 The Special Needs of Geriatric Patients in O&P:
Practitioners address the challenges and rewards of treating the geriatric patient
by Rachel Kelley
The geriatric patient presents the O&P practitioner with a comprehensive and sometimes complex set of issues. In addition to multiple and often chronic medical conditions, such as obesity, diabetes and the additional trauma of losing a limb, the older patient can be confronted with the loss of independence due to cognitive decline and other physical disabilities. This overwhelming sense of loss can trigger depression and loneliness. Working with elderly patients also can be a rewarding and joyous experience. They bring with them a unique wisdom that can only belong to a person who has lived many years. Through interviews with practitioners who work extensively with geriatric patients, this article addresses the special needs, challenges and rewards of working with the elderly in O&P.
 Special Needs and Challenges
Geriatric patients provide unique challenges for orthotists and prosthetists. The older patient often comes to the practitioner with multiple medical problems that must be considered when being fitted for a prosthesis or orthosis.
John Schulte, CPO, FAAOP, mid-Atlantic clinical vice president for Hanger Prosthetics & Orthotics in Annapolis, Md., said the problems can range from cerebral vascular accidents to arthritis, as well as obesity and diabetes.
“They also have visual and hearing impairments that can make it difficult for them to don and doff devices and understand instructions,” he said.
Oftentimes, the older patient has pulmonary disorders, such as emphysema, that limit their ability to walk long or even short distances. This can hinder the rehabilitation process. They usually have loss of skin turgor and are not able to take the pressures imposed by a socket or orthotic device such as an ankle foot orthosis (AFO).
“Moreover, because of diabetes and vascular insufficiency, they oftentimes have insensate feet,” said Schulte. “They can have a foreign body in their shoe that may lead to open sores and possibly infections. So custom shoes and orthotics
are essential.”
Additionally, obesity and a sedentary lifestyle can cause pressure areas, said Schulte.
“Just the redundant tissue in the posterior
aspect of a transtibial prosthesis can compromise circulation, leading to pressure areas and sores,” Schulte said. “It is a compounding type of issue.”
Sally Lamb, CP, of Coastal Orthotics and Prosthetics in Newport Beach, Calif., sees many patients, particularly elderly women, who have osteoporosis
with compression fractures.
“We fit them with corsets and occasionally a C.A.S.H. or Jewett orthosis,” she said. “Sometimes we will use custom body jackets depending on the severity of the fractures.”
 Lamb also sees many older people who have flat foot deformities,
which often lead to valgus knee problems and premature wearing of both hip and knee joints. She will use a high-back arch support to manage this disorder.
“It is more aggressive in cupping the calcaneous and providing medial lateral stability,” she said.
She may also incorporate custom molded articulated ankle AFOs. This allows free motion at the ankle yet provides superior medial lateral support
to control ankle and foot motion. Occasionally, a Richie brace may be used for this diagnosis.
The most difficult disorder to brace is thoracic kyphosis, frequently seen in osteoporotic women in their 70s and 80s, said Lamb.
“We often use a soft thoracic lumbosacral
orthosis (TLSO) for that, but it is hard to reverse this diagnosis when someone has weak abdominal and upper thoracic muscles.”
Lamb added that she is constantly addressing peripheral neuropathy problems through education on proper footwear and visual inspections.
Kevin Carroll, MS, CP, FAAOP, national vice president of prosthetics for Hanger Prosthetics & Orthotics, frequently educates his patients regarding conditions related to foot problems. Oftentimes, he said, patients will come into his office who have peripheral neuropathy and not even realize there is a problem. They may have visited their physician and the physician didn’t take the time to remove the prosthesis and examine the residual limb.
“I see this all the time,” said Carroll. “An older patient will tell me everything is fine, yet when they take off the prosthesis, they have a big sore. They cannot see it due to poor vision, or they are unable to feel the ulcer because of the neuropathy.”
 Choosing the Appropriate Device
There are specific criteria when considering which type of device – whether orthotic or prosthetic – when working with the elderly.
Loren Rojek, CPO, president of Fountain
Valley Orthotics and Prosthetics in Fountain Valley, Calif., said that for the prosthetic patient, good hand strength and dexterity is important.
“If they don’t have those, we become limited on what types of suspension we can use,” he said. “We tell them their first prostheses is their interim prostheses. The residual limb does atrophy due to nonuse. After the other conditions such as diabetes have been addressed,
they become better physically and are able to do more activities. We look at what their potential is and use the appropriate components.”
Initially, said Rojek, function is important to the patient. They want to walk. After they have the prostheses for a while, they start focusing on cosmesis.
Activity levels are another factor.
“If a patient is highly active, we wouldn’t want to cut them short and give them improper componentry,” he said. “If they are lower activity, we want to go with certain guidelines that have been set down and give them the most appropriate components without charging Medicare or their insurance company additional fees for something that will not be used.”
 From an orthotic perspective, Rojek again looks at hand dexterity and strength.
