ADVERTISEMENT
Diabetes Mellitus and the Elderly: Special Considerations for Foot Ulcer Prevention and Care
People in the US are living longer. In 1900, 65-year-old persons were expected to live an additional 12 years and 85-year-old persons another 4 years. By 2001, life expectancy at age 65 had increased to more than 84 years for women and about 81 years for men and at age 85, women and men were expected to live another 7 and 6 years, respectively.1 The number of young-old (age 65 to 74 years) and old-old (age 75 and older) is ever increasing.2,3
In 2005, 20.8 million people in the US (7% of the population) had diabetes.4 Of these people, an estimated 6.2 million are undiagnosed. The estimated total prevalence of diabetes among people age 60 years or older in 2005 was 10.3 million.4 That same year, approximately 575,000 new cases of diabetes were diagnosed among US adults age 60 years and older4; of all people in this age group (60 years or older), 20.9% are estimated to have diabetes (see Figure 1).
As the prevalence of diabetes increases, so will the number of people with its complications. In 2001, 42,813 people with diabetes began treatment for end-stage renal disease.5 Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.5 In 2002, approximately 82,000 nontraumatic lower-limb amputations were performed among people with diabetes.5 Heart disease death rates are two to four times higher among adults with diabetes than adults without the disease.5 Economic costs and projections increase along with diabetes complications. The total estimated cost of diabetes in the US in 2002 was $132 billion, comprised of $92 billion for direct medical costs and $40 billion for indirect costs (disability, work loss, and premature mortality).5
A review of data from the 1996–2002 National Hospital Discharge Survey4 found octogenarian patients (age ≥80) with diabetes had twice the risk for developing a lower extremity ulcer, three times the risk of developing a foot abscess, and four times the risk of developing osteomyelitis. Compared to patients of the same age without diabetes, the diabetic octogenarian is nearly twice as likely to undergo ulcer debridement and three to five times more likely to have a lower extremity amputation.6 In a population-based, 7-year follow-up study of 733 patients with diabetes (25 with lower extremity amputations), several factors that increased risk of amputation were identified.7 Compared to all patients without amputation, patients with amputation differed in 24 variables concerning diabetes and its complications7; factors relevant to the current discussion include increased age, a longer duration of diabetes, and having a visual handicap.7
The elderly constitute a large proportion of patients with diabetes who have amputations. In 1994, people older than 65 years with diabetes accounted for 55.3% of nontraumatic lower extremity amputations (LEA) in the US that year.8 In 2002, LEA rates among patients with diabetes age 65 to 74 and ≥75 years were 1.6 and 2.1 times higher, respectively, than rates among patients younger than 65 years. In 2002, the rate of hospital discharge for nontraumatic LEA per 1,000 persons with diabetes increased with age for all levels of amputation. The largest relative and absolute increase in LEA across age groups occurred for above knee LEA — the rate per 1,000 persons with diabetes increased from 0.5 among persons <65 years to 3.4 among persons age 75 years and older.5
Prevention
Lifestyle. Prevention of diabetic foot disease and lower extremity amputation begins with primary prevention of diabetes. To reduce the risk of disease onset, information regarding healthy lifestyles is dispersed through the media, schools, and healthcare providers. The latter should address relevant healthy lifestyle decisions at each patient encounter beginning in early childhood. Providers must be vigilant in prevention efforts as well as in early diagnosis and intervention — this includes attention to metabolic syndrome, obesity, and other conditions detrimental to good health. Lifestyle modifications (eg, increasing physical activity; limiting caloric, saturated fats, and sodium intake; ensuring adequate fluid intake; avoiding tobacco use; and using alcohol in moderation) are beneficial, as are social interaction and intellectual stimulation.
Reluctance to implement lifestyle changes occurs for various reasons. Some patients seem to be in denial about the significance of their disease and are unwilling to implement strategies necessary to achieve and maintain good metabolic control. Lifestyle change at this age often involves other people, further confounding the problem of coordinating patient care. Providers need to persist in informing patients of the increased risks posed by unhealthy choices. Printed information written simply with bulleted, easy-to-remember points often is helpful. Scheduled follow-up visits to monitor disease progress may provide an incentive for the patient and allow the provider to reassess the condition and alter the plan of care if needed.
