Abstract
A common debilitating condition in older adults which impact their level of independence involve conditions interfering with the ability to walk freely. Podiatric conditions develop over decades of wearing ill-fitted shoes, heels or as a result of chronic systemic conditions which impact the feet. This article will discuss the most common podiatric conditions frequently observed in older adults and steps that home health care providers should take to eliminate the threat of impaired mobility
It is no secret that the older adult segment of the population is increasing and by 2020 one in six adults in America will be over the age of 65 years. 1 The Third National Health and Nutrition Examination Survey 2 indicates approximately 18.5% of older adults between the ages of 65 and 74 years have diabetes; a common fact is a risk factor for the development of glucose intolerance; but most develop diabetes in earlier adulthood. Regardless of the length of time with diabetes, older adults suffer greater consequences from diabetes complications. One such complication is peripheral neuropathy, which is the most common underlying cause for podiatric complications in the older adult diabetic population. For example, older adults with diabetes and other conditions such as psoriasis and poor circulation are more susceptible to contracting fungal infections of the feet. The purpose of this article is to examine the types of podiatric conditions in older adults and to discuss approaches home health care providers can initiate to maximize quality of life while living with podiatric issues.
Background Information
One in every three older adults over the age of 65 years has foot complaints such as stiffness, pain, or achiness. Statistically speaking, approximately 87% of adults living in the United States have some type of foot complaint at least once in their lives. Younger adults tend to have foot complaints related to aching muscles or bone stress often from ill-fitting shoes. Older adults with diabetes, cardiovascular disease, osteoporosis, or other muscular-skeletal problems such as hip, back, or knee disorders tend to suffer from foot problems more frequently, with women experiencing more pain in their toes and balls of their feet, which usually intensifies with age. On the contrary, those with heel pain tend to experience improvement with age. Foot pain interferes with independent living, physical activity, and overall quality of life. To keep older adults aging in place, it is prudent to be cognizant of the types of foot conditions common in this population to more proactively prevent situations that interfere with functional abilities.
Common Foot Conditions
Foot pain and foot complaints are common in older adults regardless of the presences of underlying causative pathology. Physiologically, feet are anatomically small compared with the rest of the body and experience extensive impact from each footfall adding up to tons of weight each day. Consisting of 26 bones, 33 joints, and more than 120 muscles, tendons, ligaments, and nerves per foot, an average individual takes approximately 10,000 steps per day with the feet acting as shock absorbers while acting to keep one upright and balanced. Decades of standing changes the feet, and with time, the padding in the balls and the heels of the feet are lost. The arches become flatter and less flexible, the ankle and foot joints get stiffer, and the entire foot gets wider and more elongated. These changes alone can lead to pain and discomfort even if there is no risk from underlying pathology. Common medical conditions such as diabetes are also a common cause for foot pathology due to neuropathy and decreased blood circulation.
Most Common Foot Problems in Older Adults
Foot conditions most commonly observed in older adults include conditions that are associated with many years of wearing ill-fitted shoes. Calluses and corns are good examples of the build up of dead, yellowish skin usually found on toes. This tissue build up is from prolonged periods of pressure against that area, commonly seen in those wearing ill-fitted shoes. Hammertoe or digital contracture is the dislocated toe joint (usually found in the first small toe but can involved all middle toes as well) whereby the toe is curled up or under with some flexibility or can be completely rigid. Those with foot problems secondary to diabetes usually experience foot ulcers that are difficult to heal. Neuropathy and decreased circulation may be present, and if the diabetes is poorly controlled, it is not uncommon to see evidence of toenail fungal infections. Diabetic patients also suffer from dry cracking skin especially around the heels. Thick, yellowish/discolored toenails are commonly present in older adults. Ingrown toenails commonly occur especially with continuous trimming of nails too close to the nail beds. Heel pain may be due to bone spurs or plantar fasciitis. Hallux abducto valgus deformities, commonly known as bunions, are bony growths or misalignment of the bone at the base of the big toe or the small toe. Over time, big toe bunions may cause the big toe to develop an abnormal curvature toward the small toe. This type of bony deformity can be very problematic for diabetic individuals. Finally, foot complications can occur secondary to foot deformities in those with arthritis or gout.
Dunn and associates found the five most common foot problems (as single isolated incidents or in multiple conditions) among the 784 older adults randomly surveyed in a multiethnic community. These conditions included toenail disorders, which were found in 74.9% of participants, lesser debilitating toe deformities were present in 60.0% of the study group, calluses and corns were found in 58.2% of participants, bunions were present in 37.1% of individuals, and evidence of fungal infection, cracks/fissures, and/or maceration between toes were found in 36.3% of participants. In addition to finding these foot anomalies, 30.9% also complained of ankle or foot tenderness with palpation, and 14.9% stated their ankle joint pain was present for most of the days over the past 4 weeks of the study period. They also found men had more fungal infections, ulcerations, or lacerations whereas women had more corns, calluses, or bunions. Adjusting for gender and educational level, ethnic/racial differences included more toe deformities, flat feet, corns, calluses, fungal infections, edema, ankle joint pain, and sensory deficits in minorities compared with their white conterparts. 3 In short, Dunn and associates supports the current literature of commonly occurring foot conditions in older adults.
