Society Spotlight: Managing the Aging Adult Prosthesis Candidate

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By Kevin Carroll, MS, CP, FAAOP

We live in an ever-changing world, but as the years pass, it seems that the rate at which change occurs is accelerating. Technology's radical progress, in particular, inevitably impacts our interactions with our peers and our patients, especially those aging adults we might formerly have referred to as "seniors" or "the elderly."

In today's evolving O&P climate, however, older adult patients defy profiling and pigeonholing, largely due to this rapid progress. The universal accessibility of information creates a better informed and educated older patient than many O&P practitioners have ever before seen. Medical advances have made longer, healthier lifespans more common, and advances in O&P technology have opened doors that up until a few short years ago had been closed.

Along with the older adult patient's increase in education, better overall health, and a greater variety of prosthetic options, comes the confidence to ask questions, make choices, and demand a more active and fulfilling future than their own aging parents experienced.

Physical and occupational therapy are playing an increasingly significant role in the recovery process. For example, in years past a patient who underwent an amputation would remain in the hospital for awhile following the surgery, and would then go to an inpatient facility for rehab. Today's prosthetics patient may go to rehab as an outpatient, but oftentimes both the physical therapist (PT) and the occupational therapist (OT) deliver in-home rehab care, which allows these professionals to evaluate the patient's home environment and suggest modifications or assistive devices that can make a big difference toward getting the individual up and out of his or her wheelchair.

"Am I too old for a prosthesis?"

Caring for the aging prosthesis wearer presents a unique set of problems; understanding and respecting those problems is key to solving them in ways that are most beneficial to the individual. Here are some points to consider:

The fear factor. The older patient faces two very real fears: the fear of becoming inactive or incapacitated and therefore giving up the life he or she is accustomed to living; and the fear of falling.

Older patients can access the Internet as easily as anyone else and find the following Centers for Disease Control and Prevention (CDC) data:*

  • One in three adults age 65 and older falls each year.
  • Among those age 65 and older, falls are the leading cause of injury or death.
  • In 2007, more than 18,000 older adults died from unintentional fall injuries.
  • The death rates from falls among older men and women have risen sharply over the past decade.
  • In 2008, 2.1 million nonfatal fall injuries among older adults were treated in emergency departments.
  • The chances of falling and of being seriously injured in a fall increase with age. In 2008, the rate of fall injuries for adults age 85 and older was almost four times that of adults ages 65-74.
  • In 2006, there were 316,000 hospital admissions for hip fractures in people age 65 and older-an increase of 7 percent from the previous year.
  • Over 90 percent of hip fractures are caused by falling.

*www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

In addition, many older adults have friends of the same age who have experienced falls, which brings the frightening possibility even closer to home. Add a new lower-limb prosthesis to the picture, and the prospect of ambulating without falling can seem like an impossibly daunting challenge.

To address these very real concerns, it is important for both the physician and prosthetist to talk to the patient about fall prevention strategies. These strategies include the following:

  • Choose a prosthetic device that is safe and stable-one that will prevent rather than present stumbling hazards. Microprocessor knees and feet that are responsive to the wearer's gait adapt to support weight bearing safely and appropriately.
    Compared to traditional devices, these systems can reduce falls and increase patient confidence.
  • Ensure that the socket fits well and will not slip each time the individual takes a step. It is vital that the wearer understands the importance of a good socket fit.
  • Impress upon the patient the need to keep his or her follow-up appointments after the initial fitting. Explain that physiological changes in volume are likely to occur and that these changes will negatively affect the fit as well as the safety of the patient's prosthesis. Such counsel may go a long way toward securing the patient's cooperation regarding follow-up visits.
  • Explain the value of working with a PT to help with the patient's balance, core muscle strength, and confidence. Each reduces the likelihood of falls.

In truth, it appears that prosthesis wearers may actually experience fewer falls than other older adults, probably because we, the healthcare workers involved in the older adult amputee patient population, work proactively, constantly thinking in terms of fall prevention through appropriate patient education and management.

The intimidation factor. When presented with a new prosthetic system, older adults initially find the prospect intimidating due to their "gadget tolerance" threshold, which seems to diminish with age. Using a liner with a pin-lock system requires steps in handling, preparing, donning, cleansing, and maintaining, procedures that may seem overwhelming to someone who has never done them before. Taking the time to provide detailed explanations and demonstrations is essential. Supplying these patients with instructional checklists and illustrations is helpful for providing step-by-step reminders.

Arthritis is another problem commonly associated with aging. A lack of manual dexterity may make it more difficult for the older amputee to turn some liners inside out. It is wise to consider this when selecting an appropriate liner. Choose one that easily turns inside out and one that rolls onto the limb without difficulty.

If using a pin system, sometimes the sound made by the pin as it engages helps to confirm that the leg is securely attached; the wearer can count the clicks of the ratcheting pin to confirm the prosthesis' attachment. In the older adult population, however, hearing may be limited, and thus additional instruction to ensure adequate attachment may be required. Several repetitions of the donning process can be helpful. Offers of assistance from family members should be resisted. The amputee's home and community independence depends on his or her ability to don the prosthesis without assistance. Dependence on an absentee helper will be of no value to these patients.

