– by Terrence P. Sheehan, MD
When it comes to prosthesis use for older amputees, I practice with the premise that age is irrelevant. I know this might sound naïve and unrealistic, but I have had one after another older amputee prove wrong those who thought that they couldn’t do something.
Take Mrs. W, for example. I met her when she was 83. At that time, she was devastated after having a left below-knee amputation due to peripheral vascular disease (PVD ). When discussing with her the possibility of her using a prosthesis, I was most concerned about her residual limb, not her age. She is petite with beautiful, but thin, delicate skin, and I recall trying to prepare her for the strong possibility that once she started using the prosthesis, the skin might open. If it did, I was concerned that she might have to have revision surgery on her residual limb to smooth and pad the pointed bone.
Mrs. W is now 88, and Monday through Friday, she walks with her cane throughout the hospital as a volunteer. She also recently brought back four “Peace” T-shirts from her trip to Israel for my boys. During all of this activity, her skin, as well as the rest of her, has held up just fine.
Mrs. W is not the exception; in fact, she represents a group of “older” amputees whom I have had the pleasure to follow and whom I have learned a lot from.
Another patient, Mr. G, was in the waiting room having a “discussion” with his wife one day when I walked by. He is a 78-year-old who had a right above-knee amputation because of PVD .
I remember calling his vascular surgeon after his surgery to ask a question about his surgery site. The surgeon asked me if I thought Mr. G could use a prosthesis. I told him that Mr. G had been hopping around the therapy gym on one leg using a walker and that I didn’t think he would have a problem using a prosthesis.
Just as I suspected, he did very well with a computerized above-knee prosthesis. In fact, the “discussion” Mr. G and Mrs. G were having that day was about the fact that he was back plowing his and his neighbors’ fields. It seems his prosthesis was getting so dirty and scratched that Mrs. G was planning to “tell the doctor.” What a great outcome for them to tell me about and another important lesson for me and his surgeon!
Mrs. L is another delightful 85-year-old with PVD , who had a left below-knee amputation. When I met her at admission to the rehabilitation hospital, she was dependent on oxygen from a tank. She was shy, modest and very uncomfortable about being in the hospital with so many people fussing over her. She was also depressed, unable to look at or touch “that thing” (her residual limb), and on pain medication.
Her dedicated daughters were saying, “Please help. Our father who is 92 years old needs her at home. She was his caregiver and the love of his long life – the one who makes his heart beat faster.” Of course, their home has a billion and two stairs.
The insurance company demanded that I “send” her to a nursing home, and I didn’t have a leg to stand on, except for the fact that I had a patient telling me that she wanted to try to use a prosthesis to walk again. I stuck to my guns against the insurance company and stood with my patient and her family.
Fortunately, Mrs. L stayed in the hospital until she was able to get back on her feet and return home, much to the chagrin of the insurance case manager. Eight months later, Mrs. L ambulates with a rolling walker with recommended supervision on level surfaces and stairs. She needs some assistance getting her prosthesis on, but we have trained others to help her. She takes no pain medication and uses no “tank” oxygen; she also quit smoking after 60 years. Each follow-up visit brings new surprises, and I see glimmers of the young beauty her husband fell in love with. Fortunately, enough people had the vision to keep her out of a nursing home and at home with her beloved family.
The decision to use a prosthesis for older amputees depends first on their cognition, or their ability to learn, remember things, and solve problems. Someone without the proper mental capacity would only be appropriate for prosthesis use if he or she had a personal care attendant who could learn how to use the prosthesis and monitor all of the issues associated with its use.
Linked to the person’s ability to think is his or her motivation to want to use a prosthesis. Indeed, the motivation factor is essential in the decision to initiate the prosthetic process. Using a prosthesis takes the energy, patience, and time of the patient and a number of professionals (prosthetist, therapists, doctors, etc.) who work with him or her. It is also an expensive process. The patient, whether old or young, therefore, needs to be on board before beginning the process if he or she is to be a successful prosthesis user.
