Can Elderly Diabetic Patients Co-operate with Routine Foot Care? FIONA J. THOMSON, EWAN A. MASSON
Foot care education is widely promoted as a preventive strategy for reducing foot ulceration in diabetes. We describe a simple method of assessing the ability of elderly diabetic patients to co-operate with foot care advice. Using small self-adhesive red spots, foot lesions can be simulated and patients advised and prompted to detect and inspect these 'lesions'. Nineteen young non-diabetic volunteers and three groups of 14 elderly patients were assessed: diabetic patients with a foot ulcer, diabetic patients with no history of foot ulceration and non-diabetic patients. Eleven (39%) of the diabetic patients were unable to reach their toes and remove the lesions and only 6 (14%) of all elderly patients could respond to plantar lesions. It is therefore unlikely that unsupported foot care education can be effective in reducing the morbidity of foot problems in the elderly diabetic patient.
Introduction Several studies of diabetic patients have suggested that the introduction of intensive foot care programmes can reduce the incidence of lower limb amputation [1, 2]. However, the majority of diabetic patients with foot ulceration are elderly [3] and the ability of elderly patients to comply with simple foot care advice has not been demonstrated. The area of skin overlying the metatarsal heads is a common site of plantar lesions because of the characteristic deformity of the diabetic neuropathic foot; unopposed action of the long extensor tendons leads to clawing of the toes and prominence of the metatarsal heads. It has been shown that pathologically high foot pressures can develop under the metatarsal heads of the neuropathic foot during walking [4] and that the highest forces act in the region of the first metatarsal head [5]. Ulcers tend to occur at the sites of high pressure [4] and in the presence of neuropathy the lesions are painless [1]. Therefore the detection of plantar lesions frequently depends on a patients's ability to examine his or her feet. Reduced visual acuity and poor joint flexibility
will hamper foot examination and may be particular problems for elderly people. The aim of this study was to assess whether elderly diabetic patients are capable of identifying foot lesions using a practical test designed to assess simultaneously visual acuity, manual dexterity and joint mobility, and to compare the ability of non-diabetic and diabetic elderly patients to perform routine foot care. Patients and Methods Nineteen young healthy non-diabetic volunteers aged median (range) 44 (24—57) years and three age/ sex matched groups of 14 elderly patients were studied: non-diabetic patients aged 78 (65-89) years, diabetic patients with no history of foot ulceration aged 77 (65-91) years and diabetic patients with a foot ulcer aged 78 (67-89) years. A structured interview was conducted regarding difficulty with, and availability of foot care. Assessment of peripheral vascular disease (PVD) was by palpation of the dorsalis pedis and posterior tibial pulses. The pulses were classified as present or absent and PVD was diagnosed if only one or none of the four foot pulses was palpable. A standard neurological examination of the lower limbs was performed Age and Ageing 1992^1:333-337
Downloaded from http://ageing.oxfordjournals.org/ at City University, London on March 25, 2016
Summary
334
F. J. THOMSON, E. A. MASSON deformed such that one of the 'lesions' on the dorsum of the foot was hidden from the patient, the nearest suitable toe was used. The patient was then asked if they could see anything abnormal; if their answer was no, they were prompted to look for the lesions. Assessment was made of their ability to locate (visual acuity), touch (joint mobility) and remove the lesions (manual dexterity). Patients were excluded from the study if they were not capable of understanding or following simple instructions. The approximate cost of the 'lesions' for all 61 patients was £0.12. Standard non-parametric statistical tests (MannWhitney U test, •/}) were applied using the Amstat statistical package for Amstrad computers (SC Coleman, Ashby de la Zouch).
