Shoulder replacement or not?

Dominic Tramonte

Hi guys, my first post.

My MIL (82, Alzheimer's, Parkinson's, Cancer survivor) needs a shoulder replacement surgery due to arthritis caused by a rotator cuff tear. The surgeon said to get any invasive procedures done before two weeks before the date, so I took her to the dentist to have her teeth cleaned.

It was a disaster. She was incapable of tolerating the 2 or so hours necessary necessary in the chair, didn't like the Novocaine, didn't like the topical anesthetic. She also aspirated some of the water they use to do the cleaning. We got her done as best we could, but couldn't do a thorough job.

Mostly though, it seems to me she can't tell the difference between levels of pain. A pin prick is the same as a broken leg. When the nurse talks to her about pain level, her answer is always 10. Rather than a gradient, she sees an on-off switch; if it hurts then it hurts and that's it.

Which has got me to wondering if she can tolerate the physical therapy the doctor says she will need after the surgery. Actually, he put it stronger: he said he didn't want to do it at all rather than give her the surgery and have her get a frozen shoulder because she wouldn't go to physical therapy. I personally think she'll be better off even if she doesn't go, because the ache will be gone as soon as she wakes up and she already can't use her arm. It will not be a light course. The doctor said 1-1/2 hours twice a week for about 6 months.

I think the doctor is worried about his rep. He's geared towards sports surgery and likes patients that can recover fully, rather than the the 70% or so he's predicting for her. I don't care about his reputation, I'm worried about the MIL. I won't even leave a review anyway, so no worries there.

What should I do? So many questions! Should I go for the surgery anyway, knowing I won't be able to manage even 70% recovery? Isn't even 40% better for her already? How long will she live? Is it worth it? She's looking forward to it, her surgery date is one of the few dates she can recognize. Should I trust in the Lord (OK, that's not serious; of course I should) that He will provide for her care, as he has always done? Is this a waste of medical resources better spent elsewhere? Why make her life miserable with physical therapy in what might be her last weeks?

Advise me. Please.

H1235

My mil with dementia broke her arm. She forgot, didn’t know why she was wearing the sling and kept taking it off. Eventually she tried to use the arm to support herself and fell and broke her hip. She never recovered. My mom has severe arthritis in her hip. I think the normal course of action would be hip replacement (doctor didn’t even suggest it). She is just on a lot of pain killers. Keep in mind you can’t physically force her to do therapy. I can’t even get mom to wear compression socks or elevate her legs. If your mil has surgery and ends up with a frozen shoulder, will she still be in pain when she tries to use it? If so doesn’t that kind of put you right back where you are now. Is she in AL? How much will they be able to help her with ice packs and recovery? It also seems like I have read that anesthesia can cause dementia symptoms to worsen. Tough decision.

Quilting brings calm

I know you want to make things ( anything) better for your MIL. However, look at what you described that happened at a simple teeth cleaning. Now consider the realities of a shoulder replacement:

prep work the night before and the morning of: showering with a special liquid - don’t touch your face with it. No food or drink after midnight. The drive there, the endless wait in the pre/op room, the pre-op procedures. The fact that you can’t go with her to the operating room or to recovery. The anxiety that will cause. The painful days after surgery. The at home rehab on the days she doesn’t have actual rehab. The drive to and from rehab and the rehab itself. The anxiety that will cause.

The surgeon did not discourage you because he cares only about his reputation. He’s discouraging you because your MIL is not a good candidate for surgery and will likely be in worse shape afterwards than now. In addition, anesthesia is not a good thing for dementia patients. It tends to speed up the dementia process.

SusanB-dil

Hi Dominic - my little opinion - it's a 'no'.

Most alz patients cannot tolerate general anesthesia. It could knock back the cognitive reserve she does have, and parkinsons complicates it even more. And then, as the surgeon has said, she could get 'frozen shoulder' because she would probably not do the PT or keep up with it as necessary, especially considering this surgery will make things more painful at first, and she has issues with even minor pain.

It isn't a matter of the time she has left - but that the anesthesia and the follow-up pain and PT would most likely make things worse all-round.

