Walk On: Prosthetic Success for Geriatric Patients
August 2009 Issue
Successful, goal-oriented amputee rehabilitation is seldom based on a simple formula. Regardless of age, each patient presents unique and often complex challenges—many of which are further complicated in the case of an older adult. For older men and women, the overwhelming cause of limb loss is vascular disease, says Joan E. Edelstein, PT, MA, FISPO.
A number of factors can significantly influence geriatric recovery from an amputation, whether necessitated by disease or from unexpected trauma.
"People usually develop the disease in middle age; progression to amputation is often in the 60s—the peak decade for amputations in this country," Edelstein explains. "In these cases, the patient has not been feeling tiptop for a long time. Hence the amputation is not a total surprise; the premonition has been lurking for a long time."
Because of its irreversibility, the decision to undergo amputation is a difficult and distressing one—not only for the patient, but also for the family, she points out. If the patient has a spouse, the spouse is likely of similar age and may not be in abundant health, adding to the difficulty.
If the patient is unmarried, the stress of support—emotional, physical, and financial—is likely to fall on the family, whether adult children or siblings. "They are likely to be justifiably concerned about how the patient is going to manage—and, by implication," Edelstein says, "'how are we going to manage helping our relative?'"
The ripple effect of the patient's dilemma touches a number of people responsible for his or her support and well-being, in ways that are never really reimbursed, Edelstein adds. Such issues include transportation to the patient's appointments, meal preparation, housekeeping, and a supportive presence to provide extra attention, especially in the early days after surgery, when standing and walking are most difficult.
"These life issues are beyond the scope of usual prosthetic rehabilitation, but they are important," Edelstein says.
Even gender creates its own set of concerns, especially for older women, who traditionally are accustomed to being the housekeeper and cook but are hampered by difficulty with mobility.
"Appearance is also a much more important issue for women than for men," Edelstein points out. "We like to look nice. Slacks are very acceptable, and that's great because it pretty much hides the prosthesis. If a woman prefers to wear skirts, however, then the appearance, shape, and color of the leg become matters of concern, along with the kind of shoes she would prefer to wear."
Although some prosthetic feet can be worn with high heels, fashion-conscious women accustomed to wearing high heels might consider this a misnomer because commercial prosthetic "high" heels are only two inches higher than the shoe sole—a far cry from fashionable four-inch stilettos some women continue to wear into their advancing years.
Edelstein points out that comfort is also a gender-related issue, particularly in the case of women who have transfemoral amputations. "Women have more soft tissue; I like to say it's what makes us warm and cuddly! When you try to fit the thigh into a socket, subcutaneous fat in the proximal thigh can become troublesome. On average, men have proportionately less soft tissue to manage."
Older patients who have worn a prosthesis since childhood or young adulthood, whether as the result of a traumatic amputation or a congenital limb deficiency, face a new set of problems as they age, Edelstein explains.
"If a patient in his 60s or older is accustomed to a particular prosthetic foot or socket design and he is managing with it, there is a practice in some clinics to leave matters alone—an 'If it ain't broke, don't fix it!' policy. Generally, that is wise, but on the other hand, it can deprive an older person of newer, more sophisticated components—feet and knee units especially."
Age-Related Changes in the Prosthesis Wearer
The "experienced" elderly amputee is also subject to the same age-related changes that affect us all, such as arthritis. Lower-limb prosthesis wearers compensate with their sound leg. A bilateral lower-limb amputee compensates with the hips and the back. Due to the increased stresses on the area providing the compensation, arthritis is likely to be a greater issue for the person who is aging with a prosthesis, Edelstein notes.
Another major geriatric concern is osteoporosis—the bones' response to insufficient weightbearing.
"Wearing the prosthesis is a major way of putting load on the bone," Edelstein points out. "The bones are not loaded very much when one sits in a wheelchair—certainly the legs are not loaded at all. Therefore, the patient is very vulnerable to fracture. That of itself is a reason for thinking about fitting the patient, so at least she can stand up, move about, and avoid the further degeneration of the skeleton." (Editor's note: For information on the orthotic management of osteoporosis, see, "Osteoporosis: Orthoses Match Wits with the 'Silent Thief',")
There is more to using a lower-limb prosthesis than walking, however. Getting in and out of various styles of chairs and vehicles and maneuvering over various stair heights around the community are common challenges to mobility. The activities constitute obstacles for the elderly prosthesis wearer; surmounting these challenges improves the patient's fitness. Edelstein also recommends continuing those sports activities that the amputee favored previously, such as golf, tennis, or especially ballroom dancing, "which is marvelous because you don't have to worry quite so much about your balance—you've got your partner!"
