A machine learning approach to predict foot care self-management in older adults with diabetes

BACKGROUND

Foot care self-management is underutilized in older adults and diabetic foot ulcers are more common in older adults. It is important to identify predictors of foot care self-management in older adults with diabetes in order to identify and support vulnerable groups. This study aimed to identify predictors of foot care self-management in older adults with diabetes using a machine learning approach.

METHOD

This cross-sectional study was conducted between November 2023 and February 2024. The data were collected in the endocrinology and metabolic diseases departments of three hospitals in Turkey. Patient identification form and the Foot Care Scale for Older Diabetics (FCS-OD) were used for data collection. Gradient boosting algorithms were used to predict the variable importance. Three machine learning algorithms were used in the study: XGBoost, LightGBM and Random Forest. The algorithms were used to predict patients with a score below or above the mean FCS-OD score.

RESULTS

XGBoost had the best performance (AUC: 0.7469). The common predictors of the models were age (0.0534), gender (0.0038), perceived health status (0.0218), and treatment regimen (0.0027). The XGBoost model, which had the highest AUC value, also identified income level (0.0055) and A1c (0.0020) as predictors of the FCS-OD score.

CONCLUSION

The study identified age, gender, perceived health status, treatment regimen, income level and A1c as predictors of foot care self-management in older adults with diabetes. Attention should be given to improving foot care self-management among this vulnerable group.

Detection, management, and prevention of diabetes-related foot disease in the Australian context

Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.

A prospective, multicentre study to assess frailty in elderly patients with leg ulcers (GERAS study)

BACKGROUND

Although leg ulcers are a burdensome disease most common in those aged 65 years and older, frailty in this population has not yet been well established.

OBJECTIVES

The aim of this study was to prospectively explore and compare the presence of frailty in elderly patients with chronic leg or foot ulcers by applying different validated frailty screening methods in three healthcare settings and to assess the feasibility of frailty screening.

METHODS

We compared frailty of leg ulcer patients referred to an academic hospital with a non-academic hospital, leg ulcer patients receiving (primary) homecare, and a dermato-oncology patient population (control group). Frailty and quality of life were assessed using four validated questionnaires: the Groninger Frailty Indicator, Geriatric-8, Mini-Cog and Wound Quality of Life. To analyse data multiple (non)-parametric tests were performed.

RESULTS

Fifty of 60 included leg ulcer patients (83%) scored "frail" on at least one frailty questionnaire (GFI, G8 or Mini-Cog). The number of patients scoring "frail" on two or three out of three applied frailty questionnaires were significantly higher in the academic and homecare ulcer population compared with the non-academic ulcer population and control group (p = 0.002). In the academic ulcer population mean Wound Quality of Life scores were 30.2 (SD 17.6), compared with 17.7 (SD 13.1) in the non-academic and 15.0 (SD 10.4) in the homecare ulcer population (p = 0.002).

CONCLUSION

The majority of patients suffering from leg ulcers in this study was frail. The highest frailty prevalence was observed in the academic and homecare ulcer populations. The largest impaired quality of life was reported in the academic ulcer population. In dermatology practice, implementing frailty screening and initiating appropriate (paramedical) supportive care should be considered to improve patient outcomes.

Frailty in People with Chronic Limb Threatening Ischemia and Diabetes-Related Foot Ulcers: A Systematic Review

BACKGROUND

Frailty represents a state of multisystem impairment that may adversely impact people presenting with chronic limb-threatening ischemia (CLTI) and diabetes-related foot ulcers (DFUs). The aim of this systematic review was to explore the association between frailty and outcomes from CLTI and DFUs.

METHODS

We performed a systematic literature search of electronic databases to find studies using a validated measure of frailty in individuals with CLTI and/or DFUs. The primary outcomes were the impact of frailty on the severity of initial clinical presentation and unfavorable follow-up outcomes including readmissions, major limb amputation, cardiovascular events, revascularization, and wound healing.

