Prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility: a cross-sectional prevalence study

Foot Problems in Older Adults Presenting to a Falls and Balance Clinic

INTRODUCTION

Foot problems, including musculoskeletal problems, peripheral neuropathy, peripheral arterial disease and dermatologic pathology are common in older adults and are associated with an increased risk of falling. Multicomponent podiatry interventions have been shown to reduce the incidence of falls. This paper aimed to identify older adults requiring podiatry input in a Falls and Balance clinic; to describe the model of foot health care they receive; to explore cross-sectional associations between foot problems and function and ultimately demonstrate the role of podiatry input in the multidisciplinary management of falls risk.

METHODS

Cohort study of patients attending a Falls and Balance Clinic for Comprehensive Geriatric Assessment. Demographic information was collected and functional independence, mobility, foot problems, and footwear were assessed in the clinic.

RESULTS

One-hundred and two patients were included; median age 79.3 (73-84.3) years, 68.6% female, 93.1% residing independently, 62.7% used a gait aid. Podiatry referrals were made in 80.4% of cases, with muscle weakness being the most common problem identified (90.2%); 74.8% were found to be wearing inappropriate footwear. Most patients received footwear education and half were prescribed foot and ankle strengthening exercises. Hallux and lesser toe weakness were associated with lower Short Physical Performance Battery scores (p < 0.001).

CONCLUSION

The majority of older adults in the Falls and Balance Clinic required podiatry input, with foot weakness and inappropriate footwear being common reasons for referral. Those with weakness of the hallux and lesser toes had poorer balance and mobility, which is known to be associated with greater falls risk. This highlights the need for podiatry assessment and interventions as part of the multidisciplinary approach to the management of falls risk in older adults.

Foot Problems in Patients in Acute Care: A Point-Prevalence Survey

PURPOSE

Determine the prevalence of foot problems in an inpatient population and to describe demographic data, comorbid conditions, and type of footwear worn.

DESIGN

Observational point-prevalence cross-sectional design.

SUBJECTS AND SETTING

The study setting was a 722-bed licensed hospital in Western Australia. A convenience sampling was used to include adults hospitalized in the study setting during the period of data collection.

METHODS

A subset of foot questions, guided by a literature review, and input from foot, wound, diabetes, and psychometric researchers and clinicians, was incorporated into the hospital point-prevalence survey conducted annually for nursing safety and quality. Trained nurses collected data during the 1-day survey. Data were analyzed using descriptive statistics and 2-tailed tests; associations between study variables were analyzed.

RESULTS

Two hundred twenty-one patients participated in the survey; a majority (n = 193, 87%) self-reported at least 1 foot problem. More than half (n = 124) reported 3 foot problems and nearly one-third (n = 67) had 5 or more foot problems. Thick nails, damaged nails, and calluses and corns were the most frequently occurring foot problems. Older participants were more likely to have certain foot problems such as calluses and thick nails. Eleven (5%) participants were admitted to the hospital for a foot-related condition.

CONCLUSION

The majority of foot problems in our study were found to be minor and not the primary admitting diagnosis. However, even minor foot problems can pose a risk of worsening, especially in high-risk populations such as those with diabetes. Thus, detection is critical in overall patient assessment, and nurses play a critical role in assessment and management of minor foot problems through the delivery of skin and nail care and through collaboration with other professionals who provide specialized foot care.

Incorporating foot assessment in the comprehensive geriatric assessment

Background

Foot problems are common in older adults and associated with poorer physical function, falls, frailty and reduced quality of life. Comprehensive Geriatric Assessment (CGA), a multidisciplinary process that is considered the gold standard of care for older adults, does not routinely include podiatry assessment and intervention in hospitalized older adults.

Aims

To introduce foot assessment to inpatient CGA to determine prevalence of foot disease, foot disease risk factors and inappropriate footwear use, assess inter-rater reliability of foot assessments, determine current podiatry input and examine associations between patient characteristics and foot disease risks.

