Treating the Whole Patient

The coming years will take their toll on the O&P profession as baby boomers begin to flood offices in record numbers. The challenges that accompany this influx are enormous, ranging from understanding comorbidities to managing cognition and mental health impairments and the not-to-be-overlooked prosthetic fitting.

“There is more to the patient than what is happening at their prosthesis,” Gerald Stark, CP, LP, FAAOP said about working with this population.

Evaluating patients thoroughly and taking additional health concerns into consideration can help determine the prosthetic components and suspension methods selected for individuals.

Mental health challenges

“I think the younger practitioners need to understand what is going on, and that probably one of the biggest hurdles you need to deal with when working with the senior population is the psychological aspects,” Thomas Karolewsi, CP, FAAOP said.

Practitioners need to consider the patient’s state of mental health. Karolewski explained that he often sees older patients who have undergone an amputation later in life as a result of diabetes. Coupled with existing comorbidities, these patients commonly fall into depression.

Doctor treating patient“After all these years, all of a sudden they start seeing that they are missing a limb. It has got to be extremely shocking and traumatic on their psyche,” he explained. “So a lot of them get severely depressed. What you are trying to figure out is how to provide them with some hope to start getting excited; some incentive to get motivated, and that is probably one of the biggest struggles in working with senior citizens.”

Mental ability often starts to diminish within the older population, leading to comprehension problems. Did the patient understand the instructions you have provided? How can you be certain?

Being aware of issues concerning cognition will help you to decide if a family member or health care worker should be present during a fitting to learn the appropriate steps to either remind the patient, or help with care.

Physical limitations

The physical limitations that often afflict the older population can severely alter strength and balance, not only of the arms and legs, but of smaller muscle groups that are crucial to carrying out activities of daily living, especially for prosthetic users.

Stark cited the findings in “Geriatric Conditions and Disability: The Health and Retirement Study” conducted at the University of Michigan by Christine Cigolle, MD, MPH and Caroline Blaum, MD, MS as reason for delving further into the existing health conditions of aging patients.

The study analyzed the results of more than 11,000 participants and found that 50% of adults aged 65 and older had at least one of the following conditions: cognitive impairment, falls, incontinence, low body mass index, dizziness, vision impairment or hearing impairment.

In their personal practice and experience, Stark and Karolewski have seen the effects of these and other impairments firsthand.

Stark considers finger strength and dexterity to be critical functions to properly use a prosthetic device. Without these, certain devices may be difficult or nearly impossible to use.

“How do you measure dexterity or the ability to move quickly with your fingers? The power grasp is one of the last things to leave you but the dexterity is one of the first things to leave you, so you have to look at the entire patient,” Stark told O&P Business News. “It’s important to remember that the suspension is impacted by their ability to use their fingers and also the quality of their skin condition because rarely is the interface separate from the suspension method. As clinicians we need to evaluate more than what is happening at the limb.”

Skin frailty is another serious consideration when choosing prosthetic components. Devices that will cause additional harm to the skin, resulting in misuse or dismissing the device entirely, should be excluded from consideration.

“The geriatric patient has so many more things entering into the equation,” Stark said. “When you look at that study at the University of Michigan about the number of factors that affect people 65 and older … we need to look at all these different things and make a checklist. That’s just as important as taking a measurement or an impression — in some cases even more important because it influences how you take the impression.”

Understanding the Role of the Caregiver

Many geriatric patients will be cared for by others as they age. Clinicians should consider the needs of health care providers — whether they are family members or health care workers in an elder care facility — when choosing appropriate components, as well as the overall needs of the patient.

Clear directions

It is best for caregivers or home health care providers to be present at prosthetist appointments to become educated on the components and proper wearing to ensure safe and correct prosthesis donning and doffing.

“If someone puts something on upside down and backwards, that means I didn’t design it so that variability is removed,” Stark said. “I need to think about how I eliminate that. Either I affix it to the leg in a certain way or I label it better but you can’t really blame the caregiver too much. You’re the expert.”

If clinicians do label components it is also important to keep in mind who will be working with the device at home. Label components using common language such as front and back so as not to confuse people who are not as familiar with industry terminology.

“We have to use the language they use and instruct them very carefully,” Stark said.

Ease of use

“For a geriatric patient, pushing a limb on is fairly difficult for a caregiver,” Stark said. “Sometimes we have to loosen up the fit which is actually compromising the biomechanics of the socket, but to get it to be worn and worn consistently we have to make sacrifices.”

The patient often senses and reacts when the caregiver is frustrated, so easing tension is important. Also important is listening to the caregiver’s suggestions about the patient’s capacity for activity.

Reverting to a lower technology is not always a sign of failure. Sometimes it is all that patient and caregiver need.


Fitting for their needs

Once clinicians address the underlying physical and mental health concerns for each patient, that information can be used to decide what prosthetic components would be most effective for each individual.

“Try to make the effort of putting on a prosthesis and ambulating less strenuous to them,” Karolewski told O&P Business News. “The simpler that you make a system for seniors, you find that they will be more compliant with their wearing schedule.”

Even though newer and better technology is available, it may not be appropriate for the patient you are trying to fit. It might be easier for an older person to use an arguably out-of-date technology because it has a simpler design. The same can be said for liners and sockets.

It might be easier for an older person to use an arguably out-of-date technology because it has a simpler design. “You have those considerations as people start to lose muscle tone,” Karolewski said. “Instead of a roll-on liner and going with a vacuum system, maybe all they want to do is put on a foam insert and slide into the socket so they can get up and go to the bathroom at night.”

This is also helpful for patients with arthritis who may not have the dexterity to don a liner comfortably, Karolewski added, explaining that while the liner might be more comfortable, some patients would rather forego that comfort for the simplicity of a foam liner that allows them to slip into a self-suspending device.

“We have to find what things help optimize fit,” Stark said offering some suggestions. “Finger loops, Velcro or the use of another type of suspension method. We need to objectively search for a better way of having that patient don that prosthesis.”

Stark is happy to see the way the market is moving. Without sacrificing the innovation of new technologies, some component makers are beginning to revisit older designs as this population comes to the forefront.

“We are starting to see the evolution of easier to use suspension methods,” he said. “The manufacturer is improving the materials so … they have downgraded the technology, but they have upgraded the materials.”

Recalling the words of a former Northwestern director of engineering and research, Dudley S. Childress, PhD, Karolewski said, “It’s not a matter of finding high technology or low technology but finding the right technology for the individual.”

For more information:

  • Cigolle C, Blaum C. Geriatric conditions and disability: The health and retirement study. Ann Intern Med. 2007;147:156-164.

Jennifer Hoydicz is a staff writer for O&P Business News.

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