RESULTS

Ten cohort studies were included. Two studies had a low risk of bias, 1 was unable to be assessed, 5 had moderate risk of bias, and 2 high risk of bias. The prevalence of frailty in people presenting with CLTI ranged from 27% to 88% and was 71% in people with DFUs. The presence of frailty in both people with CLTI and DFUs was associated with substantially increased severity at presentation (severity of ischemia and tissue loss) and poorer outcomes at follow-up (risk of readmission, limb amputation, and all-cause mortality).

CONCLUSIONS

The presence of frailty in both people with CLTI and DFUs is likely associated with substantially higher complexity at presentation followed by a greater risk for readmission, amputation, and death during follow-up. Heterogeneity in the tools used to screen for frailty, poor definition of frailty, and unclear evaluation of exposure and outcomes limit further interpretation of findings.

Effects of contoured insoles with different materials on plantar pressure offloading in diabetic elderly during gait

To investigate the effect of contoured insoles constructed of different insole materials, including Nora Lunalastik EVA, Nora Lunalight A fresh, Pe-Lite, and PORON Medical 4708 with Langer Biomechanics longitudinal PPT arch pads on offloading plantar pressure on the foot of the elderly with Type 1 or 2 diabetes during gait. Twenty-two elderly with Type 1 or 2 diabetes participated in the study. Their plantar pressure was measured by using an insole measurement system, while the participants walked 10 m in their bare feet or used each experimental insole in random order. The plantar surface was divided into four specific regions including the toes, forefoot, midfoot, and rearfoot. The mean peak pressure (MPP) and pressure-time integral (PTI) of ten steps with or without wearing one of the four insoles were analyzed on the dominant foot and the four specific plantar regions. After completion of the activities, the participants scored each insole from 1 (the least comfortable) to 10 (the most comfortable). The analysis of variance (ANOVA) factor of the insoles had significant effects on the MPP (P < 0.001) and PTI (P = 0.004) in the dominant foot during gait. Pairwise comparison results showed that the MPP and PTI in the dominant foot were significantly lower (P < 0.001) with PORON Medical 4708 than barefoot, Nora Lunalight A fresh, and Pe-Lite. Additionally, the insole materials had a significant effect for the forefoot (P < 0.001) and rearfoot (P < 0.001) in terms of the MPP and PTI compared with the barefoot condition during gait. Regardless of the plantar region, the MPP and PTI values were the lowest when PORON Medical 4708 was used as the insole material among four insole materials. Meanwhile, a significantly lower MPP and PTI can be found in the forefoot and rearfoot with the use of the four experimental insoles when compared with barefoot. The soft insole materials (i.e., PORON medical 4708 and Nora Lunalastik EVA) had a better performance than the rigid insole materials (i.e., Nora Lunalight A fresh, and Pe-Lite) on plantar pressure offloading for diabetic elderly.

Sarcopenia, Frailty and Diabetic Foot: A Mini Narrative Review

The aim of this narrative mini review was to investigate the potential association of the diabetic foot (DF) with sarcopenia and frailty. Data is still limited, but it appears that DF patients may be more prone to frailty. In addition, patients with DF and sarcopenia exhibit more frequently foot ulcers and amputations, as well as increased mortality rates post-operatively. Further studies are now needed to see how these realizations may be used in clinical practice, aiming to improve DF outcomes.

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.

Screening for sarcopenia and frailty in patients with chronic ulcers: a cross-sectional study

BACKGROUND

Patients with venous ulcers report multiple comorbidities and are more likely to be physically inactive. Sarcopenia and frailty increase vulnerability to dependence and/or death.

OBJECTIVES

To investigate the occurrence of sarcopenia and frailty in patients with chronic venous ulcers.