Methods

Prospective, observational cohort study of older adults on geriatric rehabilitation wards. Foot assessment completed using the Queensland Foot Disease Form (QFDF) in addition to routine CGA.

Results

Fifty-two patients (median age [inter-quartile range] 86.4 [79.2–90.3] years, 54% female) were included. Six patients (12%) had foot disease and 13 (25%) had a ‘high risk’ or ‘at risk’ foot. Foot disease risk factor prevalence was peripheral arterial disease 9 (17%); neuropathy 10 (19%) and foot deformity 11 (22%). Forty-one patients (85%) wore inappropriate footwear. Inter-rater agreement was substantial on presence of foot disease and arterial disease, fair to moderate on foot deformity and fair on neuropathy and inappropriate footwear. Eight patients (15%) saw a podiatrist during admission: 5 with foot disease, 1 ‘at risk’ and 2 ‘low risk’ for foot disease. Patients with an at risk foot or foot disease had significantly longer median length of hospital stay (25 [13.7–32.1] vs 15.2 [8–22.1] days, p = 0.01) and higher median Malnutrition Screening Test scores (2 [0–3] vs 0 [0–2], p = 0.03) than the low-risk group. Patients with foot disease were most likely to see a podiatrist (p < 0.001).

Conclusion

Foot disease, foot disease risk factors and inappropriate footwear are common in hospitalized older adults, however podiatry assessment and intervention is mostly limited to patients with foot disease. Addition of routine podiatry assessment to the multidisciplinary CGA team should be considered. Examination for arterial disease and risk of malnutrition may be useful to identify at risk patients for podiatry review.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02164-3.

Foot disease and physical function in older adults: A systematic review and meta-analysis

OBJECTIVES

To systematically assess the literature examining the association between foot disease (foot ulceration, infection, critical ischaemia and/or Charcot neuroarthropathy) and physical function in older adults.

METHODS

Literature search of MEDLINE, Embase and CINAHL was performed. Studies were included if foot disease and physical function were assessed in participants of mean or median age ≥ 65 years.

RESULTS

Of 2,574 abstracts screened, 19 studies (13 longitudinal, 6 cross-sectional) reporting on 5634 participants, 43% female, were included. Diabetes-related foot disease and critical ischaemia were most studied (n = 5017, 40% female). In 8 studies with control groups, foot disease was associated with poorer physical function. Meta-analysis of 5 studies (n = 1503, 45% female) found an association between foot disease and poorer physical function (SMD (95% CI): 1.00 (0.40, 1.62), P < 0.001).

CONCLUSION

Foot disease is associated with poorer physical function in older adults. Future research should include broader study populations and intervention strategies.

Incidence and risk factors for developing infection in patients presenting with uninfected diabetic foot ulcers

OBJECTIVE

There is a paucity of research on patients presenting with uninfected diabetic foot ulcers (DFU) that go on to develop infection. We aimed to investigate the incidence and risk factors for developing infection in a large regional cohort of patients presenting with uninfected DFUs.

METHODS

We performed a secondary analysis of data collected from a validated prospective state-wide clinical diabetic foot database in Queensland (Australia). Patients presenting for their first visit with an uninfected DFU to a Diabetic Foot Service in one of thirteen Queensland regions between January 2012 and December 2013 were included. Socio-demographic, medical history, foot disease history, DFU characteristics and treatment variables were captured at the first visit. Patients were followed until their DFU healed, or if their DFU did not heal for 12-months, to determine if they developed a foot infection in that period.

RESULTS

Overall, 853 patients were included; mean(standard deviation) age 62.9(12.8) years, 68.0% male, 90.9% type 2 diabetes, 13.6% indigenous Australians. Foot infection developed in 342 patients for an overall incidence of 40.1%; 32.4% incidence in DFUs healed <3 months, 55.9% in DFUs healed between 3-12 months (p<0.05). Independent risk factors (Odds Ratio (95% confidence interval)) for developing infection were: DFUs healed between 3-12 months (2.3 (1.6-3.3)), deep DFUs (2.2 (1.2-3.9)), peripheral neuropathy (1.8 (1.1-2.9)), previous DFU history (1.7 (1.2-2.4)), foot deformity (1.4 (1.0-2.0)), female gender (1.5 (1.1-2.1)) and years of age (0.98 (0.97-0.99)) (all p<0.05).