Coming to Terms
Is it harder for the elderly patient to come to psychological terms with a new disability? In some cases, Edelstein confirms, they do embrace a "give-up-and-die" mentality when faced with limb loss.
"Some people become so depressed that they can't function," she points out. "Others are relieved by amputation, which eliminates a gangrenous foot."
Thus, Edelstein strongly recommends peer support, provided through group programs offered by the Amputee Coalition of America (ACA) or local institutions. "They provide a chance to ventilate, to clarify, and to gain new information."
Peers provide a different and often a more credible perspective for the new amputee, who may not know the appropriate questions to ask his or her healthcare team, nor the extent of the options available for building a new approach to daily life. In particular, new amputees are often fearful of the rehabilitation process; peer success stories can help to encourage and prepare patients to be more willing and even eager to face rehabilitation in whatever form it may be presented.
Rehabilitation of geriatric amputees can be conducted through an inpatient program at a rehabilitation center; nevertheless, most opt for the less expensive option of rehab as an outpatient.
"This means transportation provided by the family or other resource," Edelstein says.
Larger metropolitan areas often have special vans and transport systems, while smaller communities are less likely to have assistance available.
M. Jason Highsmith, DPT, CP, FAAOP, observes that geography also plays a role in providing appropriate care for elderly prosthetics patients. Florida, a retirement state, has a high number of geriatric healthcare providers; a state with a less dense geriatric population may not have to manage the elderly as frequently, he notes, so the care may be different.
"What defines 'elderly'?" Highsmith asks. "Different programs recognize different retirement and beneficiary ages. Depending on where you draw the line, a certain number of comorbidities will apply."
A common set of comorbidities might be hypertension, hyperlipidemia, and diabetes. Other usual age-related changes can also impact prosthetic care: presbyopia and presbycusia (difficulty seeing and hearing), plus muscular weakening, bone softening, and cardiovascular deconditioning that can begin in the 50s for individuals who don't perform maintenance exercise.
"These things can be operating in an elderly population at a sub-clinical level, and you don't really know until a catastrophic fracture or fall happens. That's when it becomes 'clinical.'"
Becoming an amputee adds another level of disadvantage to their situation, points out Highsmith, who offers the following recommendations regarding the care of the geriatric patient with an amputation:
- Because many geriatric patients are likely to be on medications for blood pressure, keep in mind that blood pressure may not be an accurate measure of cardiac response and workload.
- Use common sense: Ask them, on a scale of 1 to 10, "How exhausting is this?"
- Ask the patient if he or she has angina and monitor for its presence or emergence—angina is arguably more common in this population. Pay attention to the patient's history.
- Check their glucose levels pre- and post-intervention if the patient is diabetic or pre-diabetic. Additionally, you should know what the minimum and maximum safe levels of serum glucose are for exercise, and what is normal for the patient in front of you.
- Anticipate the possibility of vision and hearing impairments; don't yell across the room—walk up close so patients can see your face as you talk to them.
Reimbursement Issues and Bias
Even when clients are willing and providers are briefed and ready to observe all the cautions, reimbursement issues may arise to complicate matters—especially for amputees in this age group.
While many elderly patients rely on Medicare, optional plans that stress attractive pharmacological coverage are also available; in some cases, these alternate plans may not offer adequate prosthetic coverage, especially in the long-term analysis.
Highsmith advises patients to talk to their insurance carrier and get a clear idea of their coverage before making a switch. He prepares a projection of lifetime prosthetic costs for clients as needed—based on the assumption that their condition will remain stable—to guide them and their families with decision-making regarding their insurance plan.
"This is a tough discussion for people because you're talking about the end of life. You've plotted it on a graph, and now you've worked out the financial math. It's a very sensitive issue, but necessary."
