Diabetic Foot Management in the Elderly

Evaluation of Pressure Pain Sensitivity in the Forefoot of Healthy Individuals

BACKGROUND

The evaluation of musculoskeletal pain in podiatric medical practice is mainly based on anamnesis and manual examination. However, when manual palpation is performed, the digital pressure necessary to adequately explore the different structures of the foot is unknown. We evaluated the pressure pain threshold in forefoot structures to determine the intensity and duration of the stimulus as clinically relevant and representative.

METHODS

In a transversal analytical study of 15 healthy individuals, 16 forefoot points were explored with a handheld pressure palpometer calibrated to exert maximum pressing force of 1.0 or 2.0 kilogram-force (kgf) applied during 5 or 10 sec. The combinations of the different pressures and intervals were selected randomly. Participants had to self-rate the pressure pain sensitivity of each stimuli on a 100-mm horizontal line (0-100 numeric rating scale), setting the pain threshold to 50 (100 being pain as bad as it could be). Likewise, aftersensation and referred pain patterns were recorded.

RESULTS

All participants indicated painful stimuli at some of the 16 forefoot points studied in the experimental protocol when pressure was applied with the 2.0-kgf palpometer; 53.3% showed evidence of pain at any forefoot point when the 1.0-kgf palpometer was used. The odds of evoking a painful sensation are 9.8 times higher when using a 2.0-kgf palpometer versus a 1.0-kgf palpometer. In addition, referred sensations were observed with a significantly higher frequency when applying the 2.0-kgf palpometer.

CONCLUSIONS

Bone and soft structures show differences in pressure sensitivity, increasing significantly when applying higher pressure force. Soft structures, specifically intermetatarsal spaces, showed the lowest pain pressure thresholds. More research is needed to better understand pressure pain response.

The clinical management of diabetic foot in the elderly and medico-legal implications

Diabetic foot is a complex and challenging pathological state, characterized by high complexity of management, morbidity and mortality. The elderly present peculiar problems which interfere on one hand with the patient's compliance and on the other with their diagnostic-therapeutic management. Difficult clinical management may result in medico-legal problems, with criminal and civil consequences. In this context, the authors present a review of the literature, analysing aspects concerning the diagnosis and treatment of diabetic foot in the elderly which may turn out to be a source of professional responsibility. Analysis of these aspects provides an opportunity to discuss elements important not only for clinicians and medical workers but also experts (judges, lawyers, medico-legal experts) who must evaluate hypotheses of professional responsibility concerning diabetic foot in the elderly.

The influence of age on the management of patients with diabetes in the Israeli population

The authors' aim was to study the association between age and the quality of community health care of diabetes mellitus (DM). This was a cross-sectional study of patients with DM in the setting of a large health maintenance organization (HMO) in Israel. The population included DM patients aged 40-84 years who were identified at emergency rooms or through the HMO's computerized database. A set of quality care indicators were determined. Logistic regressions were used to estimate the odds ratios (OR) for diabetes care indicators, controlling for age and other potential confounders. Older patients were more likely to be in the target range of glycemic control and to be vaccinated against influenza. Patients older than age 70 years received fewer recommendations for physical activity (OR 0.41, P<0.01) and self-foot examination (OR 0.57, P=0.024). The authors found decreased performance of recommendations for physical activity and self-foot examination, and a higher performance of annual blood tests and immunizations among elderly patients with diabetes.

Impact of action cues, self-efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy

AIMS AND OBJECTIVES

To identify the effects of health belief model factors on daily foot-exam practice among diabetes mellitus patients with peripheral neuropathy.

BACKGROUND

Daily foot exams are one of the most important self-care behaviours that prevent the occurrence of diabetic foot ulcers and subsequent amputation. Although daily foot exams were under-practiced in patients with peripheral neuropathy, few studies have explored modifiable social-psychological factors related to daily foot exams.

DESIGN

A cross-sectional survey was used to collect the data.

METHODS

A total of 277 patients with diabetes and peripheral neuropathy were recruited from two hospitals in northern Taiwan. The Family APGAR and Diabetic Foot Ulcer Health Belief Scale (DFUHBS) were used to measure family support and health belief factors respectively. Data on foot-exam practice, perceived self-efficacy and action cues were collected through the use of structured questionnaires. The data were analysed using logistic regression.

RESULT

The regression model revealed that select action cues (recommendations from family, friends, or health professionals), perceived self-efficacy and perceived barriers interactively influenced the participants' daily foot-exam practice.

CONCLUSION

Factors related to daily foot-exam practice were identified. Specifically, action cues played a significant role in motivating daily foot-exam practice in this group.

RELEVANCE TO CLINICAL PRACTICE

This study recognises modifiable factors that influence the daily foot-exam practice of patients with diabetes and peripheral neuropathy. Using the findings of this study, health professionals can design interventions that aim to modify the above factors as a means to promote daily foot-exam practice.