Identifying Impediments in the Use of Walking Aids among Older Adults in their Home Environment

Introduction

Worldwide, around 18% of the population has moderate, severe, or significant walking difficulties (WHO, 2011).1 According to the 2011 Indian Census, one out of every twenty Indian people aged 60 years and above is physically or intellectually disabled. The geriatric population in India is predicted to expand from 76.6 million in 2006 to 319 million in 2050.²

Many older people have remained in their houses for long as people tend to choose homes and communities that were suited for living, working, and raising a family.³ Lack of physical activity can lead to a variety of other opportunistic unhealthy lifestyle choices, making the aging adult population prone to falling, which might impede daily activities.^4,5 Reduced physical fitness and community interactions, in turn, can result in rapid worsening of both mental and physical well-being, with adverse consequences affecting daily performing capabilities, constant self, and standard of living.⁶

To overcome these consequences, compensatory strategies are used which include environmental changes that reduce the user's physical demands, walking aids that increase the user's capabilities, human support, and behavioural change. On uneven surfaces, for instance, walkers may be less useful.3 For high-risk older persons with restricted mobility, walking aids such as canes and walkers are routinely given to help prevent falls.

Therefore, there may be an inverse correlation between physical difficulties and the usage of walking aids at home, which may differ at different time intervals. The use of walking aids, independent physical ability, and greater physical difficulties in the living environment are correlated with social difficulty and other factors. It is important to comprehend how the psychological, social, and physical features of older adults in the home environment may relate to using walking aids, especially at a time when human support is anticipated to become intermittent.³

Materials and Methods

The study emphasizes mixed research methodology, and it has been applied in the urban and rural communities of Bengaluru and Vellore districts. Data was collected using a self-administrated questionnaire regarding physical, social, and psychological factors from a published source.⁷ The procedures were approved (App. No. 20IM009) in consideration of the ethical guidelines of the Institutional Ethical Review Board (IERB), Mobility India Rehabilitation Research and Training Centre.

Selection Process

A cross-sectional study design was used involving a sample size of 40. The study was conducted among older adults living in old age homes, geriatric care, and their home environment. Non-probability convenient sampling was employed for sample selection. The study involved individuals older than 60 years frequently using a walking stick and an assistive device such as a single-tip cane, forearm crutch, and four-wheeled walker. The study excluded individuals with severe neurological (stroke, Parkinson), orthopedic (amputation) conditions, severe cognitive impairment, lack of visual and auditory control, and those requiring temporary usage of walking aids.

Development of tool

The tool consisted of two sections. Section A included demographic variables consisting of baseline data while the Section B included a self-administrated questionnaire which was a printed self-report form consisting of definite, concrete, and predetermined questions to elicit information on social and physical challenges. The social challenge section consisted of four descriptive questions and the physical challenge section had 15 descriptive questions regarding the usage of walking aid in the home environment. Psychological factors were assessed using Geriatric Depression Scale (GDS).⁷

A pilot study was conducted to assess the effectiveness of the tool and study in terms of impediments experienced by older adults during the usage of walking aids in a home environment. The Cronbach’s alpha was found to be 0.712, which showed good internal reliability of the questionnaire.

The purpose of the main study was explained, and written consent was obtained from the study participants. The participants were assured about the confidentiality of their responses. The time taken by the respondents to answer the questionnaire varied between 25 to 35 minutes. The respondent’s data were recorded in audio as well as in document.

Functional outcome and evaluation tools used in this study included, self-administrated questionnaire, SPPB (Short Physical Performance Battery) scale.⁸

Analysis

R software version 4.0.1 was used to analyse the collected data. Independent t-test was used to compare the means of the two groups. Categorical variables were subjected to Chi-square test. Statistics were deemed significant at P ≤0.05.

Results

Quantitative analysis

The first part of the analysis was categorized into two groups, restricted and moderately restricted based on the SPPB scale and walking distance per day.

Table 1 and Figure 1 demonstrates that the majority of respondents (62.5%) used walker, followed by 30% respondents using cane, while only 7.5% of respondents used crutches.

The majority of respondents (17.5%) had hypertension, and at least 2.5% of them also had cataract, diabetic mellitus, and other conditions (Figure 2).

In terms of psychological impact, 35% had a moderate psychological impact, 32% had severe psychological impact, 25% had mild psychological impact, and 7.5% had normal psychological impact (Figure 3).

Findings

Statistical and graphical data for the study were computed using R software version 4.0.1. which determined that physical challenges in the home environment are inversely associated with the use of walking aids among the study subjects (P <.05). However, we did not detect any significant correlation between social and psychological challenges (P >.05).

Qualitative analysis

The second part of the analysis was categorized based on three clear themes that emerged regarding the emotions involved in the use of walking aids.

Acceptance of walking aids

Walker use was highest among those who used a mobility aid (62.5%), followed by cane use (30%) and crutches (7.5%). Most users purchased their devices from the person who was being represented, though some did so from the camp. Most participants reported that advice by a doctor to use a device would strongly influence their decision to do so. Various responses recorded for questions regarding provisions are as below.

Participant 01: "My brother suggested using a walker”.

Participant 02: "My previous cane didn't offer enough support, so I bought a side walker from the e-commerce."

Participant 03: If anyone sees me as awkward, I walk with strength in front of them.

Stigma for usage of walking aids

Some of the participants explained that the expression of negative attitude towards individuals using walking aids whom they perceived "didn't really need them" was common, in addition to perceived stigmatization of walking aid used by others. The acceptance or rejection of walking aids was determined by people's experiences of having difficulty performing common tasks. Others experienced feelings of depression upon realizing they required assistance with mobility, making it difficult for them to accept the situation right away.

