Healthy Aging After Spinal Cord Injury
May 9, 2006
- Cardiovascular Health and Metabolic Syndrome
- Bowel and Bladder Changes
- Pulmonary Health
- Skin Health
- Mobility and Aging
- Life Satisfaction While Aging
Many of us have negative stereotypes about aging, said Dr. Steven Stiens, UW associate professor of rehabilitation medicine. “The myth is that getting older means being ill. But this isn’t necessarily the case.” Although aging does present certain inevitable challenges, we now know there are steps we can take to maintain a high level of health and function in the advancing years, even with SCI.
A recent study in Great Britain followed 834 people with SCI for more than 25 years.[1,2] The researchers found that—regardless of age, length of time since injury, and injury severity—perceptions of overall health were quite high (over 70%) and actually improved over time, until subjects reached the 40-years-post-injury milestone, at which point people reported a decline in perceived overall health. “So there is some evidence that when you get to the 40-year mark there are some points of deterioration that you need to watch out for,” Stiens said.
“We are particularly concerned about the risk of heart disease in people with SCI,” Stiens continued. “Metabolic syndrome—a condition associated with high risk of heart attack, stroke and other complications—is especially common in the SCI population,” and consists of four major characteristics:
- Obesity. “In this country we have an epidemic of obesity; this is also true for the SCI population, mainly because it doesn’t take a lot of energy to push a wheelchair or run a power wheelchair. Not infrequently we overeat for our size and the amount of energy we expend.”
- Insulin resistance and diabetes. “By insulin resistance, I mean the insulin is there, but unsuccessful in bringing glucose to cells. And cells, because of inactivity and other factors such as obesity, are less efficient at using insulin. As a result, the fasting blood sugars tend to be a little higher in people with SCI and the ability to manage large glucose loads is worse.”
- Poor cholesterol profile. “Specifically, this means low levels of the ‘good’ cholesterol (high density lipoprotein, or HDL), which goes around mopping up the bad cholesterol off vessel walls,” Stiens explained. “Exercise contributes to a rise in HDL, and people with SCI tend to have lower HDL than others their age because of lack of exercise.” HDL can be improved with exercise, as well as drinking one or two drinks (especially red wine) per day—“But no more than that, or you blow the whole thing!” Stiens warned.
- High blood pressure. Even though there is a tendency to have lower blood pressure with SCI, obesity tends to bring it up and it becomes a concern.
All of these symptoms tend to increase with age in the general population, and perhaps at a slightly younger age in persons with SCI, Stiens added.
How can you turn this syndrome around and improve your cardiovascular health?
- Keep your weight down.
- Change your diet—decrease sugars and simple carbohydrates, reduce fat and cholesterol.
- Keep moving; increase the total activity in your day.
- Talk with your doctor about whether or not you need medications for cardiovascular health. “We’re finding more and more that some of the medications originally designed to lower heart rate or cholesterol can improve risk for heart disease and directly prevent heart attacks,” Stiens said.
Urinary tract infections (UTIs) are more common as people age with SCI, perhaps due to drinking less fluid or to a weakened immune system. There is also an increased risk of bladder stones, which can block the ureters (tubes that carry urine from the kidneys to the bladder) and cause urine to back up into the kidneys, a serious condition. For this reason, Stiens recommends having an annual medical evaluation that includes an ultrasound of the kidneys and urinary collection system. If stones are found, they can be eliminated using lithotripsy, which sends sound waves through the body, causing stones to break up.
It is important to pay attention to UTI symptoms because UTI leading to sepsis is a common cause of death in people with SCI, Stiens warned. (In people with quadriplegia (tetraplegia), pulmonary problems such as pneumonia are the most common cause of death; see the section on “Pulmonary Problems,” below.) “If you have UTI associated with fever and chills, you need to get to the hospital and get on antibiotics,” he added.
Bowel care is a very significant quality of life issue. “For some people, their bowel program runs their life,” Stiens observed. “Ideally, you want a bowel program that doesn’t take too much time and that gives you confidence that you won’t have a problem when you’re away from home.”
“But the truth is, when people age, gut transit can go down,” Stiens continued. If bowel care is very prolonged and doesn’t respond to treatment, a colostomy may be a good choice. (A colostomy involves surgically connecting the colon to the abdominal wall, and collecting stool through an opening called a stoma.)
“People who’ve had colostomies after SCI are usually pretty happy because they are free of the bane of bowel care,” Stiens said. Studies show that among people with problems such as incontinence and/or excessively long bowel care times, the amount of time devoted to bowel care can be significantly reduced after colostomy, in some cases down to 1.3 hours per week from a whopping 13.4 hours per week!  “Don’t be afraid of a colostomy, because not infrequently it becomes the solution later in life,” he added.
