Older people with amputations

Original Editor - Rachael Walton-Mouw as part of the WCPT Network for Amputee Rehabilitation Project

Top Contributors - Sheik Abdul Khadir  

Introduction

The Geriatric Amputee can describe two types of people - someone who undergoes a lower extremity amputation (LEA) after the age of 65, and someone who had a LEA at a younger age, but is now over 65. Because 75% of all LEA occur in patients over 65, this article will refer to this population of geriatric amputees[1] The most significant distinguishing factor of the Geriatric Amputee is their overall health and function prior to having an amputation. As one ages, there is an increased frequency of having a single chronic diseases; and subsequently, an increase in co-morbidities effecting the health and function after an amputation.[2]

Amputation at any age is a significantly disabling event. However, when a geriatric patient undergoes a LEA, it can have devastating - even fatal - consequences. In a study by Fletcher, et al (2001), the median survival was 1.5 years after an amputation, which is significantly less than the expected survival rate of 7.5 years for age-matched controls. There is a significant increase in 30 day mortality rate related to age and number of co-morbiditis [3]. It is estimated that approximately 13% of geriatric patients will die within 30 days of undergoing a LEA. If a geriatric patient has 4-5 co-morbidities, they are 7 times more likely to die within 30 days of amputation compared to patients with only one comorbidity.

The leading cause of LEA in patients over 65 is severe peripheral artery disease (PAD) - with or without diabetes[4] .This statistic is highlighted by the finding that amputations due to diabetic complication occur at a younger age, and these patients tend to die at a younger age [5] . Although PAD is a local problem causing the ischemic event, vascular disease is a systemic disease affecting arterial function in the heart, brain, and kidneys. Up to 75% of dysvascular amputees have cardiac disease and the leading cause of death after a LEA due to PAD is a cardiovascular disease[6].

Immediate Post-Operative Considerations

Surgical intervention for a patient over 65 with co-morbidities for any reason is dangerous. When one disease process has advanced to the point of requiring an amputation, the other existing systemic diseases increase the overall risk of complication and death of the geriatric patient after surgery. Risk factors must be taken into account when treating a geriatric patient immediately post-operatively. It is important that the Physical Therapist monitor their patient’s progress and treatment tolerance by making decisions on clinical, physiologic factors rather than assuming their patient can’t do an activity or exercise solely because of their age or disease process. It is still imperative to provide the same level of post-operative care for the geriatric amputee - albeit with potential modifications to the treatment interventions. The treatment goals, guidelines, and interventions are the same for the Geriatric Amputee as the are for a younger amputee;however, there are some salient difference that should be considered for this patient population.

Special Considerations for the Geriatric Amputee:

Orthostatic Hypotension

  • Orthostatic Hypertension is defined as a drop in systolic BP of 20 mmHg or greater or a drop in diastolic BP of 10 mmHg or greater during a position change to an upright position. There is a higher prevalence of Orthostatic Hypotension associated with aging[7].Symptoms include dizziness, lightheadedness, nausea, disorientation or confusion, chest pain, a feeling of weakness, and syncope. The occurrence of orthostatic hypotension can negatively effect the progress or mobility treatment of the new geriatric amputee.
  • It is felt that in the geriatric patient, orthostatic hypotension is caused primarily by an age-related decline in the baroreflex function that results in an inadequate rise in HR and subsequent reduction in cardiac output during position changes. Other common causes of orthostatic hypotension are hypovolemia from surgical blood loss, use of diuretics, dehydration; prolonged immobility; heart conditions including heart failure, irregular heart rhythm, and valve disease; diseases of the endocrine system including diabetes, adrenal insufficiency, and thyroid disorders; and Anti-Hypertensive medication including beta-blockers, calcium channel blockers, ACE inhibitors, nitrates, and angiotensin II blockers.
  • Due to prevalence of orthostatic hypotension and its potential negative effects on the immediate post-operative interventions, it is important to monitor BP and HR during mobility training. If the patient demonstrates signs or symptoms of orthostatic hypotension, education becomes a key element in your treatment. Doing leg exercises with their intact limb to reduce venous pooling, moving their arms to increase their HR, and to taking time to stay in a newly acquired position will help the body generate an adequate cardiovascular response during mobility training and position changes.

ROM

  • Due to the aging process on the musculoskeletal tissue and likely pre-surgical decline in functional mobility, there is an increased potential of loss of ROM in the geriatric amputee patient. Hip extension is the most commonly limited ROM and has the highest potential to limit prosthetic success. Patients with transfemoral amputation level (TFA) will be more effected, but aloss of hip extension will also negatively effect a patient with a transtibial amputation level (TTA).
  • Age alone should not preclude you from having your patient get into a prone position to help increase or maintain hip extension. Pre-existing conditions like COPD or CAD may limit their comfort level while prone, but an effort to get into prone should be made. If the patient is too uncomfortable with their breathing, then active and passive hip extension can be preformed while side-lying. However, it is important to control the amount of trunk or lumbar movement while doing hip extension in this position.

