Diabetic foot management in the elderly

Guidelines for diabetes foot care are available and should be part of the routine care and evaluation of all elderly patients who have diabetes. Those individuals who have good sensation, good vascularity, without foot deformities, and are capable of reaching and seeing their feet may do well with education and reasonable approaches to footwear and foot care. Those who have advanced diabetic complications of neuropathy or vascular insufficiency should be seen by professionals and given intensive education. An experienced team familiar with the progression of illness should follow those who have ulcers. Guidelines are presented for the management of outpatient and inpatient therapy of foot ulcers.     

Diabetic foot disease in the elderly

Elderly diabetic patients are particularly burdened by foot disease. The main causes for foot disease are peripheral neuropathy, foot deformities and peripheral arterial disease (PAD). Other risk factors include poor vision, gait abnormalities, reduced mobility an medical co-morbidities. The risk of major amputations increases with age, along with the increased prevalence of these risk factors. Th true risk of amputation and other burdens of foot disease in the elderly are likely underestimated by current epidemiological data. Th prevalence of neuropathy, foot deformities and PAD as well as the risk of amputation all increase with age even in non-diabetic patients. The principles of prevention and management of diabetic foot disease may also apply to large segments of the elderly non-diabetic population. Foot ulcer prevention relies on the identification of high risk patients and avoidance of triggering events, such as ill-fitting shoes, walking barefoot or poor self-care. PAD is a major cause of amputation and should be prevented by lifelong attention to glycaemic control, treatment of hypertension and dyslipidemia, and avoidance of smoking. The treatment of foot ulcers relies on pressure relief (off-loading), wound debridement, and treatment of infection and ischemia. It requires an individualized approach considering the patient's co-morbidities and functional status. Off-loading remains essential, but devices such as total contact casts or crutches can only rarely be implemented. However, providing adapted standard foot-wear and insisting on its consistent use even at home is often effective. The benefits of aggressive vascular or orthopaedic surgery should be weighed against the risks of prolonged hospitalisation and resulting functional decline. Greater attention to prevention and individualized care are needed to reduce the burden of diabetic foot disease in the elderly.     

Diabetic foot in the elderly: Capillaroscopic findings

Microangiopathy is the most frequent complication of diabetes mellitus. It frequently precedes metabolic and biohumoral pathology. The diabetic foot is a particular aspect of the disease. Capillary videomicroscopy has proven to be a valuable technique for detecting early morphofunctional changes in the microcirculation in vivo. It is performed at the fingers' nailfold, at conjunctiva, and on the skin. This study aims to propose a qualitative assessment of microvascular complications in elderly patients with diabetes mellitus by toe nailfold capillary microscopy.     

An elderly lady with sudden blindness and a sore foot

We report the case of an elderly woman presenting with group G streptococcal septicaemia associated with osteomyelitis and endophthalmitis.     

Can elderly diabetic patients co-operate with routine foot care?

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.     

The diabetic foot

Diabetic foot problems are responsible for nearly 50% of all diabetes-related hospital bed days. Approximately 10–15% of diabetic patients developed foot ulcers at some state in their life and 15% of all load in amputations are performed in patients with diabetes. There is a need to provide extensive education to both primary care physicians and the patients regarding the relationship between glucose control and complications encountered in the foot and ankle. The management of diabetic foot disease is focussed primarily on avoiding amputation of lower extremities and should be carried out through three main strategies; identification of the “at risk” foot, treatment of acutely diseased foot, and prevention of further problems. These are several obstacles in the management of DFI that include poor knowledge and awareness of diabetes and its complications, lack of appropriate podiatry services. These goals are possible only by the establishment of a dedicated team of podiatrist, endocrinologist, vascular surgeon and a pedorthist. The plastic surgeons, orthopaedic surgeons & diabetes teaching nurses/educator dedicated to foot care could be a part of the team. Identifying the patients with diabetes at risk for ulceration requires feet examination, including the vascular & neurological systems, skin conditions, and foot structure. Conservative management of foot problems has dramatically reduced the risk of amputation by simple procedures, such as appropriate foot wear, cleanliness, aggressive surgical debridement, regular wound dressing by simple wet-to-dry saline guage, and ulcer management.     

The virtuoso foot

The foot and ankle are prone to injury in the performing arts population, not least amongst dancers who require extreme ranges of movement in this area. This is a complex anatomical area which can be vulnerable to wide array of injuries. Many of these injuries stem from the dancer’s posture, technique and environmental factors such as footwear and flooring; therefore, a thorough understanding of these by the clinician is important to ensure full rehabilitation and to prevent recurrence. This article presents an overview of the most common injuries seen in the dancer population and explores the underlying postural, technical and environmental factors that need to be addressed for full recovery.     