CONCLUSIONS

A considerable proportion of patients presenting with an uninfected DFU will develop an infection prior to healing. To prevent infection clinicians treating patients with uninfected DFUs should be particularly vigilant with those presenting with deep DFUs, previous DFU history, peripheral neuropathy, foot deformity, younger age, female gender and DFUs that have not healed by 3 months after presentation.

Foot Complications in a Representative Australian Inpatient Population

We investigated the prevalence and factors independently associated with foot complications in a representative inpatient population (adults admitted for any reason with and without diabetes). We analysed data from the Foot disease in inpatients study, a sample of 733 representative inpatients. Previous amputation, previous foot ulceration, peripheral arterial disease (PAD), peripheral neuropathy (PN), and foot deformity were the foot complications assessed. Sociodemographic, medical, and foot treatment history were collected. Overall, 46.0% had a foot complication with 23.9% having multiple; those with diabetes had higher prevalence of foot complications than those without diabetes (p < 0.01). Previous amputation (4.1%) was independently associated with previous foot ulceration, foot deformity, cerebrovascular accident, and past surgeon treatment (p < 0.01). Previous foot ulceration (9.8%) was associated with PN, PAD, past podiatry, and past nurse treatment (p < 0.02). PAD (21.0%) was associated with older age, males, indigenous people, cancer, PN, and past surgeon treatment (p < 0.02). PN (22.0%) was associated with older age, diabetes, mobility impairment, and PAD (p < 0.05). Foot deformity (22.4%) was associated with older age, mobility impairment, past podiatry treatment, and PN (p < 0.01). Nearly half of all inpatients had a foot complication. Those with foot complications were older, male, indigenous, had diabetes, cerebrovascular accident, mobility impairment, and other foot complications or past foot treatment.

Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study

OBJECTIVE

The aims of this point-prevalence study were to investigate a representative inpatient population to determine the prevalence of people admitted to hospital for the reason of a foot-related condition, and identify associated independent factors.

METHODS

Participants were adult inpatients in 5 different representative hospitals, admitted for any reason on the day of data collection. Maternity, mental health and cognitively impaired inpatients were excluded. Participants were surveyed on a range of self-reported demographic, social determinant, medical history, foot disease history, self-care, footwear, past foot treatment prior to hospitalisation and reason for admission variables. Physical examinations were performed to clinically diagnose a range of foot disease and foot risk factor variables. Independent factors associated with being admitted to hospital for the primary or secondary reason of a foot-related condition were analysed using multivariate logistic regression.

RESULTS

Overall, 733 participants were included; mean (SD) age 62 (19) years, male 55.8%. Foot-related conditions were the primary reason for admission in 54 participants (7.4% (95% CI 5.7% to 9.5%)); 36 for foot disease (4.9%), 15 foot trauma (2.1%). Being admitted for the primary reason of a foot-related condition was independently associated with foot infection, critical peripheral arterial disease, foot trauma and past foot treatment by a general practitioner and surgeon (p<0.01). Foot-related conditions were a secondary reason for admission in 28 participants (3.8% (2.6% to 5.6%)), and were independently associated with diabetes and current foot ulcer (p<0.01).

CONCLUSIONS

This study, the first in a representative inpatient population, suggests the direct inpatient burden caused by foot-related conditions is significantly higher than previously appreciated. Findings indicate 1 in every 13 inpatients was primarily admitted because of a foot-related condition with most due to foot disease or foot trauma. Future strategies are recommended to investigate and intervene in the considerable inpatient burden caused by foot-related conditions.