Mobility

  • Regaining some level of independence in mobility is often the primary motivating goal for patients after a LEA. For the Geriatric Amputee, increasing mobility is paramount in preventing post-operative complications. Of significance for the geriatric patient, there is an increased rate of mortality when there is an increased number of post operative complications [8]Due to the age-associated physiologic changes and prevalence of systemic co-morbidities, geriatric patients are at a higher risk of post operative complications including pneumonia, urinary tract infections, local and systemic infections, cardiac complications, prolonged ileus, and deep-vein thrombosis[9]Decreasing the amount of time the geriatric patient is in bed will decrease their risk of immobility related complications and, in turn, increase their survival rate after a LEA.
  • It should be noted that all patients after a LEA are at an increased risk of falling; therefore, any and all mobility should be done with safety in mind. If gait retraining is not a viable option immediately post operatively, transfers to a bedside chair or wheelchair will provide a great deal of physiologic and physiological benefit. Doing assisted lateral transfers may be as effective as stand pivot transfers with an assistive device. Care should be taken to progress each treatment intervention according to the patient’s physiologic response - with continual monitoring for signs and symptoms of low tolerance or decompensation.
  • Gait retraining with an assistive device will provide greater functional independence, but the risk of falling also increases. Pre-gait activities are an effective segue to gait. Pre-gait activities, including standing, lifting their own body weight onto a walker, or assisted single leg balance, will allow the geriatric amputee to gradually acclimate to the increased functional demand of walking. Care should be taken to limit the amount of abnormal stresses on the contra-lateral or intact limb. Focus on soft steps lessens the hard impact and stress during single leg walker gait.

Prosthetic Considerations and Issues

Prosthetic success is low for the Geriatric Amputee with one study reporting only 36% being successfully fitted with a prosthesis [6]. However, the definition of prosthetic success may be at odds with the overall functional success of the geriatric amputee with a prosthesis. The baseline functional level will provide insight to the potential success of the geriatric amputee with a prosthesis. The presence of medical co-morbidities has also been found to be an indicator of prosthetic success[10]

Although it is well known that the energy expenditure for an amputee walking with a unilateral prosthesis is at least 120% greater for an TFA and 62% greater for a TTA as compared to normal gait[6]. This increase in energy expenditure sounds unsurmountable for the geriatric amputee. However, if one compares the energy expenditure of an unilateral amputee walking with a walker stepping with only their intact limb to the same unilateral amputee walking with a walker and a prosthetic limb and their intact limb, it makes sense that assisted bipedal gait with the prosthesis and walker is more effective and efficient. It is important to make a comparison relative to that patient’s specific functional gains. Also, the geriatric amputee will decreased their self-selected gait speed in order to compensate for the increase in energy expenditure during prosthetic gait.
Gait isn’t the only functional task that should be considered beneficial for the prosthetic user. Being able to use a prosthesis for safer wheel chair transfers or household mobility may lessen the risk of fall, increased the person’s sense of independence, and positively impact their sense of progress. Even standing can be very significant task for the geriatric amputee. This would allow them to do meaningful activities of daily life or household tasks.

Prosthetic Design

When deciding on a prosthetic design and the prosthetic components for the geriatric amputee, there are several issues that should be considered including safety, efficiency, and ease of use. A good way of separating the prosthetic components/designs is that stance phase provides stability and swing phase provides efficiency. There is often a give and take between these components.The prescriber of the prosthesis must weigh the need for safety to the benefit of efficiency. It is the belief of this writer that with the geriatric amputee, safety must take precedent.

Safety

During prosthetic gait training, it is imperative that the amputee feels safe when in an upright, standing position including during the stance phase of gait. If they have a fear that the prosthetic or any of its componentsare unstable during stance, then the amputee will not feel safe and will subsequently not trust the prosthetic. They must trust that the prosthesis will keep them upright or standing.

  • Although some believe the micro-processor knees are “too much” knee for the older amputee, there is an apposing belief that the stance control features of these micro-processing knees is a paramount feature needed to maximize their safety and reduce their fall risk and occurrence. Most of the micro-processing knees have stance phase control at a minimum.
  • Prosthetic ankles and feet that allow for a lot of movement to simulate the natural ankle may actually give the amputee a sense of movement or sense of decreased stability/control. The amputee needs to be strong enough to control an movement in the prosthetic foot/ankle/shank.