Highsmith also reports observing occasional cases of age bias toward some seniors who are not initially identified as candidates for a prosthesis—or were labeled poor prospects at best—perhaps because of a chip-on-the-shoulder attitude that made a healthcare provider question their compliance.
The age bias can also prompt insurers to respond negatively in cases where there is any uncertainty regarding the potential outcome.
"If it's not clear how well a patient is going to do, there is sometimes less willingness to risk providing as much assistance," he explains.
However, Highsmith's own experience fitting questionable senior candidates provides evidence to the contrary.
"We have managed folks who were told they were not going to be a candidate for a prosthesis; they end up strolling into the office where we evaluate them and similarly conclude that they probably won't do well with a prosthesis—and they surprise us by doing very well!"
He remembers a group of amputees aged 80-plus. "They were individually told they were not going to be candidates for a prosthesis, but they happened into our office, where we worked with them. They ended up not only being prosthetic candidates, but one uses a microprocessor knee."
Another 83-year-old diagnosed as a "low-level ambulator" appealed to Highsmith for assistance. "He was bound and determined not only to walk well, but to walk well enough to care for his wife, an Alzheimer's patient, in their own home. He would not tolerate the suggestion that he put her into an institution for care, but insisted that he was going to take care of his wife."
Highsmith provided the patient with prosthetic care and says that the patient spent "a lot of time in therapy!"
Although he was a significant fall risk—and actually did fall and had some injury, reports Highsmith—the patient succeeded in the long run, probably due to his uniquely powerful motivation. He was dedicated to his therapy and went through an inordinate amount of it—four regimens in one year.
"Some folks might have decided that it wasn't worth all the time and effort, but when all was said and done, this gentleman did meet his goals and ended up taking care of his wife," Highsmith says. (Author's note: Highsmith's paper on this case appears in the Journal of Prosthetics & Orthotics (JPO): Highsmith MJ, Kahle JT, Fox JL, Shaw KL. "Case Report: Decreased heart rate in a geriatric client following physical therapy intervention and accommodation with the C-Leg." J Prosthet Orthot. 2009;21(1):43-47.)
"What we're finding in our area is that seniors may occasionally need more assistance, and when they get it, they can do really well."
Age Itself Is Not a Disease
Although seniors have a reputation for being set in their ways, that should not preclude their providers from giving them the respect and the care they need. Highsmith points out that part of being a good healthcare provider is recognizing when you're not relating well on a personal and professional level, and when it's time to get someone else to care for the client.
"Sometimes two personalities just don't mesh; large generation gaps sometimes complicate this further, and it takes a little effort to work through it. But if you make that effort, the outcomes are usually pretty good."
There are several reasons for an amputee of any age to be identified as "not a candidate" for a prosthesis. Many are cognitive and psychological issues. Some geriatric amputees in nursing homes suffer from senile dementia and are cognitively so impaired that they are not candidates for prostheses; however, they can benefit from different types of closely supervised mobility therapy, Highsmith notes.
Unfortunately, many elderly amputees with mild dementia simply lack the support system of family and/or friends that might enable them to enjoy the benefits of a therapeutic prosthesis that would allow them to be vertical and weightbearing. Those essential benefits include loading the bones, moving the muscles, draining the kidneys, and allowing gravity to work on the digestive system and other systems that need to be vertical, Highsmith says.
Nursing home amputee clients who lack a supportive family presence may be at a significant disadvantage as well. A considerable amount of time and assistance may be needed to maintain safe and satisfactory use of a therapeutic prosthesis, to help don and use it and manage the situation, he points out. "Busy institutional staff, who may be justifiably liability-minded in our litigious system, may opt against the therapeutic prosthesis in favor of other, more conservative management alternatives.
"If adult children or caregivers can be shown how to use the prosthesis as a therapy tool—to assist with walking their loved ones in the home, to use it to get to the restroom, but then to take it off—it could make a big difference to the amputee's psychological and physical well-being."
Sometimes there's a gray area where the decision to fit an elderly amputee rests on a team evaluation by his or her healthcare providers. In the final analysis, Highsmith says, someone has to step up and say, "I want to give this person a shot. Let's try it."
Here's to those with the courage to take that step.
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.