Developing O&P Solutions for Seniors: Meeting the Challenge

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By Maria St. Louis-Sanchez

With life expectancy increasing, and an ever-growing geriatric O&P patient population, O&P professionals are learning how to best treat this population and improve their outcomes.

Finding the right solutions for a population that varies so much from person to person will continue to be a challenge, the experts say.

"Within that senior age group, there is such a wide variety of levels of activity and health," says Jon Jaskiewicz, CPO, The Orthotic and Prosthetic Center, headquartered in Fairfax, Virginia.

The geriatric patient population is expected to grow dramatically in the coming years and O&P clinicians should be prepared to see an increase in the older demographic reflected in their patient populations. By 2030, all baby boomers will be older than age 65, according to the U.S. Census Bureau. This means that one in every five U.S. residents will be retirement age. By 2035, the Census Bureau estimates there will be 78 million people age 65 and up compared to 76.7 million under age 18.

"We are starting to see more elderly patients coming through our doors," says Kevin Carroll, MS, CP, FAAOP(D), vice president of prosthetics for Hanger Clinic, headquartered in Austin, Texas. "The baby boomers are definitely here, as are older adults, and they are beginning to need our services."

O&P experts say the size of the senior population and that the ages within it span decades also makes it tough to generalize the needs of this its members. However, there are some issues that tend to come up more often for this population than others.

"I don't think we can say they present with issues that are just limited to that population," says Scott Cummings, PT, CP, FAAOP, staff prosthetist and compliance director at Next Step Bionics and Prosthetics, headquartered in Manchester, New Hampshire. "Rather I think they have issues that the general population has but in more frequency. Issues like transportation issues, housing, comorbidities, and memory challenges. We see these across the board, but I find it's more prevalent with our senior population."

Despite their differences, the experts say there are many ways to help improve outcomes for these patients. Some ideas include:

•   Improve communication skills to get needed health information even if the patient is not always forthcoming.

•   Understand the challenges, both physical and otherwise, that this population is more likely to face and be adaptable as your patients age and change.

•   Be able to assess the technology needs for this population and make adjustments from patient to patient.

•   Have high expectations and keep patients motivated.

"It's all about trying to keep older patients healthy for as long as possible," Carroll says. "We want them to be able to live life to the fullest, and as care providers we all have a role in facilitating that for these patients."

Effective Communication

All patients have different communication styles, but seniors may have other compounding issues that prevent them from communicating their needs and concerns well. Older seniors, especially those who may not have family members to help, may have difficulty quickly or accurately answering all of the questions asked by practitioners. Others may not be forthcoming with important information about their health or home life, in fear that if they say the wrong thing, clinicians may question their ability to be independent.

"Many are afraid of losing their independence," Jaskiewicz says. "They are already seeing a loss of independence as they age, and this may be quickening that loss."

Speaking to seniors to get the needed information about their health and living conditions isn't always a straightforward process, says Jaskiewicz. He recommends patience and to continue the conversation with patients throughout the appointment in hopes that all of the necessary information may eventually come through.

"I find myself always talking with them, and something will come out later in the appointment that the patient might think is germane, but it really isn't," Jaskiewicz says. "[The information] doesn't always come out in a linear fashion. You have to really take the time and tease out what is going on. A lot of times, that can be a time-consuming process."

Understanding your own communication style is key, Carroll says. "I'm Irish and I am already aware that I will have to speak slower and in a tone of voice so they can understand me," he says. "Some are hard of hearing but shouting won't get the point across. You have to pick the level of volume that comes out of you. If you don't feel like you are getting the point across, maybe have another clinician come in and talk to them."

Clinicians should also ask about issues other than the patients' health that might impact their outcomes. For example, if they have transportation issues, patients may not be able to see their physicians or O&P clinicians as often as they should. It's helpful to understand these issues so clinicians can work with patients to either find a way around the obstacles or figure out how to work together within those parameters.

Physical and Other Challenges

Human bodies change with age, and O&P practitioners who are treating older patients should be aware of potential physical issues to keep an eye out for, the experts say. Some issues older patients may face are skin fragility, stiffer joints, and longer healing time if there is an injury.

Watching out for skin abrasions is very important, Jaskiewicz says. Since the skin tends to thin as people age, seniors can be more sensitive than the general population to a bad fit.

"Older skin is more fragile and you will probably see a higher incidence of diabetes in this population," he says.

If the skin is compromised, older patients may have longer recovery times as well, Cummings says.

"The older we get, our capacity to heal slows down," he says. "It's important for all patients to get the right fit. However, I don't think there's the amount of leeway with the population as there may be for others."

Physical and health challenges aren't all that this population is more likely to face. Lack of a support system or memory issues can impact outcomes as well, the experts say. Again, communication is crucial to ensure that practitioners are aware of challenges in these areas.

The issues may be difficult to perceive. A patient who has memory issues or difficulty taking care of themselves might not be willing or able to discuss those issues with their practitioner.

"We need to understand that someone at age 70 may be on top of it with instructions and three to five years later, they may be having significant memory challenges that could impact their quality of life and quality self-care they can provide," Cummings says. "If they are not following our instructions, or keeping appointments, or calling us in a timely manner when they have a problem, that can negatively affect the outcome."