“If they have a stroke and they are paralyzed on one side, we want to make sure the straps are conveniently located toward the middle of the body where they put the buckle or loop in. Otherwise, they will have a hard time stretching from one side to the other.”
Rojek added that many times older patients will want to use their existing shoes, and that can be a challenge when getting an AFO. They don’t want anyone to see they are handicapped.
“Sometimes they think having an orthosis will make them look handicapped even though they may be dragging their foot without it.” To make the device appear less conspicuous, Rojek will look at the outerwear, e.g., skirts and pants, and if, for example, an AFO is prescribed, the color of the device may be changed to match the clothing.
Raymond Francis, CP, chief prosthetist for Ohio Willow Wood in Mount Sterling, Ohio, uses lightweight components for the geriatric patient.
“They are usually weaker than the nongeriatric,” said Francis. “Their lack of strength becomes an issue, so a prosthesis needs to be as light as possible.”
At the same time, Francis said, function or strength cannot be sacrificed in attempts to make the device lighter.
He recognizes that fit is an important factor of lightness.
“By that I mean if the socket fits really well, it feels like it is a part of the body. This transfers into less weight being perceived by the patient as well as energy expenditure required by the patient.”
Psychological Issues
Because older patients have often experienced illness, death of loved ones, impaired function and loss of independence, the elderly are at a high risk for depression. The cumulative effect of these negative experiences can be overwhelming. Complicating
a diagnosis of depression in the elderly person may be Alzheimer’s disease or other dementias, medications or sleep disorders.
“Dementia will sometimes mask depression in the older patient,” said Schulte. “Many times, because they are in a rehabilitation facility or staying with loved ones, a diagnosis of depression is not made and they don’t get the necessary treatment.”
Carroll believes there is a stigma about depression among the older population. They feel ashamed and embarrassed to admit there may be something wrong.
“You have to be discreet and cautious
about how you introduce the idea of seeing a counselor,” said Carroll. “The best setting is to introduce the counselor at the rehabilitation
facility where everyone else is seeing a counselor too.”
It may get to a point where the older patient feels suicidal. Carroll
believes it is important for the clinician to identify whether this may be true.
 “Oftentimes, practitioners are not trained in how to deal with suicidal patients,” he said. “Thoughts of suicide are frequently hidden. The clinician needs to be educated on how to approach this issue.”
For a variety of reasons such as loneliness and loss of independence,
the older patient can experience anxiety and fear. There is a scenario that often takes place with the geriatric patient, said Francis. The children of these patients frequently have moved away. The parent has lost a limb, which brings back the children temporarily.
“They fuss over the parent, which the geriatric patient enjoys. The parent misses not having their family around. It doesn’t take the geriatric patient long to figure out that the quicker they get well, the quicker their children will return to their own home.”
When Not to Fit a Prosthesis
There are circumstances when it is not in the patient’s best interest to fit a prosthesis. According to Schulte, the patient must be able to understand the prosthesis itself.
“Our goal is to get everyone up and back into society,” he said. “If the person is not cognizant enough to understand how to use the device, or has a hearing impairment that prevents him or her from hearing the click of the lock in a pin suspension system, we can actually cause them to break a hip.”
Moreover, if the elderly patient lives alone and does not have good home care, they are left alone trying
to cope with the situation. They may get exhausted in attempts to put the device on by themselves.
“The only time we feel it is not appropriate
to fit a prostheses is when a patient cannot safely get out of a chair and do a pivot transfer,” said Francis. “If a patient can’t do that by himself or herself, then we raise an eyebrow as to whether he or she is a prosthetic candidate.”
Basically, if a patient has the ability to get out of bed and transfer, they more than likely will be fitted with a prostheses.
 Education and Rehabilitation
Education and follow up are crucial components of treatment.
Schulte believes all clinicians are educators whether they are teaching someone how to tie their shoes using a special Velcro lace or donning and doffing a prostheses.
“A lot of times practitioners need to realize that the geriatric patient may not be comprehending what they are trying to communicate,” said Schulte.
Schulte and his staff will have the patients watch videos or send them home with written information.
“Every time we have a follow-up visit, we review and make sure they understand
how everything works,” he said.
Additionally, the diabetic patient who is obese, for example, may not be able to see their feet.
“So we teach them how to look at the underside
of their feet with a mirror, make sure that they understand the importance of keeping their feet dry and to check their shoes everyday for foreign objects, especially if they have children in the house. They can end up with little matchbox toys, jacks or marbles in their shoe and not realize it.”
Carroll emphasized the importance of a team approach in the rehabilitation process. Everybody must be on the same page, he said. Everyone, including the physical therapist, prosthetist and physician, must collaborate and include the patient and family in the plan of care.
Francis said he and his staff like to see the elderly patient for follow-up visits in the early stages because their progress is somewhat slower than the younger patient. Often, transportation
is an issue.