老年糖尿病足截肢相关因素分析

目的分析老年糖尿病足住院患者的临床特点和截肢的相关因素。方法通过我院检索系统收集2000～2007年收治的220例≥60岁的糖尿病足患者,按其住院期间是否实施截肢手术分成：截肢组58例,未截肢组162例。回顾性分析其临床特征与截肢之间的关系。如果老年糖尿病足的截肢率为26．4％。截肢组的入院血糖、糖化血红蛋白及白细胞计数均高于未截肢组（P〈0．05或P〈0．01）,而血红蛋白低于未截肢组（P〈0．05）;低蛋白血症、糖尿病周围血管病变、骨髓炎、坏疽以及高Wanger分级者多于未截肢组（P〈0．05或P〈0．01）。多因素非条件Logistic回归分析显示：糖化血红蛋白（OR=1．69,P=0．007）、低蛋白血症（OR=4．71,P=0．006）、坏疽（OR=3．24,P=0．043）、糖尿病足Wanger分级（OR=1．18,P=0．001）是老年住院糖尿病足患者截肢的独立危险因素,而血红蛋白（OR=0．85,P=0．03）是独立保护性因素。结论老年糖尿病足住院患者有很高的截肢率,积极控制血糖,改善营养状态,尤其是早期及时多科协作治疗是避免糖尿病足截肢的关键。     

The relationship between the body mass index (BMI) and foot posture in elderly people

We wanted to evaluate the postural characteristics of the feet of older people and their relationship with the BMI. We evaluated 227 older women and 172 older men with respect to the BMI, the arch index (AI) and the foot posture index (FPI). The obese women presented mean values for the AI significantly greater than those of the normal and overweight women. The means for some of the criteria of the FPI were significantly higher in the obese men. There was a positive correlation between the BMI and the AI and some of the FPI criteria. The conclusion was that obese women presented flatter feet while obese men presented more pronated feet, indicating a relationship between high BMI values and postural characteristics of the feet of subjects studied.     

老年人糖尿病足80例临床分析

目的 探讨糖尿病足的起病诱因、临床特点、治疗及预后.方法 对80例糖尿病足患者临床资料进行回顾性分析.结果 53例患者为细菌感染;存在下肢动脉严重狭窄、闭塞(狭窄率70%以上)30例,髂动脉以下完全闭塞5例,腘动脉以下完全闭塞4例;糖尿病性周围神经病变65例;有明确诱因者72例(90.0%).痊愈40例,截肢20例,未愈出院12例,病情恶化死亡8例.结论 糖尿病足发生多数有诱因,预后与下肢动脉闭塞程度呈明显相关性,与感染情况及其他基础疾病严重程度呈相关性.应积极予控制血糖、抗感染、改善下肢血供、营养神经、局部处理、支持治疗等综合治疗.     

老年糖尿病足防治的重要原则

糖尿病足的定义是发生于糖尿病患者的与局部神经异常和下肢血管病变相关的足部感染、溃疡和／或深层组织破坏。糖尿病足病是严重的糖尿病慢性并发症,从足皮肤到骨与关节的各层组织均可受累,严重者町以发生局部的或全足的坏疽,需要截肢。截肢可以严重地影响患者的生活质量,并增加对侧截肢的危险性。糖尿病足病可以迁延不愈,也可以发展迅速,短期内病情急转直下,严重致残,甚至死亡。糖尿病足病更多地发生于老年糖尿病患者,尤其是合并多种糖尿病并发症的老年患者。     

思维导图式认知行为干预对老年糖尿病足患者自我管理能力的影响

目的探讨思维导图式认知行为干预对老年糖尿病足患者自我管理能力的影响。方法按照不同的治疗方法将本院2017年3月至2018年6月接收的104例糖尿病足患者分为对照组和研究组,对照组(n=52)给予老年糖尿病足患者自我管理的常规治疗,研究组(n=52)在对照组的基础上给予思维导图式认知行为干预。通过自我管理行为量表(DFS-BS)、中文版糖尿病自我效能量表(DSES)及社会支持评定量表(SSRS)对患者进行测评。结果治疗后两组患者DFS-BS评分均有所提高,且研究组评分显著高于对照组,差异具有统计学意义(P<0.05);治疗后两组患者DSES评分均有所提高,且研究组评分显著高于对照组,差异具有统计学意义(P<0.05);治疗后两组患者SSRS评分均有所提高,且研究组评分显著高于对照组,差异具有统计学意义(P<0.05)。结论思维导图式认知行为干预能够有效增强老年糖尿病足患者认知情况,提高自我管理能力,对患者的病情具有显著影响。     

Differences in foot sensitivity and plantar pressure between young adults and elderly

ObjectiveThe understanding of foot sensitivity and plantar pressure contributes to the design of insoles, shoes, as well as to guide therapeutic interventions. Here we investigate differences in plantar pressure and foot sensitivity between young adults and community-dwelling elderly.MethodsThirty-eight participants (19 young adults and 19 elderly) underwent clinical assessment of foot sensitivity and upright standing with eyes open and closed for measurement of plantar pressure in each foot. Data were compared between feet, groups, and visual conditions.ResultsFoot sensitivity was lower in the elderly and, in contrast to young adults, differed between the foot regions (loss of sensitivity was primarily seen at the heel). Elderly shift plantar pressure to more distal foot zones, namely towards midfoot and forefoot. Asymmetries in foot sensitivity and plantar pressure were not observed. Visual condition did not influence plantar pressure distribution.ConclusionsThe forward shift in plantar pressure (away from the insensitive heel) constitutes a strategy of elderly to maintain balance.