Skin issues present another level of concern for the older prosthesis wearer. As skin ages, it loses elasticity and thus requires more protection than the skin of a younger amputee. Better quality sockets and interfaces can make a vast difference here. The silicone materials that interface directly with the skin can reduce skin breakdown and increase comfort and wear time for the individual.

A variety of products are designed specifically for extraordinarily fragile skin that reacts poorly to direct contact with gel materials. Socks that sandwich the gel materials between two layers of fabric help to optimize comfort, as does placing a very soft, cushion-like material against the skin of the residual limb.

Communication complications. With advancing age come certain inevitable diminutions of sensory capabilities. In addition to hearing loss, vision can begin to decline as well, further inhibiting communication. Be sensitive to the possibility of such losses and begin by addressing your remarks to the patient when you are facing each other at a polite conversational distance, rather than beginning to speak with your head bent over a chart the moment you enter the room. Some people with hearing loss supplement hearing deficiencies through self-taught and often unconscious lip-reading strategies.

Vision and hearing skills are also an important part of success when ambulating with a prosthesis: a person's ears tell them when a car is coming, a door is opening, or a running child is approaching. To fail to hear these things is to be less prepared and less able to respond proactively and preventatively. Older prosthesis wearers must be even more watchful than others because their reaction time may be slower.

Carrying a cane can be an aid to the prosthesis wearer, even if it is not needed for support. In cases where the prosthesis wearer may not spot certain hazards, there's a good chance that the hazards-the running child or the approaching car-may be alerted by the presence of a cane and exercise special vigilance and thus avoid potential accidents.

In the diabetic population, blindness or some degree of visual impairment is an unfortunate consequence. As prosthetists we are able to teach a patient to walk with a prosthesis, but we need another kind of expert to coach visually impaired patients how to safely find their way around their homes, their local stores, schools, and places of business. It is very helpful for such persons to contact the American Council of the Blind (ACB) or their local training center for the blind. (Author's note: Contact the ACB at www.acb.org; , or call 800.424.8666.)

When communicating with an older adult, attitude is just as important as what you say and how loudly you say it. Aging baby boomers will not tolerate being patronized and treated like small children by merchants, financial advisers, or healthcare providers, as the previous generation often had to. Today's savvy seniors are informed and involved activists, well ahead of the game and well aware of the worth of their experience, skills, goals, and spending power. They are able to contribute materially in strategy sessions regarding their prosthetic care.

With their longer, healthier lifespans, many older adults in retirement communities and assisted living facilities are losing their spouses and reconnecting with new partners in their 80s and 90s. So when you plan a conversation with your patient's family, be aware that it may well include a significant other whose wishes need to be heard and considered as well.

Joan E. Edelstein, PT, MA, FISPO, notes that "People usually develop [vascular] disease in middle age; progression to amputation is often in the 60s-the peak decade for amputations in this country."

She notes that because of its irreversibility, the decision to undergo amputation is a very difficult and distressing one, not only for the patient, but also for the family; if no spouse is present, the stress of emotional, physical, and financial support is likely to fall on adult children or siblings.

"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 says. "For example, transportation to the patient's appointments, meal preparation, housekeeping, and a supportive presence...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." (Author's note: Edelstein is quoted in "Walk On: Prosthetic Success for Geriatric Patients," The O&P EDGE, August 2009.)

Rather than being taken care of, it's important to note that many of today's older adults are taking care of themselves and each other, and intend to keep it that way. This in itself often provides excellent motivation for higher level achievement than might otherwise be expected.

M. Jason Highsmith, DPT, CP, FAAOP, describes the case of an 83-year-old low-level ambulator who committed himself to doing well with his prosthesis in order to continue caring for his wife, an Alzheimer's patient. Keeping her in their home and out of an institution provided powerful motivation for him to remain dedicated to his therapy and to succeed in the long run, meeting his goals in truly inspirational fashion. (Author's note: Highsmith's paper on this case appears in the Journal of Prosthetics & Orthotics: 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.)

As prosthetists, our goals should be to get older adult amputees back on their feet, rehabilitate them, and enable them to return to their active lives, especially with today's responsive prosthetic technologies to aid them. We must advocate for our patients to make sure they have the opportunity to benefit from state-of-the-art advances.

The good news is that most of our older adult patients are doing amazing things on their prostheses today. They're living their lives, enjoying their retirement, playing golf, going for walks, and attending social events with their friends, largely because we, as a community of prosthetics practitioners, have done a really good job of advancing the art and science of building prosthetic devices and offering rehab services that work with this patient population.

With commitment, continuing education, and a little bit of luck, we can continue to serve our older patients with the same level of success and dedication.

Kevin Carroll, MS, CP, FAAOP, is vice president of prosthetics for Hanger Prosthetics & Orthotics, Austin, Texas. He is a member of the American Academy of Orthotists and Prosthetists (the Academy) board of directors and chair of the Academy's Lower Limb Prosthetics Society.

Society Spotlight is a presentation of clinical content by the Societies of the American Academy of Orthotists and Prosthetists in partnership with The O&P EDGE.