care resources are crucial for managing patients at home. Regular monitoring of skin integrity ... Bowel management consisted of increased dietary fibre, stool ...
CME 0*009
Rehabilitation of the
elderly
paraplegic
ROBERT W TEASELL, MD, FRCPC PETER R. LONG, MD
health until she noticed the sudden onset of low back pain and leg weakness. She "passed out" and was admitted to a tertiary care hospital, where she was treated for a dissection of the ascending and descending thoracic aorta extending down to the diaphragm. She survived despite the fact that, at one point, her husband was asked to consider withdrawal of life support equipment. At that time it was noted that she had flaccid paraplegia with decreased sensation below T-9 and no sensation below T-12. Physicians diagnosed spinal cord infarction. She returned to her local hospital 9 days after the aortic dissection. The patient spent 2 months at a small local hospital where she received only minimal rehabilitation and developed a grade 2 sacral pressure sore. A Foley catheter was used to drain her Case report bladder. She was transferred to a secAn 80-year-old housewife lived with ond tertiary care hospital where she her 78-year-old retired husband in a was admitted to the rehabilitation sersmall town. She had enjoyed good vice approximately 3 months after developing her flaccid paraplegia. She Dr Teaseil is an Associate Professor of was cognitively intact apart from probMedicine at the Universi of Western Ontario in lems with her memory. London, Ont and is Chief ofPhysical Medicine Rehabilitation started with a lowand Rehabilitation at the University Hospital. level exercise program for her upper Dr Long practisesfamily medicine at the extremities, which met with good results. Static sitting balance was very Wingham Medical Centre in Wingham, Ont. E XTENSIVE LITERATURE HAS BEEN
SUMMARY Elderly patients with spinal cord injuries can be rehabilitated successfully. Community home care resources are crucial for managing patients at home. Regular monitoring of skin integrity and for bladder infection is important.
RESUME Les patients ages souffrant d'atteinte de la moelle epiniere peuvent franchir avec succes les itapes de la readaptation. Le traitement a domicile necessite l'implication des ressources communautaires de soins a domidle. 11 est important de surveiller reguli&rement l'integrite de la peou et les
infections vesicales. Can Fam Physician 1994;40:1319-1321
published on rehabilitating young patients with traumatic spinal cord injuries. However, little has been written about rehabilitating elderly patients with the same injuries despite the fact that injuries among this age group are growing as our population ages. Elderly patients might not be considered for admission to rehabilitation units even though they are cognitively intact and physically able to participate in rehabilitation programs. There are differing management issues for young and old patients with spinal cord injuries. The following case report illustrates that age alone is not a barrier to successful rehabilitation and that community home care resources are crucial to successful management of patients at home.
Canadian Family Physician VOL 40: Jul 1994 1319
CME *---0-0
Rehabilitation of the elderly paraplegic
poor initially, and it was several weeks before she was able to sit unassisted. She was taught to do sliding board transfers although she continued to require some assistance for wheelchair to chair or car transfers. She was eventually able to propel her wheelchair for several hundred feet on a level surface. Basic activities of daily living were performed with minimal assistance. She was even able to prepare light meals. A ramp was installed at her home and doorways were altered. This woman was noted to have a hypotonic bladder and started on a program of intermittent catheterizations. Balance problems, osteoarthritis of the hands, and poor patient acceptance made a program of self-catheterization or Crede's maneuvers difficult. She was eventually discharged with an indwelling catheter. Bowel management consisted of increased dietary fibre, stool softeners, a morning suppository, and selfdisimpaction. Before she could return home, her husband was given 1 week of intensive teaching in hospital in order to assist in her care. Her husband was relatively well although painful arthritic shoulders made it difficult for him to assist in her lift transfers. At the time of discharge, regular home care visits were organized, initially on a daily basis; however, despite assistance, she failed to maintain proper skin care. She remained seated for long periods without pressure relief and unexpectedly traded in her standard wheelchair for a reclining wheelchair, which resulted in increased forces at the sacrum. She developed a grade 4 ischial pressure sore requiring readmission to hospital almost 1 year after the onset of her paraplegia. The ulcer was excised followed by partial ischiotomy and an inferior gluteus maximus musculocutaneous flap closure. Her condition was complicated by inflammation of wrist osteoarthritis, which affected her ability to perform transfers. However, with time and further therapy she was again able to