When using a mobility aid in public, several device users reported encounters ranging from unwanted attention and embarrassment to outright discrimination. Few of the participants believed that the use of the devices made them feel "inferior". "There's always a little group that laughs," said one participant.

Participant 01: "At first they were concerned about why this happened to me, but then they got used to it."

Participant 02: "They thought I was invulnerable because in middle age I had some foot problems and my foot got swollen."

Participant 03: "Yes, I felt awful for the first two to three months, and I think my family thought something was wrong with me because I used to walk with mighty."

Some device users admitted that they occasionally skipped using their device out of fear that they were or might become "dependent" on it and lose the ability (and desire) to ambulate without it. “Because I have a small amount of storage space for my aid”, users explained the inconvenience, particularly when using it inside the home or when going outside and needing a place to put it. Some people claimed that using standard walkers or crutches presented even greater difficulties, making it difficult or impossible to carry daily tasks.

Addressing the issue

Postural deformity and other complications are brought on by lack of training and knowledge regarding usage of walking aids, such as how to lift the walker or adjust the height of the walker to accommodate the individual’s height.

Appropriate exercise regimen enhanced mobility and made it simpler to overcome obstacles for using the device while walking. A different tactic was to encourage people to develop a positive outlook regarding usage of mobility aids. This tactic involved hearing what other users had to say about their mobility aids, which encouraged them to try using them outside. There are now more opportunities to go for a walk.

Discussion

Our results suggest that physical challenges in home environment are often related to the use of walking aids, regardless of physical ability, social challenges, and other characteristics of older adults. According to the study findings in quantitative analysis, physical challenges in the home environment are inversely associated with the use of walking aids in the overall samples that represent P value (P <.05). However, we did not find any significant correlation between social and psychological challenges with respect to walking aids in the home environment which represents a P value (P >.05).

The qualitative and quantitative analysis for the study was categorized into three different sections, and data from both research phases were used to discuss each section based on relevant literature.

Section ‘A’ describes the psychological factors in the older adult population that may vary with each subject, due to medical conditions where depression and dizziness are most common. Participants mentioned several negative feelings about themselves, and others have reported improvement in depression with the use of walking aids.

In section ‘B’, according to various studies, it can be considered that social factors impact the mobility of older adults as they frequently move into senior housing because they can no longer live independently.6 The social environment of older people can change in this housing facilities, which usually occurs 3 and 12 months after relocation to senior housing and the physical performance is also affected based on how they spend leisure time with others, also considering the visitors to whom their meet regularly, experience with walking aids usage and emotionally anxious to use walking aids in front of others. When family members visit and communicate with them frequently, even over a telephonic conversation, can make older people feel loved. Another study discovered no appreciable difference in the number of visits by relatives and friends to older people before and four months after their move into senior housing. To change one's life circumstances and integrate into senior housing, family members' motivation and support are unquestionably crucial. However, this study shows that there is no significant difference with the usage of walking aids.

In section 'C,' physical challenges were examined based on findings reported in the literature. The prior study highlights the complexity of the relationship between older adults using walking aids and their surroundings. Depending on what other variables were considered, both discovered that people who experienced barriers at home were more likely to use ‘any compensatory strategy’. They also found that living with someone increases the likelihood of requiring personal assistance in relation to walking aid alone. When it comes to social challenges, it affects the type of compensatory strategy among those who use them.⁹

Our observation shows that the average living environment and physical challenges among moderate users at baseline were higher than the restricted users. This might raise the question of whether healthier older adults choose to live in more difficult environments. Therefore, extrapolating any causal links between the difficulty of the home environment and health or function from this study would not be acceptable. Although beyond the scope of our descriptive objectives, these intricate, potentially reciprocal relationships contain very significant directions for future research.¹⁰ Studies into these issues might postulate that a certain level of challenge at home might lessen the need for walking aids in the future, based on the significance between home environment and disability outcomes.¹¹ Using a cross-sectional, descriptive analysis, it will take more research to fully understand these intricate relationships.

Our data implied that walking aids acquired by older adults were not recommended by verified skilled practitioners, but were obtained from other sources such as family, acquaintances, etc. No proper training was received from trained practitioners for use of walking aids. Subjects were unable to manoeuvre through the stairs due to lack of training for proper usage of walking aids. Less mobility is exhibited in the home setting since ambulation with walking assistance by the elderly would be preferred from bed to toilet and toilet to bed. It is important to focus on the physical difficulties at home. It also offers important variations discovered in the physical challenges as the significance level for the three questions was achieved.

The study suggests offering some preliminary support for the idea that when designing future interventions aimed at improving the ability to age cohorts to age in place, attempts to achieve shared choices on the use of walking aids with individuals, whether for clinical or social reasons, maybe most successful if they are established based on knowledge of the variables that may affect a patient's choice to use aids. This study also recommends further research with large sample sizes, involving all mobility devices. It is also necessary to investigate areas where a policy may be framed for medical practitioners and the users as a guide.

Conclusion

Our study finds few impediments in the usage of walking aids by older adults such as, inappropriate facilitation in creating a barrier-free home environment, lack of knowledge in the selection of appropriate walking aids, inadequacy of guidance and assistance for the use of walking aids.

From the observations made in this study, it is suggested to improve the physicians’ awareness of the need for use of walking aids and their role in making prescription referrals, exposure to peer role models (emphasizing older adults' autonomy and independence, as well as their capacity to participate in family and community events). Also giving subjects a choice of style and design of the equipment, and production of safe, low-impact walkers are various other ways for increasing acceptance of walking aids among older adults.

Conflict of Interest

There is no conflict of interest among the authors.