It’s best to have a bowel movement every day, but it can be every other day if you aren’t eating too much fiber. “If you are waiting too long between bowel movements, you can overfill and distend (stretch out) the bowel, and as a result the bowel may not perform as well as it should,” Stiens explained. “So the message is: eat a diet with enough fiber to have good stool consistency; drink enough fluids to keep stools soft, but formed; do bowel care on regular schedule; and empty the bowel adequately. You will probably stay out of trouble.”
“With age, risk of pneumonia increases, lung capacity generally decreases, and risk of sleep apnea increases,” Stiens said. People with cervical injuries have a high risk for respiratory infections due to a weakened respiratory system and an inability to cough deeply enough to clear the lungs. “The higher the injury level, the higher the risk for pneumonia.” (To read more about pneumonia and SCI, click here for the SCI forum report on respiratory illness and SCI.)
There are cough assistance devices that can help clear the lungs, such as the mechanical insufflator-exsufflator (MIE), that blows air into the lungs and then pulls air and mucous out. “I’m a T-2 and don’t have full use of my chest muscles,” Stiens said. “So as I get older, I may keep an MIE machine around the house to improve my quality of cough during an upper respiratory infection.”
Sleep apnea—pauses in breathing while sleeping—“affects the quality of your sleep and puts you at risk for daytime sleepiness and even sudden death,” Stiens said. If you have symptoms such as loud snoring and excessive daytime sleepiness, you should talk to your physician about being evaluated for sleep apnea. (To read more about sleep apnea, click here for the SCI Forum report on sleep apnea and SCI.)
Recommendations for maintaining pulmonary health while aging:
- Stop smoking.
- Get a flu shot yearly and a pneumovax vaccine (to prevent pneumonia) every five to seven years.
- Exercise and keep weight down.
- Take deep breaths to keep the chest expanded.
- Treat sleep apnea if appropriate.
“Pressure ulcers are a source of decreased quality of life and there’s a higher risk of pressure ulcers as time goes on,” Stiens reported. “One study we did on people living with SCI in the community found that 25% have skin breakdown. So this is an extreme risk and something you have to watch for very carefully.”
How to avoid pressure ulcers:
- Perform daily skin checks, using a mirror or with the help of a caregiver.
- Review seating regularly (once or twice a year) with a physical therapist. Make sure a pressure mapping assessment is done for each of your seating surfaces.
- Keep your weight down.
- Modify your diet to get adequate protein, vitamin C and zinc.
- Protect yourself from sun exposure (to avoid skin cancer).
Years of pushing a wheelchair can take a toll on the shoulders. “If you’re beginning to get shoulder pain, it might be a good time to look into getting an assist wheel or power chair,” Stiens said. “The trick is to get into power mobility before you have trouble with your shoulders so you don’t develop trouble with transfers.”
Increased fatigue, weight gain, loss of muscle mass and medical complications can impact mobility. “Developing a program of regular physical activity early on is one way to fight against that,” he added. “Keep in mind that people with a loss of mobility over time are less satisfied with their lives.”
How to protect your mobility and your shoulders as you age:
- Keep your shoulders strong and make sure your wheelchair propulsion technique is safe and efficient.
- Transition to power mobility early, but keep exercising.
- Keep weight down.
- Avoid overhead reaching.
- Avoid sleeping on your shoulder.
- Stretch front shoulder muscles and strengthen back shoulder muscles.
- Sit upright with shoulders pulled back.
- Cultivate your passions. (Renoir continued painting into his eighties—from a wheelchair—despite arthritis.)
- Choose fun activities that keep you flexible and fit.
- Plan activities so you always have something to look forward to.
- Cultivate enriching long term relationships.
- Look at your environment and don’t let it trap you if you have a change in function. It might require redesigning your current dwelling or moving to a house on a flatter surface.
“Many of the risks non-disabled people face (obesity, hypertension, diabetes) are equally if not more important for SCI survivors,” Stiens said. “The lifespan of the SCI individual is continually extending, so that many people with SCI now die of the same things the average American dies of.”
“Certain conditions are associated more with age (diabetes, cardiovascular), others with time since injury (shoulder and skin problems),” he added. “And, thankfully, life satisfaction does not necessarily correlate with age.”
Janna Friedly, MD, in the UW Department of Rehabilitation Medicine, contributed to this SCI Forum presentation.
- Whiteneck GG, Charlifue SW, Frankel HL, et al. Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago. Paraplegia. 1992 Sep;30 (9):617-630.
- Gerhart KA, Bergstrom E, Charlifue SW, et al. Long-term spinal cord injury: functional changes over time. Arch Phys Med Rehabil, 1993 Oct:74(10):0103-4.
- Rosito O, Nino-Murcia M, Wolfe VA, et al. The effects of colostomy on the quality of life in patients with spinal cord injury: a retrospective analysis. J Spinal Cord Med. 2002 Fall;25(3):174-83.
- Hammond MD, Bozzacco VA, Stiens SA, et al. Pressure ulcer incidence on a spinal injury unit. Adv Wound Care, 1994 Nov:7(6):57-60.