Ease of Donning

If the prosthesis or prosthetic liner is too difficult to don or is too difficult to don correctly, then an easier system should be identified. Cognitive decline is more prevalent in the geriatric population, and has been noted to be a limiting factor in prosthetic fitting/use ; therefore, the donning process and prosthetic system must be easy in order to decreased potential complications with use of a prosthesis. Osteoarthritis, decreased grip strength, or loss of dexerity may also play a factor in the geriatric amputee’s ability to effectively don the prosthesis.

Efficiency

Lighter weight material, in theory, will decrease the energy demand placed on the geriatric amputee. The higher level prosthetic components may not provide the desired functional impact. Often the more sophisticated the prosthetic components are, especially the prosthetic foot and ankle, the heavier they are. This added weight, especially at the distal end of the prosthesis, will increase the perceived weight of the entire device. It may also create an uncomfortable pendulum effect during swing phase.

Prosthetic Training

Just as was done during post operative gait and/or mobility training, the physical therapist should continually monitor the physiologic response to the increased energy demand of prosthetic use. Again, it is known that there is a significant increase in energy expenditure during prosthetic gait for the TTA and TFA amputee. The patient’s subjective perceived exertion, blood pressure, heart rate, respiration rate, and gait speed are good indicator of physiologic response. Gait Speed can also be used as a functional outcome measure. As the amputee increases their tolerance and confidence, their gait speed should increase. Other functional outcome measures that can be useful are the 6MWT or 2MWT - the distance walked in a specific time frame should increase as their tolerance and confidence improves.

Prosthetic training for the geriatric amputee should first focus on stance phase control and stability. Again, this will increase the trust that the patient has in the prosthesis and it’s ability to keep them from falling. After stability in stance phase is effective, one can progress to work in the swing phase. It is important during this progression the amputee’s safety and stability is maintained throughout. This may mean that the gait training take place with a walker versus a lesser restrictive device such as a cane. As the amputee increases their confidence and control during stance and swing phases of gait, then more challenges can be placed on the individual.

References

  1. Fletcher DD, Andrews KL, Butters MA, Jacobsen SJ, Rowland CM, Hallett JW Jr. Rehabilitation of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil 2001;82:776-9.
  2. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care Linda P. Fried, Luigi Ferrucci,Jonathan Darer,Jeff D. Williamson, and Gerard Anderson; Journal of Gerontology. 2004, Vol. 59, No. 3, 255–263
  3. Morten Tange Kristensena, Gitte Holmb, Klaus Kirketerp-Møllerb,Michael Krasheninnikoffb and Peter Gebuhrb Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do? Interact CardioVasc Thorac Surg(2012) 14 (5): 543-547.
  4. Carmona GA1, Hoffmeyer P, Herrmann FR, Vaucher J, Tschopp O, Lacraz A, Vischer UM. Diabetes Metab. 2005 Nov;31(5):449-54. Major lower limb amputations in the elderly observed over ten years: the role of diabetes and peripheral arterial disease.
  5. Timothy R. Dillingham, MD, Liliana E. Pezzin, PhD, Andrew D. Shore, PhD Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputationsfckLRhttp://www.archives-pmr.org/article/S0003-9993(04)01176-1/fulltext
  6. 6.0 6.1 6.2 Aisling M Fleury, Salih A Salih and Nancye M Peel Rehabilitation of the older vascular amputee: A review of the literature Geriatr Gerontol Int 2013; 13: 264–273.fckLRhttp://onlinelibrary.wiley.com/store/10.1111/ggi.12016/asset/ggi12016.pdf?v=1&t=iaqpebj6&s=a75e516b1072b920ce5c3ad92a7e5b08e38ee706
  7. Hypertension. 1992 Jun;19(6 Pt 1):508-19. Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group. Rutan GH1, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS. http://www.ncbi.nlm.nih.gov/pubmed/1592445?access_num=1592445&link_type=MED&dopt=Abstract
  8. PREVENTING POSTOPERATIVE COMPLICATIONS IN THE ELDERLYfckLRFrederick E. Sieber, MDa,b and Sheila Ryan BarnettcfckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073675/
  9. Chapter 29 Common Perioperative Complications in Older Patients fckLRSandhya A. Lagoo-Deenadayalan, Mark A. Newell, and Walter E. Pofahl
  10. Patrick L1, Knoefel F, Gaskowski P, Rexroth D. J Am Geriatr Soc. 2001 Nov;49(11):1471-7. Medical comorbidity and rehabilitation efficiency in geriatric inpatients.

Additional References