Determinants of Quality of Life in Older Adults After Lower Limb Amputation and Rehabilitation in Skilled Nursing Facilities

The most common causes of lower limb amputation (LLA) are peripheral arterial disease (PAD) and diabetes mellitus, which frequently occur in elderly adults. LLA and its associated comorbidity cause major problems in daily life, such as physical disabilities, psychological challenges, and dependence on care.1 In the literature, in predominantly younger adults time since amputation,1, 2 physical disability,1, 3, 4 social activities,1, 3 vascular disease,1, 5, 6 depression,2, 3 sex,2, 7 and age,1-3, 6 are factors that affect quality of life (QoL). The current study was aimed at investigating QoL and its determinants in home-dwelling elderly adults with LLA and a history of PAD recently after rehabilitation in a skilled nursing facility (SNF). This study was part of the Geriatric Rehabilitation in AMPutation and Stroke (GRAMPS) study,8 which is a prospective multicenter cohort study aimed at identifying determinants of rehabilitation outcomes. Three months after discharge, QoL was assessed using the RAND–36 Health Survey (eight subscales) (Table 1). The Geriatric Depression Scale (GDS8), Neuropsychiatric Inventory Nursing Home version (NPI-NH), Frenchay Activities Index, Barthel Index, One-Leg Standing Balance test, and Functional Ambulation Categories (FAC) were used to determine mood, behavioral problems, activities of daily living, instrumental activities of daily living, balance, and functional status.8 The possible determinants of RAND-36 QoL were identified using linear regression analysis. Of the 48 individuals with amputation who were admitted to participating SNFs, 27 (18 female) were successfully discharged after rehabilitation. They had an average age of 75 and a mean elapsed time after amputation of 180 days. Eight underwent a transfemoral amputation, four a knee disarticulation, and 15 a transtibial amputation. Eight were fitted with a prosthesis for cosmetic reasons or with limited weight-bearing option, 11 had a definitive prosthesis used for walking short or long distances with a walking device, and two were able to walk without a walking device. Mean QoL scores ranged from 22 to 87. Low QoL on physical functioning (with a low mean score) was correlated positively with FAC (explaining 46% of the total variance). High QoL on role limitations emotional, social functioning, and mental health (with high scores) and vitality was negatively associated with more neuropsychiatric symptoms and depressive complaints (NPI-NH and GDS8, explaining 41–69% of the total variance). Vitality was positively correlated with the Frenchay Activities Index (coefficient of determination 16%). Bodily pain was not associated with any of the potential correlates (Table 1). This study focused on determinants of QoL in elderly adults with LLA after rehabilitation. It is unique in that QoL was measured shortly after discharge to home. The QoL for these elderly adults with LLA was good, with the exception of the physical functioning domain. Even in this small sample of 27 successfully rehabilitated individuals, high and significant correlations and explained variances were found. High QoL was found, in contrast with some other studies,1, 7 but in line with one previous study.3 In the present study, time elapsed after LLA was short (on average within half a year). This may indicate that elderly adults adapt quickly to living with LLA. Individuals with disabilities may experience good QoL, a phenomenon earlier described as the disability paradox,9 although before LLA, most individuals with PAD experience pain, sleeplessness, and other discomforts related to PAD. LLA may help ameliorate these symptoms. Low scores were found on the physical functioning domain. Surprisingly, walking disability (FAC) was the only factor that contributed significantly to explaining the low QoL on this domain. LLA and the (non) use of a prosthesis affect walking ability. Older adults often have multiple medical problems that must be considered when being fitted for a prosthesis.10 Also, some do not use it for walking even though it was intended for walking. Given the importance of walking ability for QoL, it is recommended that further insight be gained into this matter. Neuropsychiatric symptoms (NPI-NH) and depressive complaints (GDS8) were independent determinants for six QoL domains. It is unclear to which extent depressive complaints in the present study were reactive to LLA, although it underpins the importance of treating neuropsychiatric symptoms and responding to depressive complaints as early and adequately as possible, during and after rehabilitation to improve QoL. Conflict of Interest: None of the authors have financial or personal conflicts of interest. This study was funded by Stichting De Zorgboog and Stichting Voor Regionale Zorgverlening, who employed the primary investigators during the study period. A grant of 25,000 Euro for the GRAMPS study was received from the science promotion foundation for nursing homes. Authors Contributions: MS and BB are the primary investigators of the GRAMPS study; they designed the study and collected the data. BB: Data analysis and writing the manuscript. MS, HL, DG: Writing the manuscript. SZ, RK: Study design, data analysis, and writing the manuscript. Sponsor's Role: The organizations that funded the GRAMPS study were not involved in the design of the study, data collection, data processing, or manuscript preparation.

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