Cognitive function. Diabetes mellitus is associated with lower levels of cognitive functioning and greater cognitive decline in elderly.8 In a cross-sectional study of patients aged 55 to 74 years, cognitive dysfunction was impaired in patients with non-insulin dependent diabetes compared to a nondiabetic control group.9 The cognitive performance deficit was related to the degree of diabetic control as measured by glycosylated hemoglobin levels. Cognitive impairment in elderly diabetic patients with type 2 diabetes may complicate adherence to medical regimens and limit or prevent success of foot care education programs.9
Foot care. Foot care education and routine foot care are widely promoted as preventive strategies for reducing the risk of foot ulceration in diabetes. However, poor vision, arthritic complications, loss of manual dexterity, and memory loss will affect the ability of the elderly patient with diabetes to successfully prevent or treat lesions on the foot. In a prospective study of 42 elderly patients with diabetes compared with 19 patients without diabetes, 39% were unable to reach simulated lesions on their toes and only 14% were able to respond to simulated plantar foot lesions.10 Elderly patients with diabetes also have an increased risk for ocular complications that will affect their ability to care for their feet. Diabetic retinopathy is common in older patients with type 2 diabetes mellitus. In addition, patients with diabetes have an increased incidence of cataracts and glaucoma.11
These situations demonstrate the need for a paradigm to deal with the diabetic foot in elderly patients. Independent, unguided foot care will likely not reduce the morbidity of foot problems in the elderly patients with diabetes.10
Shoes. Therapeutic shoes are a recognized way to protect the diabetic foot from injury and prevent skin breakdown. In 1993, the US Congress passed legislation to provide coverage of therapeutic shoes for Medicare beneficiaries at risk of foot disease; it was found that this benefit would increase the possibility that a person with diabetes would obtain and use prescribed footwear.12 However, a 1995 review of three states found a low utilization of this footwear benefit — in Washington, Alaska, and Idaho only 0.6% of beneficiaries meeting the risk criteria submitted a footwear claim.13
Proper or appropriate shoe gear is an important treatment focus for the elderly patient with diabetes. Studies support the long-held clinical assertion that ill-fitting shoe gear that is too tight, too large, or inappropriate for the type of neuropathic or musculoskeletal deformity is often the precipitating cause or a significant contributor to skin breakdown and ulcer formation.14,15 In a prospective study of 65 consecutive elderly residents (ages 64 to 93 years) of a rehabilitation ward, 47 people (72%) wore ill-fitting shoes. Investigators found a correlation between incorrect shoe size and the presence of ulceration and pain.16 Properly sized shoes that accommodate musculoskeletal deformity and sensory impairment could improve comfort and reduce the risk of foot problems in the elderly population.
Table 1 provides recommendations for foot care and prevention of diabetic foot disease in the elderly patient.
Foot Ulcer Challenges
Despite prevention efforts, wounds occur. Chronic ulcers, including diabetic foot wounds, are encountered in hospital settings, outpatient clinics, skilled nursing facilities, and assisted-living facilities. Based on previous data, the cost of managing pressure ulcers is probably greater than $1.3 billion annually. In addition, ulcers are frequently the reason for litigation in long-term care facilities and home health care settings.17
Assessment. Caring for the elderly patient with diabetes with a foot ulcer can be challenging and complex. Assessment and follow-up care must be comprehensive. With the physiological and psychological changes of old age come the burden of chronic illness, significant (often multiple) comorbidities, and psychosocial and socioeconomic complications. Among people older than 80 years, 70% have one chronic disability; of this group, 53% suffer a severe disability and 36% are afflicted with cognitive impairment.18
Physiologic changes are an inevitable part of normal aging; these changes occur in every body system, including the immune system. A small decline in the body’s capacity to completely recover from illness and injury occurs with each incident of illness.18 As the capacity to recover decreases, the ability of the body to protect itself diminishes. The decrease in ability to resist infection and recover from other assaults due to immune dysfunction is referred to as immune senescence — ie, progressive dysfunction of the immune system or the decline in function of the immune system with age.19 Immune senescence leads to an inappropriate, inefficient, and sometimes detrimental immune response. Clinically, immune senescence has been implicated in an increasing number of age-related disorders19 and directly impacts the ability of the body to resist disease. In elderly patients with diabetes, even mild infection can cause significant disability and functional incapacity due to progressive immune dysfunction. Older patients often exhibit fewer manifestations of severe infection; thus, diagnosis of septic conditions often is delayed.20
The healthcare provider must clinically rule out infection in non-healing diabetic foot ulcers in the elderly, even if the patient is afebrile and laboratory values are normal. All elderly patients with foot infection should have imaging studies to evaluate the presence or absence of osteomyelitis. If plain film radiographs are negative but clinical examination suggests more extensive infection, MRI or nuclear medicine studies (ie, white blood cell scan and Technetium99 bone scan) should be considered.
Treatment. To successfully treat the diabetic foot ulcer in the elderly patient, the healthcare provider often must address not only pathologic comorbidities, but also social, physical, and/or economic challenges. For example, access to regular healthcare for some seniors can be difficult and the expense of prescription drugs can limit treatment options. In wound care, access to home care nursing or expensive dressing supplies often needs to be addressed. Integral to treatment of the diabetic foot ulcer is the ability to successfully offload or relieve pressure from the ulcer site.14 Frequently, the older patient lacks the strength to ambulate with crutches or a total contact cast and/or the patient’s home is not conducive to wheelchair or walker use. In these and other cases, the clinician’s creative attention to detail and imaginative solutions are required. Close interaction with social workers, case managers, and home health agencies often is necessary.
