Aging Gracefully with an Amputation

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When working with the elderly patient population, prosthetists generally see two types of people: those who have become amputees during their sunset years, and those who have been living with limb loss for years-whether it's the result of a birth defect, a traumatic accident, or a battlefield injury. These "experienced" patients tend to bring a different perspective to the normal aging process. Many have developed a longstanding routine for managing their residual limb and are comfortable with their prosthesis. They may be reluctant to modify their routine or device-even as their bodies change.

By scheduling regular appointments, prosthetists can play an integral role in helping their long-term patients with what William Shakespeare called "the thousand natural shocks that flesh is heir to." An awareness that people with lower-limb amputations are more susceptible to certain age-related health issues gives practitioners an opportunity to educate patients and their caregivers alike.

"As the saying goes, 'Old age is no place for sissies,'" says Joan E. Edelstein, MA, PT, FISPO, adjunct professor of physical therapy and former senior research scientist in the Department of Prosthetics and Orthotics at New York University (NYU), New York. "Aging affects every system of the body, and prosthetists are in a particularly good position to work with older people."

Some of the age-related concerns that affect patients with lower-limb amputations in particular include arthritis, stability and balance, vascular disease, and skin issues, as well as changes in activity levels and weight.

Arthritis

Even for people with sound limbs, years of wear and tear take a toll on the joints. Disruptions in normal body mechanics and alignment make a patient with a unilateral amputation, in particular, even more susceptible to arthritis in the spine and hips as well as his or her sound-side limb.

"As arthritis progresses in the sound limb, the patient starts to rely more on the prosthetic side," explains Richard Frieden, MD, medical director of the Amputation Specialty Program and assistant professor in the Department of Rehabilitation Medicine at The Mount Sinai Medical Center, New York, New York. "That increases the force on the socket, so the prosthetist should look at modifying it for greater weight bearing."

Whatever the individual challenge, prosthetists should fit their aging patients with the appropriate technology to meet their needs. In some cases, this can mean adding assistive devices such as canes or walkers, says Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics at Hanger Clinic, headquartered in Austin, Texas.

"It all depends on how mobile they are and what they want to do," he says. "It's our job to come up with solutions that let them live their lives the very best they can."

Edelstein adds that the socket suspension system in particular must allow the individual to don the prosthesis quickly, accurately, and independently-or the prosthesis won't be worn. Prosthetists should make modifications for easier donning and doffing to accommodate for reduced function in arthritic fingers, or low vision, she advises.

Baby boomers who want to remain active are increasingly opting to replace arthritic knee and hip joints, but these implants present particular challenges for people with lower-limb amputations. Frieden recommends prosthetists be involved both preand post-operatively.

"Immediately after surgery, people tend not to trust the operated leg. Therefore, amputees will rely on the prosthesis as the 'sound' limb," he explains. "It's important that they have sufficient strength in their arms and shoulders to use a walker or crutches during post-operative rehabilitation. Ideally, they should have physical therapy before the surgery. The prosthetist should assess socket fit both before and after surgery as [the patient] learns to walk again."

He points out that a patient's gait characteristics will change after a hip or knee replacement, which may require modifications to the prosthesis to maintain stability.

Balancing Act

Everyone's sense of balance changes with age, making falls one of the most common and serious reasons for hospitalizations among the elderly. Walking with a lower-limb prosthesis-or two-is a nonstop balancing act. As amputees age, they may require modifications to their prostheses to maintain stability.

"The selection of the foot, or foot and knee, should be appropriate for this person at this stage in his or her life," Edelstein says. She also recommends paying close attention to footwear on both the sound and prosthetic foot to further ensure stability.

Prosthetists should also consider the weight of the entire prosthesis and whether the patient can still meet the energy demands required to walk the same distance as when the prosthesis was first fit.

Skin Care

Skin care is vitally important for anyone with an amputation- regardless of how old they are. But as people age, their skin becomes drier, thinner, and less elastic. Atrophied or ulcerated skin on a residual limb can lead to infection and other serious consequences, so even minor skin issues must be addressed immediately.

Leslie Pitt Schneider, JD, RN, CCRC (ACRP), HT (ASCP), manager of clinical and regulatory affairs at Ottobock, Minneapolis, Minnesota, has been a transfemoral amputee since she was six years old. Now in her early 40s, she ranks skin care as being just as important as guarding against falls.

"I've always had sensitive skin, and I've learned the hard way that not being observant can lead to skin breakdowns," says Pitt Schneider, who washes her prosthetic socks in hypoallergenic laundry soap to reduce the possibility of irritation. "A breakdown keeps me out of my leg until the lesions heal, so I have gotten very good at listening to my body and paying attention to my socket fit."

Prosthetists have a wide range of protective materials to use as an interface between the skin and the socket, Carroll says, and the trick is to find the one that works best for the individual patient.

Weight Control

Another issue that can affect any amputee is weight gain. As people age, their metabolisms can slow down and their activity levels decrease, but excess poundage puts stress on more than the prosthetic socket. A sedentary lifestyle also puts stress on the human skeleton, which increases the risk for serious fractures in the event of a fall.

The experts interviewed for this article agree that prosthetists should encourage all of their patients, regardless of age, to remain as active as possible, at whatever level they can.

"There is no reason in the whole wide world that anyone with an amputation can't engage in consistent exercise," Edelstein says.

Vascular and Other Diseases

Amputation may result from vascular disease, but it doesn't cure it, "so it is important to continue to pay attention to the underlying causes [for the amputation], which can increase the possibility of heart attack and stroke, and pay particular attention to the health of the remaining limb," Edelstein says. When older people are hospitalized, they can spend long periods not wearing their prostheses. Carroll advises prosthetists to check on these patients in the hospital to fit pressure socks whenever they anticipate extended time out of socket.

People with amputations who are in renal failure face a unique challenge when transferring to and from the dialysis couch, since the couches aren't usually height adjustable, Frieden notes. His rehabilitation department has patients practice pivot transfers before they go to the dialysis area to ensure a safe treatment.

Insurance

The one age-related change that affects both the patient and the prosthetist is insurance coverage.

"People going on to Medicare from the [employer-based] insurance they've had for years may experience some changes," Carroll says. "It's important for people to be familiar with their insurance and budget for outstanding costs such as co-pays or supplemental insurance."

Sometimes those changes mean high-end components are no longer covered. Patients who enroll in a Medicare Advantage plan, for example, may find that their prosthetist is no longer in the plan's network.

Pitt Schneider knows firsthand the challenges of transitions in coverage. Before joining Ottobock, coverage for her C-Leg was denied twice when she changed jobs.

"This is a huge issue that I am passionate about," she says, adding that's why she sits on the Amputee Coalition's board of directors and uses her legal background and personal experience as an amputee to advocate at the state and national level to get coverage for O&P included as an essential health benefit, separate and distinct from durable medical equipment (DME).

"To me, it's a no-brainer," Pitt Schneider says. "I'm missing a limb, and a prosthesis is medically necessary to get back to work, but this is our third attempt to get it passed [in Minnesota]. If insurance companies pay for implantable knees, why not state-of-the-art external knees?" As prosthetists and patients alike know all too well, that issue will likely have longevity of its own.

Kate Hawthorne is a freelance writer living and working in Fort Collins, Colorado. She can be reached at