MissOldMom

I have heard the same thing from my mom’s neurologist as Quilting brings calm…any anesthesia can move them into more cognitive loss. It’s the reason we haven’t done a colonoscopy for my mom with chronic diarrhea for years. Her gastro dr treats hers as IBS but without a colonoscopy, all that can be done is to manage it with the best med for it without truly knowing the entire goings on inside her colon. It’s the difficult choice we had to make because of the risk of the dementia progressing faster if she gets put under anesthesia. It’s just something else to consider in your decision. Best of everything. This disease sucks in every way.

psg712

My mom fell and fractured the acromion (very top of the shoulder, close to the collarbone). It was a small fracture and not one that they would normally do surgery on. She did not understand and would not wear the sling. It was only prescribed for comfort anyway, so we didn't push her to keep it on.

Occupational therapy was ordered at my request when I saw she was avoiding use of the arm. She was actually trying to steer her walker one-handed. OT was successful in getting her to use 2 hands on the walker. She would make a small effort to do exercises with the therapist but of course had no memory or motivation to do them on days the therapist wasn't there. When I tried to do them with her, she would cut every corner she could find (leaning forward in her chair to reach my hand rather than stretching out the arm). She does a little better now but still guards that arm, won't use both hands to push up from seated to standing position.

There is no way to reason with her. She does not remember the fall and is unable to understand goals of rehab. All she knows is that certain movements hurt and she wants to avoid the pain. I thank God that she didn't have a more serious injury requiring surgery to repair. There is no way that she would push through the pain to do an extensive rehab. She didn't tolerate anesthesia well when she was young and cognitively intact; now with dementia it would be a disaster.

If your MIL had trouble cooperating with dental cleaning, I really wonder about putting her through a surgery that requires long and painful rehab for successful outcome.

Dominic Tramonte

https://alzconnected.org/discussion/comment/238292#Comment_238292

I really don't know if she will be worse off. The Surgeon said she would. I don't see how, myself. She already can't use the arm.

It would put us right back where we are, yes, except her shoulder wouldn't hurt any more (until the next fall.) But we can alleviate the pain with steroid shots.

She is not in AL yet. Hopefully never. We promised her we would never put her in a home. We're going to have to break that promise, at least for hospice, towards the end, but we are committed to caring for her.

I don't know how much they can help. The best solution seems to be to plan for the worst and hope for the best.

And I have read the same. There is currently no direct evidence that anesthesia results in cognitive decline, and some studies show the effect is minor.

As you say, tough decision.

Dominic Tramonte

I know. Believe me, I know. I have factored in everything you mention and more. I am really on the fence with this. There seems to be no clear way out; no smoking gun that says do or don't. Put another way, it's a matter of choosing your poison. There will be problems either way, not the least is the fact she'll hate us for denying her the surgery if we do.

I am probably persuaded that is the deciding factor. She doesn't have anyone else or anywhere else to go. Maybe PT will make her last weeks miserable. I am certain her hating us will do so.

And hell, who knows? She might outlive me, too. Especially since I have to shoulder decisions like this.

Dominic Tramonte

Thanks for replying. I am leaning toward doing the surgery at the moment (subject to change with no warning, of course). Her cognitive decline is evident all the time. She usually remembers she trusts me, but she doesn't always remember my name or that I'm married to her daughter, who she also forgets.

She isn't capable any more of remembering or understanding the potential effects of accelerated cognitive decline. But she will doubtless remember whom to blame if we deny her the surgery. That will make things much harder, I'm thinking.

harshedbuzz

@Dominic Tramonte

The PT after should surgery can be quite extensive. My cousin was discharged from hers with 30 appointments already scheduled post-op.

Given that a dental cleaning is beyond her right now, regional anesthesia will not be an option which means exposing her to anesthesia which typically results in a significant progression of dementia symptoms.

While no one has a crystal ball to give an exact life expectancy for your MIL, if you know her stage (and I say late stage given that she forgets her own daughter) you should be able to make an educated guess looking.

This is a link to DBAT which lists the behaviors/symptoms and stages in which you might expect them along with typical duration of the stages. Take a look at "late stage 5". It includes challenges in both recognizing family members and participating in rehab as key changes.

DBAT.pdf

HB