METHODS

Observational study with cross-sectional design. Nine patients (67.4 ± 8.42 years) with lower limb venous ulcers classified as CEAP 6 according to International Consensus on Chronic Venous Diseases criteria (open and active ulcer) were evaluated. Sarcopenia was assessed and classified by assessment of strength (manual dynamometry), gait speed (10-meter walk test), and muscle mass (calf circumference). Frailty screening was based on the Fried criteria, consisting of five components: unintentional weight loss; exhaustion; weakness; slow gait speed; and low physical activity.

RESULTS

Frailty was more frequent (n=9; 100%) than sarcopenia (n=1; 11,1%). The most common Fried criterion was exhaustion (n=9; 100%), followed by low physical activity (n=8; 88,8%), muscle weakness (n=5; 55%), and unintentional weight loss. Finally, the least frequent criterion was slow walking speed (n=2; 22.2%). In the subject diagnosed with sarcopenia, both weakness and reduced muscle mass were observed (n=1; 11,1%).

CONCLUSIONS

Patients with chronic venous ulcers exhibit frailty or pre-frailty and the components that comprise the condition of frailty in this population are exhaustion, low physical activity, and muscle weakness. Sarcopenia was identified in a small proportion of the patients.

Qualidade de vida de pessoas com feridas crônicas

Resumo Objetivo: Avaliar a qualidade de vida de pessoas com feridas crônicas. Métodos: Estudo transversal realizado com 176 pessoas com feridas crônicas em acompanhamento ambulatorial e domiciliar em um serviço público de saúde. Foram utilizados: formulário para a caracterização sociodemográfica, clínica e terapêutica e o questionário Cardiff Wound Impact Schedule para a mensuração da qualidade de vida. As análises foram descritivas e inferenciais empregando-se os testes t de Student, ANOVA, Mann Whitney e Kruskal-Wallis. Resultados: Dentre as pessoas acompanhadas em domicílio, predominaram lesões de origem vasculogênicas, com tempo de existência superior a 12 meses e área de até 25 cm2. No ambiente ambulatorial, prevaleceram feridas vasculogênicas e traumáticas, com tempo máximo de seis meses e extensão de até 25 cm2. Os fatores clínicos associados à qualidade de vida foram: tempo de duração da lesão, etiologia da lesão, grande extensão, aspecto do exsudato, presença de odor e de dor. O domínio de QV “bem-estar” apresentou maior impacto negativo decorrente da presença de lesão. Conclusão: Os fatores clínicos influenciaram diretamente os domínios de QV, sendo necessária a utilização de estratégias diferenciadas com o intuito de reduzir o impacto na QV por se tratarem de aspectos que poderiam ser atenuados ou evitados mediante a avaliação da lesão e a escolha do tratamento adequado.

Patient-Reported Outcome Measures for Patients with Diabetes Mellitus Associated with Foot and Ankle Pathologies: A Systematic Review

Background: Diabetes mellitus (DM) is a chronic and complex disease, which is a major cause of morbidity and mortality and affects all age groups. It commonly produces secondary effects on the foot, often making daily activities impossible. Patient-reported outcome measures (PROMs) provide a standardised method of obtaining patients’ outlooks on their functional status and wellbeing. Although many instruments have been proposed for obtaining data on persons with DM whose feet are affected by the disease, in many cases the psychometric properties of the instrument have yet to be established. The principal objective of our review was to identify PROMs specific for patients with DM affecting the foot and ankle and to evaluate the psychometric properties and methodological quality of these instruments. Methods: In this systematic review, we investigate studies (published in English or Spanish) based on the use of one or more PROMs specific to foot and ankle pathologies for patients with DM (type I or II). To do so, the databases PubMed, Scopus, CINAHL, PEDro and Google Scholar were searched for studies that analysed psychometric or clinimetric properties in this respect. These were assessed according to Terwee or COSMIN criteria. Results: Of the 1016 studies identified in the initial search, only 11 were finally included in the qualitative review. Analysis according to Terwee and COSMIN criteria showed that the Foot Health Status Questionnaire (FHSQ) presented the greatest number of positive values. Conclusions: The FHSQ is the highest-quality PROM currently available for the foot and ankle, for patients with DM.