1320 Canadian Famiy Physician VOL 40: JU 1994
manage in her own home with the help of her spouse and home care support. After 6 months at home, she was reviewed again by the rehabilitation specialist. She was having difficulty with her bowel care, was still not doing regular pressure-relieving techniques in her wheelchair, and was gaining weight. A stern warning about the risk of pressure sores and advice regarding prevention was issued. A review conducted 6 months later showed she had followed a diet and lost weight and was performing skin pressure relief regularly. She was reviewed again by the rehabilitation specialist more than 3 years after the onset of her flaccid paraplegia and continued to do well in her own home. Her weight had stabilized, and her skin was well cared for. The Foley catheter was still in place, and her kidney function was unchanged. Approximately 6 years after the onset of her paralysis, she presented to her family physician with a new pressure sore despite encouragement to do wheelchair push-ups every half hour and daily skin inspections. She was admitted to the local hospital where a period of pressure relief allowed the pressure sore to heal. The patient was subsequently discharged home but developed another superficial pressure sore, which was treated
conservatively. Catheter blockage was a constant problem but resolved with daily catheter irrigations of 50 mL of a urinary sequestrant. Constipation was a problem and at one point resulted in a bowel obstruction. This was resolved with a strict bowel routine, including disimpaction. With daily home care support and the assistance of her spouse, she has been able to manage well at home. Discussion This case illustrates that elderly patients with spinal cord injuries, even with a flaccid paraplegia and lack of sensation, can be rehabilitated
CME *S . . .
successfully. Unfortunately, elderly patients are often excluded from rehabilitation because of lack of resources or perceived lack of rehabilitation potential.' In cognitively intact, well motivated, elderly paraplegics with reasonable family supports, this exclusion could deny the opportunity to achieve independence and return home. This case also illustrates some of the differences between young and old patients with spinal cord injuries. Necessary new skills are learned more slowly, and strengthening exercises must be continued for a longer period.' Hospitalization is, therefore, likely to be longer for each degree of neurological deficit in older patients. Intermittent catheterization is the bladder management method of choice for younger patients.2 However, because of manual dexterity and balance problems, it
.
might be difficult for elderly patients and might preclude discharge home. A shorter natural life expectancy makes long-term preservation of renal function less important. ' Although intermittent catheterization or Crede's maneuvers are considered optimal management, older patients are less reluctant to use a Foley catheter than younger patients. Vocational issues are generally not important for elderly patients, while they are often crucial for younger patients. 1 Elderly patients with spinal cord injuries can be maintained at home only with close community support. Here the family doctor and home care resources are crucial. Regular monitoring of skin integrity and for bladder infection is important. Early hospitalization to relieve developing pressure sores can avoid a later prolonged
a ~~~~~I I/a6g noreq''ea /nae.
hospitalization or even transfer to a tertiary care centre for surgical correction. Aggressive treatment of bladder infections is important to avoid complications of kidney infection or sepsis. Acknowledgment We thank Ms Cathy Walker and the Huron Count Home Care Program for their contributions to this article. We also thank Mrs Debbi Harley for helping to organize and prepare this manuscript. Requests for reprints to: Dr Robert W Teasell, University Hospital, 339 Windermere Rd, London, ON J'6A 5A5
References 1. Teasel R, Allatt D. Management of the
older spinal cord injured patient. Geriatrics 1991 ;46(6):78-89. 2. Block RF, Basbaum M, editors. Management ofspinal cord injuries. Baltimore: Williams & Wilkins, 1986.
