05 | SCI in Older Persons

Discussion

Spinal cord injury (SCI) has a devastating and traumatic impact on all those it affects. An older person with SCI can present unique challenges within a rehabilitation setting. These persons bring a variety of age-related problems as well as resources that can greatly influence the rehabilitation process. Mr. Meier’s case is a good illustration of rehabilitation in older persons with SCI.

Age-related Risks and Complications

Increasing age is associated with a higher risk of aortic aneurysm. In Mr. Meier’s case, it is clear that the corrective surgery required for this condition carries with it the unfortunate higher risk of SCI. 18 It resulted in a non-traumatic and incomplete SCI, the type of SCI that is more prevalent among older persons. 10

"Rehabilitation providers must be attuned to the fact that older persons are confronted more frequently by complications, both mental and physical, during the rehabilitative process."

As SCI survivors of older age recover, there are numerous factors that can affect the rehabilitation process and outcomes. Mr. Meier reflects the higher incidence of complications during hospitalization in persons over 50 years of age. 9 10 In his case, comorbidities, limited tolerance for physical activity, age-related personal factors and psychological factors all had a significant effect on Mr. Meier's general health and rehabilitation.

In the assessment phase of Mr. Meier's Rehab-Cycle® it was observed that some factors that are common among persons with SCI were independent of age, while others could be considered age-related. Age-related factors included comorbidities that resulted in impaired cardiovascular and respiratory functions as well as a weak musculoskeletal system. Such limitations and complications have the potential for creating a negative feedback cycle, that in turn, can lead to poorer outcomes. In Mr. Meier’s case, his physical limitations adversely impacted the physical training and exercises that were part for his rehabilitation program. This slowed his progress and perhaps even contributed to the less than optimal outcome after intervention. This, in turn, resulted in weakening Mr. Meier's general health.

His general health was further harmed by an unexpected and sudden downturn of his mental state, specifically the appearance of dementia-like symptoms, late in the Rehab-Cycle®. It is unclear whether Mr. Meier's dementia-like symptoms were related to his advanced age or something else. In any case, rehabilitation providers must be attuned to the fact that older persons are more frequently confronted by mental and physical complications during the rehabilitative process.

Facilitating Factors and Challenges

In addition to age-related factors that can pose barriers to rehabilitation outcomes, there are other factors that can have a facilitating effect. Such age-related factors could be social or economic in nature or reflect personal characteristics and geographic aspects. In Mr. Meier’s case, he was already retired and due to many years of working and running his own business, he had accumulated significant monetary capital that safeguarded him from any financial worries. This is contrary to what many younger persons with SCI experience. Since older persons are generally no longer in the workforce, 5 9 they ar no longer dependent on employment for their livelihood.

The presence of a spouse can also have a significant impact on the lived experience of an older person with SCI. Spousal support has been associated with less depression, greater life satisfaction, psychological well-being and better perceived quality of life among persons with SCI.20 One question remains: If the spouse him or herself is elderly, is the spouse capable of caring for the partner with SCI or does the spouse require care him or herself? Fortunately in Mr. Meier’s case, he had a wife and family that were willing and able to support him. Both of these factors were of great benefit to Mr. Meier during the course of his recovery.

"The presence of a spouse can also have a significant impact..."

Furthermore, an older person's view of life may differ from those of a younger person living with SCI; this different life perspective may have an impact on the person's psychological status. For example, Mr. Meier felt strongly that he had already lived a long and successful life. Overall, he felt he had a "good life". This view of life offered him a degree of comfort and strength. While this was a facilitating personal factor of Mr. Meier, and perhaps of many older persons, it did not pre-empt other psychological challenges. Feeling helpless or "being lost", along with having feelings of diminished masculinity were issues that plagued Mr. Meier throughout his rehabilitation. While such feelings may not be specifically age-related, powerlessness and dependency among older men who have always maintained traditional gender roles may be prevalent.

Another mental issue that Mr. Meier had to deal with during his rehabilitation was worsening memory. Mr. Meier’s difficulty in remembering the individual steps necessary for successful transferring or for performing other multi-step tasks forced him to be dependent on others. In this case, the memory limitations Mr. Meier expererienced could largely be considered age-related.

"Feeling helpless or "being lost", along with having feelings of diminished masculinity were issues that plagued Mr. Meier throughout his rehabilitation."

Older and elderly persons with SCI can present a special set of factors, both facilitative and challenging, that impact the rehabilitation process. Within the Rehab-Cycle®, many of the factors can be assessed at the beginning and constructively used to inform the rehabilitation process with the hope of achieving better outcomes.

Awareness of comorbidities and the risk of complications associated with older persons is the first step toward prevention and management. In addition, facilitating aspects of the person’s character, social network and environment should be taken into consideration, since these can facilitate the rehabilitation process and prepare the person for returning home or, if needed, to a nursing home or another appropriate health care facility.

For older persons with SCI, the Rehab-Cycle®’s holistic approach to rehabilitation can support the person's and the rehabilitation team’s decision-making along the way, allowing for the best possible recovery and outcomes.

ICF Research Branch CoordinatorICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI)

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