William A. Kraft, Ph.D.
Director, Brain Injury and Spinal Cord Injury Programs,
Psychology Department and Neuropsychological Services
Frazier Rehab Institute
Assistant Clinical Professor of Medicine, University of Louisville Medical School

What Is Known
Four of the most common myths about aging are that an older person has less enjoyment, less quality of life, less mental activity and is sure to be ill. While these are myths, there are less attractive realities of aging with spinal cord injury that require our attention. Also, there are several ongoing evaluations and treatments that can positively address the problems of aging with SCI if appreciated and anticipated.

The most frequently researched areas of aging and SCI include: mortality; morbidity or complications associated with SCI and aging; age at the time of injury and length of time since injury. As research progresses, it is becoming more apparent what are problems related only to aging versus aging with spinal cord injury.

Mortality: The population of SCI survivors is aging. Dr. Stephen Burns reports that 20% of persons with SCI are over 60 years of age and the average age is 40. Approximately 40% of persons with SCI are over age 45 and 25% are more than 20 years post injury. Perhaps the most extensive information on aging and SCI comes from longitudinal research conducted in England involving more than 800 individuals with SCI under the direction of researchers at Craig Hospital in Colorado. The good news is that life expectancy has steadily improved and mortality rates decrease as survivors get older and have lived longer with their injuries. This seems to be a paradoxical finding, however, the data suggest mortality rates eight times higher than the general population at age 20 but only 1.5 higher at age 70. The three leading causes of mortality among persons with SCI are respiratory illness (22%), heart disease (20%), and external causes (16%) according to SCI model systems data.

Problems Associated with Aging: There are several problems that are especially prevalent with aging and SCI. The University of Washington Department of Rehabilitation has generally grouped these health concerns as: skin; cardiac; pulmonary; urinary tract; gastrointestinal; neurological; musculoskeletal; personal care needs; adjustment; strength and smoking.

In the British studies up to 1990, pressure sores were the number one cited problem at 23%. Older persons who had their injury for a shorter period of time appear to be more prone to pressure sores. Younger people several years post injury were less likely to have sores. The frequency of pressure sores was highest with paraplegia, those with previous sores and those who did not work.

Other frequent problems are urinary tract infections (20%) and decreases in physical independence (22%). Decreases in independence was attributed to fatigue or weakness (25%), medical problems (25%), pain and stiffness (18%) and other illness or age (14%).

Upper extremity pain tends to increase with age, especially for person with functionally complete paraplegia. This is due to nerve entrapments or over use syndromes. Frequency rates for pain of 29% at 5 years, 54% at 15 years and 77% in long term SCI have been reported.

Longer duration SCI is also associated with joint pain, fractures, motor or sensory changes and increases in total cholesterol levels. Lower HDL cholesterol, a tendency toward insulin resistance, smoking, weight gain and decreased activity levels are all related to cardiovascular problems.

Individuals with more recent injuries tend to have higher levels of psychological stress than those many years post injury. Stress is likely not to be related to severity of injury nor presence of medical problems related to SCI. Good news is that stress levels do not appear to be higher than the general population and life satisfaction is generally rated as high. Depression seems to be lowest in those injured for the longest time.

Nearly one-half of persons with SCI require some personal assistance. Individuals with paraplegia are most likely to need assistance with transfers and for tetraplegia, mobility is the number one need. Sixty percent of individuals under age 60 are independent for all self care and 30% after age 75. Transfers, bathing and toileting are the most frequent activities of living (ADL's) affected by age and shopping, household chores and transportation the most frequent independent ADL's affected by age.

What Can Be Done Good health management over time can help address many of the problems associated with aging with SCI. This includes:

" Regular evaluations for blood lipids and glucose, blood pressure and thoughtful medication management.

" Appropriate activity levels, weight maintenance, smoking cessation, good dietary habits and alcohol limitation.

" Adequate hydration and hygienic bladder management.
" Screening for diabetes and insulin resistance.

" Particular attention to respiratory, cardiovascular and musculoskeletal health.

" Periodic evaluations to address posture, cushions, pressure release strategies, chair modifications or need for power assist, stress reduction, especially for wrists, elbows and shoulders.

" Maximize social and community involvement and activities that reduce stress, combat depression and maintain self-esteem

Readers interested in further information may wish to consult:

" Aging With Spinal Cord Injury by Gale. G. Whiteneck Ph.D. and others. (Book - 388 pages, 1993)