ATLANTIC CITY, N.J. — Geriatric patients will be a significant focus for O&P practices in the coming decades, and aging patients require a specific brand of care, according to speakers at the annual meeting of the New Jersey Chapter of the American Academy of Orthotists & Prosthetists.
Heikki Uustal, MD, medical director for the Prosthetic and Orthotic Team at JFK-Johnson Rehab Institute and Gerald Stark, MSEM, CPO/L, FAAOP, senior upper limb clinical specialist for Ottobock Health Care, said the aging of the US population is leading to a different set of problems for patients.
“The aging population has special needs. We want to make sure we improve their function and maintain it for as long as we can, while maintaining quality of life,” Uustal said.
Both speakers emphasized the influx of geriatric patients expected in the near future.
“The geriatric population is changing,” Stark said. “Patients over [age] 65 [years] are going to double in 30 years, 20% of our population by 2020 will be over 65 [years] … And 80% of these people [will] have some kind of musculoskeletal complaints.”
Uustal said, “There are not enough [orthotists and prosthetists] to take care of all of them … to meet a doubling or tripling of that aging population over the next 20 years. And physicians are in the same position. That is why this is important.”
Caring for more geriatric patients also means going about business differently. According to Uustal, most people accumulate health problems over a lifetime. Younger patients can overcome many medical issues, but when patients age, their health problems tend to stick around longer and compound one another.
“As your patient ages, there are a bunch of problems, not just one or two,” Uustal said. “Successful geriatric management requires that we as medical professionals understand how all those problems interact. You need to understand how they are going to impact [the patient’s] mobility.”
For example, Stark recommends addressing the following potential issues an in initial evaluation: cognitive difficulty, falls, incontinence, dizziness, full body mass vision impairment and hearing impairment, all of which can affect a patient’s receptiveness to treatment.
Falls in particular are a major risk for the elderly, and are the leading cause of accidental death for people older than 75 years. According to Stark, fall-related injuries will have cost $32.4 billion by 2020.
He said, “What we need to look at is predictors for falls: abnormal gait parameters such as slow walking, short stride length, impaired range of motion, lateral center of gravity migration when they have a wide center of support – all of these predict the use of some sort of orthosis that we need to help them with their stability.”
Uustal said patients at risk of falling should be handled with care. Good communication is essential to build trust with geriatric patients because many times they already have developed their own methods of self-protection.
“They do what they are going to do because they are afraid to fall down,” Uustal said. “They recognize that they do not want to fall down so no matter what you say, they are going to do whatever they think is right to avoid falling down. They are going to adopt a gait pattern that they will avoid falls, they are going to hopefully use their medication appropriately to make them safe and stable, but they are going to make judgments on those things every day.”
Stark added that resistance to new treatment is common for older patients, and O&P practitioners should try to get the patient involved in the decision making process in order for them to accept any changes that need to be made.
“It is very difficult to get patients to change,” he said. “Sometimes they are not going to buy in [to the treatment] and if they are not going to buy in it is not going to happen. So the prosthesis or orthosis has to be made with them. They have to make certain choices.”
Other psychosocial issues can affect the way geriatric patients perceive their treatment and their changing bodies.
“Older people have a tendency to become more depressed, more anxious,” Stark said. “They have a greater fear of falling, they have lower scores on their mental health exam and they are very dependent on others. They are also concerned about cosmetic effects [of O&P treatment].”
Dementia can affect a patient slowly and cause them to forget instructions or to become upset more easily.
“Patients may even become combative and aggressive with you because they do not understand. They get confused,” Uustal said.
Being aware of the signs of dementia is important for O&P practitioners, who should make sure to write instructions down for these patients or make sure a family member knows what the patient needs to do to stay healthy.
“Some motivation, some caring, some coaching can go a long way for the patient,” Stark said.
Learning to work with geriatric patients is more important now than ever, Stark noted, because the health care industry is transforming: “The emphasis on greater health care volume and demands [is] changing what O&P is becoming. O&P, you have already seen it, is becoming more about volume processing, volume products, volume services. It is not about those one or two types of patients.”
“The take-home message is pay attention to your patients as they age,” Uustal said. “Make sure you understand what medical problems they are having … because many of these problems do not really go away completely. You have to truly assess which [problems] are permanent, which ones are interfering with their function. You have to reassess your treatment plan.” — by Amanda Alexander
For more information:
Stark G. Clinical overview of O&P geriatric management. Presented at: New Jersey Chapter of the American Academy of Orthotists and Prosthetists Annual Meeting; Nov. 5-7, 2014; Atlantic City, N.J.
Uustal H. Geriatric mobility, Keeping the aging O&P patient moving, the physician’s perspective. Presented at: New Jersey Chapter of the American Academy of Orthotists and Prosthetists Annual Meeting; Nov. 5-7, 2014; Atlantic City, N.J.
Disclosures: Stark and Uustal have no relevant financial disclosures.