Outcomes from prosthesis use vary, depending on the initial goals of the patient and the rehabilitation team orchestrating his or her care. A prosthesis can be used for everything from cosmetic purposes (to make the person “look better”) to the full range of functional purposes, including long-distance running. For the older person with limb loss, the members of the rehabilitation team formulate the goals based on their initial assessment of the patient and their vision of the patient’s abilities and potential. This largely depends on the patient’s other medical conditions and most recent functional capacity.
If a patient has a severe heart condition, trying to use a prosthesis can add additional stress to his or her cardiac system and result in damage and/or death. Unfortunately, there is no crystal ball to reveal if someone will have an untoward cardiac effect. The important thing is for the physiatrist or other qualified physician to acknowledge these medical issues and discuss the potential risks of using a prosthesis with the patient and his or her supports. The decision to proceed then belongs to the patient who has been appropriately advised. He or she can then initiate the prosthetic process with eyes open, risks understood, and a realistic agreed-upon plan.
I try to partner with my patients, not parent my patients. I am very much in favor of trying and proceeding slowly. The results I have witnessed with older patients learning to use a prosthesis have been nothing short of breathtaking.
I have a couple of more stories to tell about my older patients. Like most of my older patients, they have complex medical profiles, which is a nice way to say that they have chronic heart disease, lung disease, kidney disease, vascular disease, AND diabetes all at once.
The first is Mr. T, who is 55 and has diabetes, which has resulted in renal failure and reliance on dialysis. Mr. T also has severe PVD and a new left below-knee amputation. Two days before he was re-admitted to the rehabilitation hospital for initial prosthetic training, he had a heart attack. Unfortunately, there were no warning signs, which is not unusual for a person with diabetes. If he had been in the therapy gym using a new prosthesis instead of at home when he had his heart attack, we might have too quickly and unfairly blamed it on his use of the prosthesis.
Still, if Mr. T survives this event, he will most likely want to try to use a prosthesis, and we will get the chance to discuss it again. He is a very motivated man who wants to remain independent, and his risks are there with or without the prosthesis.
Another patient had a cardiac arrest in the therapy gym after his amputation but before the prosthetic phase began. He survived and did well enough to insist on learning to use a prosthesis despite his severe nonoperable heart disease. This was three years ago. Today, he does well with a prosthesis and is thrilled that he can join his friends on the golf course; whether he plays and uses the cart depends on the day. He decided to proceed with prosthetic training knowing that he could drop again from his heart disease. (I prayed a lot).
The medical literature tells me that the “predictors for poor prosthetic fit” for older amputees are advanced age, cardiovascular disease, dementia, and above-knee amputations. I’m not in disagreement with the stats, but I would argue that each case should be looked at as an individual case, that the options should be presented to the patient, and that the wishes of the patient should be seriously considered.
No doubt, a prosthesis can be a danger for some people; it can, for example, injure skin or lead to a traumatic fall if the person is not able to use it safely after training and education. It is important, however, that those providing care and direction after limb loss offer the use of a prosthesis as an option to those who can use it safely.
It’s also important that patients have multiple evaluations separated by time. Although an older person may be quite debilitated after a complex surgery and be unable to benefit from a prosthesis at that time, he or she might be ready for a prosthesis after therapy and a longer recovery period.
I have never met an older person who told me that he or she did not want to try. This is important in light of the medical literature that says that older amputees who are referred to an amputee rehabilitation program have a 74 percent success rate compared to a 36 percent success rate for those who are not referred. “Well, then,” you might ask, “why aren’t all of them referred?” The largest reason for nonreferral is death, which accounts for approximately 50 percent of those not referred. The other 50 percent are the ones I’m concerned about, however, especially if they are not referred because some “nearsighted” caregiver does not have the vision to understand the potential that older amputees still have. If that’s the case, it is a tragedy. ?
About the Author
Terrence P. Sheehan, MD, is the medical director for Adventist Rehabilitation Hospital of Maryland and the director of its Amputee Rehabilitation Program.
Disclaimer: The following information is provided and owned by the Amputation Coalition of America and was previously published on the website http://www.amputee-coalition.org or the Coalitions Newsletter, inMotion.