Several care principles are generally accepted by clinicians. To successfully manage the diabetic foot before, during, and after an acute problem, a multidisciplinary team approach is recommended. Cooperative metabolic management of diabetes between primary care providers, podiatrists, nurses, dietitians, and diabetes nurse educators is encouraged. Adequate nutrition, hydration, exercise, and rest help support immune function. Patients with mobility, balance, or edema issues should be referred to physical therapy. Elderly patients may have impaired eyesight or arthritis and require aid at home in order to comply with medical and wound care instructions; patients having problems performing necessary self-care tasks should be referred to occupational therapy for optimization of motor skills — even a daily foot exam may require some help and creativity.
An understanding of underlying and associated medical disease processes will assist in the assessment and treatment of these hard to manage wounds.21 Healthcare providers should work with the patient and family members to build realistic expectations regarding if, how, and when an ulcer will heal.
Conclusion
Diabetes mellitus is a major risk factor for lower extremity amputation. Amputation risk is compounded by advanced age, sensory neuropathy, limited joint mobility, loss of manual dexterity, and visual impairment. The elderly population is physiologically, socially, and economically diverse — while some older patients are active and fit, others are afflicted with multiple ailments accompanied by varying degrees of impairment. Each patient must be approached as an individual with unique circumstances and needs. Healthcare providers should not be hesitant to aggressively treat the diabetic foot in the elderly population, regardless of previous misconceptions concerning quality of life and life expectancy. As initially noted in this article, a 70-year-old woman can expect to live at least 14 more years —more than 12% of her life.
Clinical evidence related to the clinical approach of the diabetic foot in the elderly patient is sparse. More research is needed to better understand current practice patterns among elderly patients with diabetic foot ulcers. Failure to prevent or treat complications associated with the diabetic foot severely hinders care and affects quality of life. Individualized assessment and therapy that take into consideration multiple disease processes, patient expectations, functional status, cognitive impairment, social support, and economic limitations are important components of successful management of the diabetic foot in the elderly patient population.
1. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2004: Key Indicators of Well-Being. Washington, DC: US Government Printing Office. November 2004.
2. Abdel-Ghany M, Sharpe DL. Consumption patterns among the young-old and old-old. J Consumer Affairs. 1997;31(1):90.
3. Peterson P. Gray dawn: the global aging crisis. Foreign Affairs. 1999;Jan/Feb:42–55.
4. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general information and national estimates on diabetes in the United States, 2005. Bethesda, Md: US Department of Health and Human Services. National Institute of Health;2005.
5. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, Ga: US Department of Health and Human Services;2005.
6. Reed JF. An audit of lower extremity complications in octogenarian patients with diabetes mellitus. Lower Extremity Wounds. 2004;3(3):161–164.
7. Hamalainen H, Ronnemaa T, Halonen JP, Toikka T. Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: a population-based 7-year follow-up study. J Int Med. 1999;246:97–103.
8. Gregg EW, Yaffe K, Cauley, JA, et al. Is diabetes associated with cognitive impairment and cognitive decline among older women? Study of the Osteoporotic Fractures Research Group. Arch Int Med. 2000;160(2):174–180.
9. Perlmuter LC, Hakami MK, Hodgson-Harrington C, et al. Decreased cognitive function in aging non-insulin dependent diabetic patients. Am J Med. 1984;77:1043–1048.
10. Thomson FJ, Masson EA. Can elderly diabetic patients co-operate with routine foot care? Age Aging. 1992;21:333–337.
11. Morley JE, Mooradian AD, Rosenthal MJ, Kaiser FE. Diabetes mellitus in elderly patients: is it different? Am J Med. 1987;3:533–544.
12. Woolridge J, Moreno L. Evaluation of the costs to Medicare of covering therapeutic shoes for diabetic patients. Diabetes Care. 1994;17(6):541–547.
13. Sugarman JR, Reiber GE, Baumgardner G, et al. Use of the therapeutic footwear benefit among diabetic medicare beneficiaries in three states, 1995. Diabetes Care. 1998;21(5):777–781.
14. Apelqvist J, Larsson J, Agardh CD. The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers. J Diabetes Complications. 1990;4:21–25.
15. MacFarlane RM, Jeffcoate WJ. Factors contributing to the presentation of diabetic foot ulcers. Diabet Med. 1997;16:867–870.
16. Burns SL, Leese GP, McMurdo MET. Older people and ill-fitting shoes. Postgrad Med J. 2002;78:344–346.
17. Takahashi PY, Kimele LJ, Jones JP. Wound care for elderly patients: advances and clinical applications for practicing physicians. Mayo Clinic Proc. 2004;79:260–267
18. Amella EJ. How is dying old different? Geriatr Palliative Care. 2003;5(1):40–48.
19. Clinical effects of immune senescence. In: Beers MH (ed). The Merck Manual of Geriatrics, 3rd ed. Whitehouse Station, NJ: Merck and Co;2006.
20. Yoshikawa TT, Norman DC. Clinical features of infection. In: Aging and Clinical Practice: Infectious Disease. Diagnosis and Treatment. New York, NY: Igaku-Shoin; 1987:20.
21. Available at: http://www.ncbi.nlm.nih.gov. Accessed August 25, 2006.