“Many do not drive or don’t want to drive, especially if they have a limb loss. They are afraid, so they have to depend on someone to bring them,” said Francis.
Schulte said dealing with rehabilitation in the geriatric population
is a world all its own. The physical therapist and occupational
therapist must focus on getting them up and moving. This will help to prevent pulmonary edema and pneumonia.
“It must be a team effort,” he said.
Challenges and Rewards
It can be challenging to work with the geriatric population, but it can also be rewarding. The older person tends to have more medical issues and their cognitive impairments can make it difficult for them to comprehend and follow through with instructions.
“Their inability to understand can pose difficulties,” said Schulte.
However, Schulte enjoys seeing older patients increase their level of activity after being fitted with a device.
“Whether it is an AFO to control the damage done from a stroke, a hip abduction orthosis that keeps them from getting
the chronic pain from a dislocation or just a prosthesis that enables them to get up and about, this part of my work is extremely satisfying.”
 Carroll said it is a challenge to make certain that their skin can hold up to the use of a prosthesis.
“Gel liners have made a huge difference, as well as the use of modern components,” he said.
Carroll enjoys talking with elderly patients. Their stories, he said, can keep you going forever.
“We can learn a lot by listening to them,” he said.
Lamb also enjoys listening to her elderly patients.
“I like to chat with them. I see the young person underneath the 85-year-old patient.”
Lamb said she can also lose patience with some of her older patients. Sometimes they do not listen or will not trust the practitioner.
“You can’t always gain their trust,” she said. “They gather an initial opinion when they first meet you. You have to win them over with your knowledge, information and presentation.”
Francis finds that older people generally appreciate the things that are done for them, whereas young people seem to expect it.
“I call it old-fashioned respect,” he said. “I get great joy from knowing that I have helped them.”
Francis also realizes that some of his older patients have gotten
to the point where they do not understand simple instructions.
“You know they are going to go home with this prosthesis and some of the instructions that appear simple will become mentally taxing for them. They just don’t remember what you have told them. It is disheartening,” said Francis.
Optimizing Chances for Success
Lamb believes that giving the older patient the time they need, being patient and listening are crucial components of successful
treatment outcomes.
 “Quite often with our clients, they have been to a physician and they are not sure why they are seeing us. They may not even understand what their diagnosis is, so we explain that to them in detail.”
Oftentimes, they will have expectations that are not realistic or they may be pessimistic about the outcome, said Lamb.
“First we have to explain things properly so they are understood,”
she said. “When we repeat ourselves, we are not always listening to what we are saying as a practitioner, so it is important that we listen to ourselves and pay attention to how it could be misunderstood. We do a lot of reinforcement.”
Schulte emphasized that the older person must have the cognitive ability to understand what is happening.
“They must be able to check the device for wear and a positive fit. They also need to have some kind of support system or advocate, either from a loved one or a rehabilitation center – anybody who can give us feedback. We put our phone number
on the device. That way, whomever is taking care of that patient can call us with any questions.”
Success, according to Francis, depends on the particular patient’s motivation. If cognitive and medical issues are minimal,
they will rehabilitate quickly.
“Usually if there is a dedicated spouse, this will occur. If there isn’t, it will take longer.”
Advice to New Practitioners
Rojek does his best to really listen to the patient. If they don’t want something the first time he sees them, he does not force it on them.
“They will never be happy with the device if we do that,” he said. “They need to make the decision.”
Schultz believes treating the geriatric patient, in many ways, is not unlike treating a child. “The child believes you and trusts you. That is the same with the geriatric patient. They are often frustrated with their disabilities. Do not write them off. There is a lot of experience
and willingness to talk in the geriatric patient. He or she is a young person in an old body. Try not to walk past them when they are sitting in the hallway in a nursing home. Take a minute and talk to them. It can make a huge difference in their life.”
Future of Geriatric Care
According to the World Health Organization, there were 600 million people age 60 and older in 2000. By 2025, this number will increase to 1.2 billion. By 2050, 2 billion people will be age 60 or older. Today, about two-thirds of all older people are living in the developing world; by 2025, it will be 75 percent. It is apparent that people are living longer.
In 1900, life expectancy at birth was about 49 years. In 1997, life expectancy at birth was 70 years for women and 74 years for men. Currently, people who survive to age 65 can expect to live an average of 18 more years. As people age, chronic diseases
contribute to declines in functioning and the increased need for prosthetic and orthotic care.
“The patients we see are getting older and limbs are being amputated later,” said Carroll. “There is going to be a huge growth in older adults using prosthetic systems.”
Schulte thinks the need for geriatric specialists will increase.
“There will be a unique need within the O&P field for these specialists,” said Schulte. “They will deal with the many specific issues associated with geriatric care such as lighter components and complex medical problems affecting O&P treatment and follow up of this population.”
For more information:
Copyright 2004, SLACK Incorporated. Revised 24 February 2004. Reprinted by permission.
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