by easily confused at 12:38 PM on October 22, 2015

I am a nurse in a long term care facility.

Your grandmother has rights. If she wants to stay in bed, the staff is going to leave her in bed. Period.

The language barrier is a big deal, yes, but even if you are your grandmother's DPOA, she still has a right to lay in bed all day if that's what she wants. Were it me, I'd get a translator involved to make it more clear what your grandmother's wishes are.

I cannot speculate on the reasons behind the nursing home disliking the power chair idea, but I do know that in my 200 bed facility, there is only one resident with a power chair, and he is exceptional in that he has VA benefits and they paid for his equipment.
posted by Athene at 1:28 PM on October 22, 2015 [1 favorite]

Seatbelts are considered restraints in the ltc setting, and have to be avoided per federal regulations. Honestly, it's probably time to look at other facilities and a new pt eval. However, there might be other things at play. Is there a change in her behavior at night that makes her more of a fall risk? Has she had falls in the facility already? Is her depression (not uncommon after a stroke) being treated? Are there language peers she might be able to socialize with? (There or at other facilities...)
posted by cobaltnine at 1:53 PM on October 22, 2015

Does she have a regular doctor that she sees that is NOT connected to the facility? Perhaps s/he could do an evaluation and make the recommendation that your grandmother sit upright for some of her day.
posted by PorcineWithMe at 6:04 PM on October 22, 2015 [1 favorite]

Another question, is she allowed to sit in a regular, stationary chair? If not, it seems like a highly restrictive facility given that the OT thinks she is fine to sit upright.
posted by PorcineWithMe at 6:05 PM on October 22, 2015

Hi everyone, thank you for your advice and ideas.

She is well cognitively, and I forgot to mention that we are in Australia. I agree that going the legalistic route would be a challenge and probably just make life miserable for all involved, even if it did work out. I am looking into an ethnic nursing home where the staff/residents speak her language, but they have a long waiting list, so who knows how long it will take. It would be much better if she could get in, as none of the residents speak her language (Chinese), which I'm sure contributes to her unhappiness. I'm not sure if there's much else we can do to treat the depression other than to try to improve her situation (I believe she is already on medication for depression).

I have found a friend who speaks her language to communicate with her every so often via phone. I guess it turns out grandmother is more comfortable in bed, but when I told her it is physically healthier to use the chair, she agreed to give it a shot.

I thought about wheelchair seat belts, but the staff raised this issue of her sliding down and choking on the seat belt (not sure of the likelihood of this one?). I wonder if there are safer seat belts where the choking hazard is limited? Also, they have this kind of strong disapproval of seat belts as a kind of “restraint,” which I found odd. It’s not like we’re tying her down or restrict movement. However, they said if the GP approves it, and I insist they use the seat belt, it might be slightly safer on balance.

The idea of a soft helmet is good, and it might be added peace of mind for the nursing home. Not sure if grandma would be up for that, but worth considering I suppose.

To clarify, I’m definitely not aiming for a power wheelchair. I did try this with her a few years ago, and although she could drive it, it wasn’t perfect within a week, so I thought better not risk it. I would like to one day try the manual wheelchair (I know she is keen on this as well), but at this point, I’ll be happy just to get her sitting up.
posted by strekker at 6:10 PM on October 22, 2015

What you'd want is more like what a jet pilot wears. Something like this.
posted by SMPA at 7:02 PM on October 22, 2015

Oh, also, if she has the ability to hold herself upright comfortably, they make nifty padded table-like things that pop off and on quite easily. Honestly, there are more wheelchair accessories out there than can be adequately described by me.
posted by SMPA at 7:07 PM on October 22, 2015 [1 favorite]

Hi SMPA that's a really good idea with the alternative seatbelt-style (Thanks!) Yes, I should really spend some time just looking at all of the different options. I think I just figured that the OT would know of all the options, but perhaps not. With the table-like things, do you mean like a wheelchair tray? Indeed, that could potentially serve as a barrier to stop her from falling forward.
posted by strekker at 5:51 AM on October 23, 2015 [1 favorite]

Glad to hear you're in Oz, as cost will be a lot less of a barrier.

There are a lot of accessories indeed, many of them designed just for reducing fall risks. It all depends on the mobility of the person involved. My maternal grandfather was quadriplegic with limited mobility in his arms (he could move his arms a bit, but no fine motor movement). He had special seat cushions to keep him in the most secure upright position, elbow cushions, and back cushions. They could all be exchanged in different setups to vary the general secure position and avoid sores, too.

Nthing that wheelchairs can indeed be dangerous. She'll need training on proper usage of one – is the nursing home able to provide this? The person has to be really good and aware about when and how to brake, turn, things like that. Even fully mobile people can have trouble with wheelchairs. I lost count of the number of people who'd helpfully try to push my grandfather and futz it up, not for lack of goodwill, just they had no experience with what it means to move one and the person in it safely and securely.

She would also need a way to communicate when she wants to get in and out, and be very aware that she'll always need to do that. The biggest risk is a person thinking they can do it themselves. My grandfather got in and out of bed and into his chair just fine with a system of strap pulleys on his bed (he used his arms), until he didn't. Thankfully he was always careful to try it when my grandmother was around, so she was able to grab him, but yeah – imagine someone with less practice, awareness, and proximity to help...
posted by fraula at 8:00 AM on October 23, 2015 [1 favorite]

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