As a doctor and medical director of a rehabilitation program, I strongly believe that age does not matter when it comes to prostheses. I have treated many older amputees, who accomplish things others thought they could not do. I’d like to share some of their stories along with lessons learned.
Mrs. W was 83 years old when I met her. At that time, she was devastated after having a left below-knee amputation due to peripheral vascular disease (PVD ). When we talked about a prosthesis, I was most concerned about Mrs. W’s residual limb and not her age. This is because of her beautiful, but thin and delicate skin. I warned Mrs. W that her skin might open once she started using the prosthesis. If so, she might need revision surgery to smooth and pad the pointed bone on the residual limb.
I am pleased to report that Mrs. W is now 88 years old. Although she walks with a cane, Mrs. W volunteers in the hospital 5 days a week. She also just went to Israel and brought back “Peace” t-shirts for my 4 sons. Mrs. W’s skin, as well as the rest of her, has held up just fine. Mrs. W is not an exception, but part of a group of older amputees I have had the pleasure to follow.
Mr. G is a 78-year-old man who had a right above-knee amputation because of PVD. I remember talking with his vascular surgeon after surgery about whether Mr. G could use a prosthesis. I told the surgeon that Mr. G had been hopping around the therapy gym on one leg using a walker. I didn’t think he would have a problem using a prosthesis.
Just as I thought, Mr. G did very well with a computerized above-knee prosthesis. In fact, one day I overhead Mr. G talking with his wife. They were discussing the fact that he was back to plowing his and his neighbors’ fields. It seems his prosthesis was getting so dirty and scratched that Mrs. G was concerned about how to tell the doctor. What a great outcome for them. And another important lesson learned for his surgeon and me!
Mrs. L, a delightful 85 year-old woman, had a left below-knee amputation due to PVD. At that time, she also was dependent on oxygen from a tank.
I met Mrs. L when she was admitted to the rehabilitation hospital. At that time she was shy, modest, and did not like being with so many people “fussing” over her. Mrs. L was also depressed, on pain medication, and said she did not want to look at or touch “that thing” (her residual limb).
Mrs L’s daughters asked me to help, saying that their 92-year old father needed her at home. She was his caregiver and the love of his long life – the one who makes his heart beat faster. But their home had “a billion and two” stairs, the daughters said.
The insurance company wanted me to send Mrs. L to a nursing home. I did not agree as Mrs. L wanted to try walking again with a prosthesis. I convinced the insurance case manager to let Mrs. L stay in the hospital until she could return home.
Eight months later, Mrs. L ambulates with a rolling walker. A trained caregiver supervises her walking and helps put on her prosthesis. Mrs. L now needs no pain medication. She also quit smoking after 60 years and no longer needs “tank” oxygen.
Each follow-up visit with Mrs. L brings new surprises. I now see glimmers of the young beauty her husband fell in love with. Fortunately, enough people had the vision to keep Mrs. L out of a nursing home and at home with her beloved family.
Factors to think about when making a prosthesis choice
There are many factors to think about when older amputees choose whether or not to use a prosthesis. These factors include:
- Cognition - the ability to learn, remember, and solve problems. A person with cognition problems might only be able to use a prosthesis if others help. A prosthesis may not be a good idea if no one can help.
- Motivation - whether or not a person wants to use a prosthesis. Patients, whether old or young, need to be “on board” from the start if they are to be successful prosthesis users. Motivation is needed when choosing whether to use a prosthesis and learning how to do so. Motivation is also needed when working with doctors, prosthetists, and therapists.
- Goals – reasons why someone wants a prosthesis. Goals can be cosmetic, to make a person feel like he or she looks better. Goals can also be to increase function, such as for long-distance running. The rehabilitation team assesses each older adult with limb loss and looks at the person’s abilities, potential, and goals.
- Medical history . Sometimes a person has a complex medical history, which means he or she might have chronic heart disease, lung disease, kidney disease, vascular disease and diabetes – all at once. These problems affect whether or not to use a prosthesis. For instance, a prosthesis may cause damage or death when a person has a severe heart condition. This is due to the extra stress on a person’s cardiac system. There is no way to know ahead of time if something like this will happen. The doctor and patient should talk about medical problems and risks of using a prosthesis. Together, they can agree on a treatment plan.
Here are some success stories about patients with complex medical histories who use prostheses.
Mr. T is 55-year old man who has diabetes. He is in renal failure and needs dialysis each week. He also has severe PVD and a new left below-knee amputation. He had a heart attack two days before he was to start prosthetic training. There were no warning signs of this heart attack, which is common when a person has diabetes. If Mr. T had been in the therapy gym using a new prosthesis instead of at home when he had his heart attack, we might have blamed it on his use of the prosthesis. And we would have been wrong.
Mr. T most likely will want to try using a prosthesis again. We will talk about his health risks. He is a very motivated man who wants to remain independent. His risks are there with, or without, the prosthesis.
Mr. A, an older man, had a heart attack in the therapy gym. This happened after his amputation but before the prosthetic phase began. He survived and did well, even though he had very serious heart disease. Mr. A still wanted to learn how to use a prosthesis.
Three years later, Mr. A does well with a prosthesis. He is thrilled to still play golf, though he decides each day whether or not to use a cart. Mr. A made a choice to go ahead with the prosthetic training even if it means he might die from heart disease. As his doctor, I pray a lot.
Lessons learned from my patients
Medical text books discuss “predictors for poor prosthetic fit” for older amputees. These predictors include advanced age, cardiovascular (heart) disease, dementia (cognition problems), and above-knee amputations. While I do not disagree with these predictors, I strongly believe that we need to look at each person. This means taking into account each person’s wishes and goals.
No doubt, a prosthesis is a danger for some people. For instance, a prosthesis can injure skin or lead to a traumatic fall if the person does not learn to use it safely. But doctors and therapists still need to offer a prosthesis as an option to those who can use it safely.
It is important to assess patients with limb loss more than once. For instance, an older person may be quite frail soon after surgery and not able to benefit from a prosthesis then. But, after weeks or months of therapy and recovery, he or she might be ready for a prosthesis.
I partner with, not parent, my patients. This means trying new things and going slowly. Over the years, I never met an older person who told me that he or she did not want to try. Medical texts say that older adults who are referred to an amputee rehabilitation program have a 74 percent success rate. This is compared to a 36 percent success rate for those who are not referred. You might ask why all older adults are not referred. About half the time, this is because a “nearsighted” caregiver does not see the potential that older amputees have. If that’s the case, it is a tragedy. The results I have seen with older patients learning to use a prosthesis have been nothing short of breathtaking.
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.