Dementia, Foot Surgery & Neuropathy Not a Winning Combination
I suffered for years from painful bunions on both feet. My podiatrist told me that my bones would heal more quickly if I had surgery before age 65. However, because I was working full-time, I risked it and waited to have surgery on my left foot until I retired at 66 and on my right foot a year later. Although the recovery for each was about 4 months, I would do it all again to walk and stand pain-free, as I do now.
At age 78 and in the early stages of vascular and Alzheimer’s dementia, surgery and anesthesia would be more risky for my husband. His badly deformed right foot would require more complicated surgery with a longer recovery period. I think my success story motivated him to risk the surgery, in spite of opinions pro and con. I felt I was in a no-win situation. If I refused to allow him to have the surgery, I would be responsible for his not having a chance at a more normal foot. If I allowed him to do it knowing about his physical and mental difficulties, I could be responsible for months of inactivity and caregiving that might prove to be useless.
He first tried the less invasive surgery of having his second toe removed. It was being pushed up by his big toe moving under it, and it made wearing almost any shoe uncomfortable. The podiatrist assured us he had done it “hundreds of times” with great success. The surgery was performed with local anesthetic in an out-patient setting. At first, it seemed to solve the problem, but then his big toe began to move over even farther. He went to a second podiatrist who was willing to try extensive bunion surgery.
It is common for people with dementia to not be aware of what they can’t do or are unable to figure out. My husband had already been through 2 rounds of physical therapy for balance and walking problems related to his cognitive challenges and the idiopathic neuropathy in his feet. I knew he could not balance on one foot, and that post-surgery, following non-weight-bearing instructions would be difficult for him.
As someone who had been through it, and as the person who would be his primary caregiver, I told him he needed to prove to me that he could move from bed to bathroom or chair using a scooter and/or walker during the 6-8 weeks of non-weight bearing the Dr. prescribed. I begged him to practice his balance and strengthen his left foot, to no avail. He was sure he would be able to do what was required after the surgery.
Our situation is not that unusual. The caregivers at DTN Homecare have had clients with a variety of wounds or surgeries who do not or cannot follow physicians’ orders so they can heal properly. What to do?
If surgery is not optional or a wound is the result of an accident, a caregiver has no choice but to try everything possible to encourage and enable the injured person to follow the prescribed recovery instructions. The physical therapist neighbor who I called in a panic the evening after the surgery showed me by example that praise for what is done right often has better results than criticizing what is done wrong. He also said that people with cognitive difficulties learn slowly by repetition. I wondered aloud how repetition could work when I couldn’t get my husband to make the correct moves even once!
If surgery is optional, seek multiple opinions, weigh the risks against the benefits, and learn from my experience with my husband, where applicable.
Another complication was my husband’s neuropathy. Until after the surgery, we did not realize how far it had progressed. He felt no pain! He didn’t take one pain pill after the surgery, when most people experience throbbing, stabbing pain for at least 2-3 days. What at first seemed like a blessing contributed to his difficulty in keeping weight off of his foot. He couldn’t use pain as a guide as to when he was putting weight on his foot or even to know when he had his weight on the toe or the heel of the boot. Because of his cognitive problems, every time he moved from one place to another, it was like he was doing it for the first time, trying to figure out how to use the walker or the scooter without putting weight on his bad foot.
The results of being unable to follow instructions showed up quickly. When we saw the Dr. after 2 weeks to have his stitches removed, my husband’s big toe was already moving back to where it had been before surgery. The doctor showed me how to wrap his foot and toe in an Ace bandage so it would pull the toe more toward a straight-up position. This also proved to be a setback. The bandage rubbed on the toe at its base, but my husband couldn’t feel it. One day as I was helping him shower, I noticed that his surgical sock was wet. I removed the Ace bandage and was horrified to find a blister about one-half inch wide all around the base of his toe. In some places the skin had already been rubbed off and the wound was raw and weeping! I immediately called the Doctor’s office, and they said to come right in. The Dr. removed the rest of the skin and the nurse showed me a 7-step process to dress the wound that had to be done every day!
Neuropathy causes nerve damage that can also affect the length of time it takes wounds to heal. Our next visit, when the first X-rays were to be taken, was already scheduled in 2 weeks (6 weeks out from surgery). After two weeks, the wound around my husband’s toe was only partially healed, but it didn’t hurt, either. I was instructed to continue changing the dressing daily.
The X-rays showed that, in spite of the plate and the screws in his foot, the big toe bones were close to being in almost the same position as before surgery. The Doctor said the cause was two-fold: 1) the lack of the second toe provided space for the big toe to move, and 2) my husband’s inability to keep his weight off of his foot. He advised that nothing more be done, as the results would likely be the same unless his big toe were to be fused, making walking more difficult.
At the end of the 6-week visit, the doctor gave us a page of instructions as to how to gradually increase weight-bearing over the 4-week period before our next visit. Again, because putting full weight on his foot didn’t cause him any pain, after one week, my husband was walking around the house without a walker or a cane to help keep any of the weight off of his foot. It didn’t matter what I said, or how I demonstrated the right way to follow the instructions, he couldn’t do it and/or didn’t feel the need.
At 10 weeks, we saw the Dr. again. New X-rays looked about the same as the ones 4 weeks previous. The Dr. was not happy with the results and neither were we, but he did not advise any more surgery unless the foot developed friction sores or other extreme discomfort. We’ll have to keep an eye on it, because he probably won’t feel his shoe rubbing on his foot, just like he didn’t feel the Ace bandage. He was told he could go without the boot and wear a regular sneaker with an arch support insert. I was given new instructions for caring for the wound that still hasn’t healed. PT was prescribed to reteach walking in the correct way for balance and strength building. We’re not done yet. If we could go back, would we do it again? NO!
You can’t force a person with cognitive dementia to follow post-surgical or post-injury instructions that require planning and “problem solving before movement,” even if you are with your loved one or client almost every minute. Constant nagging is a waste of emotional energy. An in-home physical therapist might be able to help, if you can qualify or pay for one. Dakota Travel Nurse Home Care will give your loved one an in-home evaluation to see what types of help you need and/or qualify for.