According to van Leeuwan and associates, increased body mass index (BMI) also contributes to foot problems, particularly involving the plantar fascia. 4 Their meta-analysis of 51 studies found a consistent association between increased BMI and plantar fasciopathy. Their analysis of the pooled imaging data found significantly thicker hypoechogenic plantar fascia, increased vascular signal, and perifascial fluid collection. They concluded their findings may be a consequence of being more sedentary or less athletic.
Some foot conditions also interfere with balance in older adults. In a study of 135 community-dwelling older adults, Menz and Lord 5 found the presences of particular foot conditions revealed impairment with more challenging balance and some functional tests. For example, older adults with foot pain had poorer performance in the leaning balance test, stair ascent and descent, timed 6-meter walk, and alternate step-up test. They concluded that foot problems, particularly foot pain impaired balance and functional ability.
Ill-fitting shoes can initiate and/or perpetuate foot impairment. Many older adults (in some populations, the prevalence is three out of four) wear ill-fitted shoes. Burns et al 6 found 72% of older adults with chronic conditions (i.e., diabetes, peripheral vascular disease, sensory impairment) on a rehabilitation unit wore poorly fitted shoes, specifically in length. They found participants who reported wearing ill-fitted shoes with ulcerations also had a history of peripheral vascular disease. Those with inappropriate shoe length also were associated with foot pain and sensory impairment.
Assessment and Intervention
Most foot conditions can be prevented especially if health care providers are continuously monitoring for changes regardless of the absences of chronic diseases frequently associated with severe consequences. Consideration should be given to all experiencing normal physical decline associated with aging; this decline contributes to the difficulty in performing appropriate foot care. For example, after 75 years of age, fewer than 30% of older adults are able to care for their own feet for several physiological reasons: (1) poor vision, (2) inability to reach their own feet, and (3) grip strength is diminished.
At least annually do a complete foot assessment as part of the routine health assessment of all older adults. A comprehensive history should assess the following: (1) home environment, which includes living conditions and family/social interactions, (2) history of medical conditions (i.e., diabetes, peripheral vascular disease, infection, neuropathy, etc.), (3) foot surgical procedures performed, (4) current or past treatments for foot problems and outcomes of treatment, and (5) time spent walking, including the distance covered on a daily bases, time spent standing, the use of walking aids, and history of falls. Be vigilant for potential skin complications and or functional impairment. Also assess whether older adults are able to perform daily foot care, that is, trimming their own nails, inspect their own feet for skin breakdown/changes, and so forth.
The physical assessment should include identifying the presences of potential foot problems. Assess tibial and pedal pulses, check capillary refill using the plantar surface of the halluces, and using a 10-g monofilament, perform sensory testing over areas void of hyperkeratosis. Palpate to assess for warmth and pain, check range of motion of the toes and ankle joint mobility, assess for potential fall risk by checking for structural and postural problems, and assess neuromuscular function of the ankles and feet. Check shoes for appropriate fit by assessing each for foot width and length and forefoot height. Assess the length of time the older adult is able to stand on one leg and use the timed up and go test (able to stand from a sitting position without using hands and able to walk for 3 minutes, returning to the chair, and ending in a sitting position).
Based on findings, older adults should be provided education on a variety of elements to help maintain good foot care. Teaching on good hygiene and daily care is imperative and should include details on toenails trimming to avoid ingrown toenails and other pedicure treatments to avoid skin cracking/fissures or skin breakdown. Educating this population about proper footwear is also important, including the correct footwear based on the condition present, which many include a prescription for orthotic or made-to-fit shoes. Frequent referral to a podiatrist and/or an orthopedic specialist is necessary for further assessment and care.
Conclusion
Many older adults suffer from foot problems after decades of abuse by wearing heels or ill-fitting shoes. Being overweight or obese, performing jobs that require prolonged standing/walking, and having chronic diseases are all contributors of foot problems. It is obvious that maintaining good foot health to keep older adults walking is paramount to maintaining independence and improving/maintaining quality of life for this population. To maximize this goal, home health care providers need to think comprehensively/inclusively in terms of the approach to care. Providers must remain vigilant and initiate a plan of continuous assessment, education, intervention, and possibly referral to specialist with the goal being preventing or improving foot problems if older adults are to remain independent.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.