One thing O&P professionals should always be aware of are changes that could impact the health of their patients or their ability to take care of themselves.

"It's well known that their health changes pretty quickly," Cummings says. "As they approach their final years, their health will often spiral downward."

Senior Population and Technology

Just because a patient is older, doesn't mean he or she won't ask about advanced technology. Today's seniors are more connected than ever and more likely than the generations before them to ask about the latest devices, the experts say.

"Earlier in my career, we could make assumptions that the older folks would stick with a basic design," Cummings says. "They didn't want a whole lot of bells and whistles. They wanted something consistent and reliable that could prove the test of time. Now, especially the younger half of the senior population, they are more likely to try something they heard about online or heard a friend talk about."

However, just like other populations, the needs for technology will vary from patient to patient.

"There are some pretty springy 70-year-olds bounding around and would easily qualify for a microprocessor knee,"
Cummings says. "There are others who may have comorbidities and other issues that mean they would have trouble meeting the functional threshold that would qualify them for a microprocessor knee."

The sad thing, he says, is that those patients may be the ones who would benefit the most from a knee like that. It could propel them to the next functional level, he says.

"It can be a self-fulfilling prophecy," Cummings said. "If only they would be eligible, they would improve their function. But they can't be eligible because they aren't functional enough."

Financial constraints are also more likely to impact a senior's ability to access a high-tech device, Cummings says.

"Even if Medicare will come up with 80 percent, their fixed income might not permit the other 20 percent," he says. "It's not a stretch to say that advanced technology tends to be more expensive than a standard design."

If a patient is eligible for technology, communication is key to help ensure he or she gets the right device. Older patients are more likely than ever to be educated about different technologies and clinicians should be prepared to help them find the device that is best for them, Carroll says.

"This population has access to all sorts of information. They can reach into their pocket, pull out their smartphone and find out more about technologies than ever before," he says. "They are coming in equipped with great questions and we have to be ready to guide them in the right direction. Just because they found something on the internet doesn't mean it's always right for them…. We don't want to fit advanced technology, and then have a patient not utilizing it. We have to be mindful about the approach that we take."

That approach might mean using something that is less-than-optimal but more likely to produce better outcomes, Jaskiewicz says. If the patient doesn't have the strength to don and doff the device, then it probably won't get used.It also won't get used if the patient doesn't have the cognitive ability to apply the technology, he says.

"Sometimes the patient just doesn't grasp what is going on with the technology," he says. "You have to ask yourself if there is a next best solution the patient can grasp. Is that optimal? It might not be, but sometimes you have to back off from the best or newest technology because the simplicity might work better for them."

Involving others, such as family members and other health professionals, may help the patient come up with solutions that provide technology he or she will use, the experts say. If for example, a patient with memory or physical challenges has a family member to help them remember to charge their device every night or can help them put it on every day, that might make the difference about whether it's a good device for them. Occupational therapists can also helpful in coming up with creative solutions.

"Their comorbidities might impact their balance or gadget tolerance," Carroll says. "We might reach out to an occupational therapist to help develop strategies about how they can use their devices."

High Expectations and Motivated Patients

One potential mistake O&P practition­ers should avoid is underestimating the abilities of their senior patients says Carroll. Just because they are older doesn't mean they can't go on to live full, active lives after an amputation or injury. It is the clinician's job to look past a senior patient's age and keep expectations high.

"When a patient comes in who is 90 years old and feels they want to go back to scuba diving and riding around on their jet ski, don't discount that because they are 90," Carroll says. "We have to keep an open mind. There are 90-year-olds out there who are doing that. With an open mind, a clinician can really facilitate a lot of advancement for these patients."

Sometimes that underestimation comes from the patient themselves. While some patients come in wanting to get back to their active lifestyles, others underestimate their own future abilities.

"Oftentimes a patient will come in and they think their life is over and their family thinks their life is over," Carroll says. "They think it's all downhill after this."

Having reached an advanced age without having the challenge of an amputation, patients may find the thought of adjusting to a new life disheartening and overwhelming. In cases like these, motivation is key, Carroll says.

"We have to come in with energy that we can pass on," Carroll says. "They need to be energized and we have to get them up and moving."

If a patient is feeling angry or sad, it's possible to use those feelings to help with motivation, he says.

"Maybe tap into that anger and harness the energy that goes into it," he says. "Like, ‘I know you are a fighter; you can do this.' Before you know it, that emotion starts to slip away and in comes a new healthier approach to their new beginning."

If clinicians are having a hard time motivating a patient, Carroll recommends bringing in other patients to talk to that person. Sometimes talking to others who have the same injuries or experiences can help the newly injured see beyond their current grief toward their future lives.

"Have a peer come and speak to them," Carroll says. "Ideally not a 20-year-old, but a 60-, 70- or 80-year-old peer. That typically results in good outcomes because the peer support helps them understand they can do it."

The pairs often become friends and that leads to continued peer support Carroll says.

The best motivation however comes from practitioners doing their jobs well and helping their patients start their new lives with devices that work best for them. The faster a plan is established and set into motion, the easier it will be on the patient, Carroll says.

"The good news is that the sooner we can get them up and moving, the more fulfilled they can become after their loss," he says. "Now instead of being in the unknown, they know what their future holds for them."

Maria St. Louis-Sanchez can be contacted at