Results The characteristics of the four groups are summarized in the Table. The young nondiabetic control group had better near vision (all n5 except one) and less PVD and sensory impairment than all three elderly groups (p < 0.01). The three elderly groups were wellmatched for age and sex and were similar in the numbers living in the community. Peripheral vascular disease and peripheral sensory loss were more common in the foot ulcer group than in non-diabetic subjects (p
Foot care education is widely promoted as a preventive strategy for reducing foot ulceration in diabetes. We describe a simple method of assessing the ability of elderly diabetic patients to co-operate with foot care advice. Using small self-adhesive red spots, foot lesions can be simulated and patients advised and prompted to detect and inspect these 'lesions'. Nineteen young non-diabetic volunteers and three groups of 14 elderly patients were assessed: diabetic patients with a foot ulcer, diabetic patients with no history of foot ulceration and non-diabetic patients. Eleven (39%) of the diabetic patients were unable to reach their toes and remove the lesions and only 6 (14%) of all elderly patients could respond to plantar lesions. It is therefore unlikely that unsupported foot care education can be effective in reducing the morbidity of foot problems in the elderly diabetic patient.
Introduction Several studies of diabetic patients have suggested that the introduction of intensive foot care programmes can reduce the incidence of lower limb amputation [1, 2]. However, the majority of diabetic patients with foot ulceration are elderly [3] and the ability of elderly patients to comply with simple foot care advice has not been demonstrated. The area of skin overlying the metatarsal heads is a common site of plantar lesions because of the characteristic deformity of the diabetic neuropathic foot; unopposed action of the long extensor tendons leads to clawing of the toes and prominence of the metatarsal heads. It has been shown that pathologically high foot pressures can develop under the metatarsal heads of the neuropathic foot during walking [4] and that the highest forces act in the region of the first metatarsal head [5]. Ulcers tend to occur at the sites of high pressure [4] and in the presence of neuropathy the lesions are painless [1]. Therefore the detection of plantar lesions frequently depends on a patients's ability to examine his or her feet. Reduced visual acuity and poor joint flexibility
will hamper foot examination and may be particular problems for elderly people. The aim of this study was to assess whether elderly diabetic patients are capable of identifying foot lesions using a practical test designed to assess simultaneously visual acuity, manual dexterity and joint mobility, and to compare the ability of non-diabetic and diabetic elderly patients to perform routine foot care. Patients and Methods Nineteen young healthy non-diabetic volunteers aged median (range) 44 (24—57) years and three age/ sex matched groups of 14 elderly patients were studied: non-diabetic patients aged 78 (65-89) years, diabetic patients with no history of foot ulceration aged 77 (65-91) years and diabetic patients with a foot ulcer aged 78 (67-89) years. A structured interview was conducted regarding difficulty with, and availability of foot care. Assessment of peripheral vascular disease (PVD) was by palpation of the dorsalis pedis and posterior tibial pulses. The pulses were classified as present or absent and PVD was diagnosed if only one or none of the four foot pulses was palpable. A standard neurological examination of the lower limbs was performed Age and Ageing 1992^1:333-337
Downloaded from http://ageing.oxfordjournals.org/ at City University, London on March 25, 2016
Summary
334
F. J. THOMSON, E. A. MASSON deformed such that one of the 'lesions' on the dorsum of the foot was hidden from the patient, the nearest suitable toe was used. The patient was then asked if they could see anything abnormal; if their answer was no, they were prompted to look for the lesions. Assessment was made of their ability to locate (visual acuity), touch (joint mobility) and remove the lesions (manual dexterity). Patients were excluded from the study if they were not capable of understanding or following simple instructions. The approximate cost of the 'lesions' for all 61 patients was £0.12. Standard non-parametric statistical tests (MannWhitney U test, •/}) were applied using the Amstat statistical package for Amstrad computers (SC Coleman, Ashby de la Zouch).
Results The characteristics of the four groups are summarized in the Table. The young nondiabetic control group had better near vision (all n5 except one) and less PVD and sensory impairment than all three elderly groups (p < 0.01). The three elderly groups were wellmatched for age and sex and were similar in the numbers living in the community. Peripheral vascular disease and peripheral sensory loss were more common in the foot ulcer group than in non-diabetic subjects (p
