There is perhaps no program more in need of podiatric involvement than the concerns for older individuals and the entire aspects of gerontology and geriatrics. In the stress of today’s society, physical and psychological degeneration associated with aging and chronic disease, years of microtrauma, use and abuse, as well as neglect contribute to the development of foot and related problems in older individuals. If we recognize that motivation is a key for older individuals to remain active and productive so that there is a quality of life and life is worth living, the ability to walk and remain ambulatory is an important catalyst for society’s goal of independent living and dignity. To older individuals, the poor, and individuals with physical or mental impairments, the inability to move about means social segregation, a loss of efficiency, declining health, and resultant personality and emotional changes. In effect, older individuals are running out of time, out of health, out of usefulness, and out of everything but life, and that’s not far away. The ability to retain the dignity of older age must be rekindled. Foot problems deprive older individuals of so their self-respect increases isolation and social poverty. We need to convert some of the negatives to positives (Alvarez 1961; American Geriatrics Society and British Geriatric Society 2011).
There are many broad factors that contribute to the development of foot problems in older people. Some of those factors include but are not limited to the following examples: the degree of ambulation; the duration of hospitalization or institutionalization; previous types of podiatric and other foot care services; the environment; emotional adjustment to aging, disease, and lifestyle; current medications and therapeutic programs; associated systemic diseases; associated foot changes from youth and older age; and past foot conditions and/or pedal manifestations of chronic disease.
The skin is one of the first structures to demonstrate changes (American Podiatric Medical Association 1967, 1968). The earliest sign is usually the loss of hair along the outer side of the leg and on the dorsum of the toes and feet. Brownish pigmentations follow with an associated increase in the presence of hyperkeratotic areas due to keratin dysfunction. Added to this, some loss of muscle mass and soft tissue in the foot occurs. The toenails tend to become thickened and brittle, due to repetitive years of microtrauma, and onychomycosis is more prevalent (American Podiatric Medical Association 1968; Blue Cross and Blue Shield of Greater New York 1971).
There are numerous changes in the musculoskeletal structures of the foot and lower leg with age. Due to wear and tear, repeated trauma, years of abuse, and decreasing arterial supply, the feet are easily fatigued, and there is a consequent decrease in work tolerance. With the associated loss of muscle and soft tissue mass, there are frequent complaints of leg and foot cramps, which may or may not be associated with peripheral arteriosclerosis (American Podiatric Medical Association 1968; Blue Cross and Blue Shield of Greater New York 1971). Osteoarthritis, hyperostosis, osteopenia and osteoporosis, fixed deformities, and marked limitation of motion are also noted and further contribute to the problems of ambulation (Blue Cross and Blue Shield of Greater New York 1971).
The vascular system demonstrates trophic changes, coldness, decreased pedal pulses changes, and color variations (American Podiatric Medical Association 1968). Arterial pathology can turn simple abrasions into gangrenous lesions. Venous stasis and varicosities become more prevalent (Blue Cross and Blue Shield of Greater New York 1971). Aging and chronic disease also produce many functional changes in the foot and ankle. Among these are a loss of sensation, complex gaits, reduced agility, and tremors.
It is important to demonstrate the need for early diagnosis of foot, ankle, and related pathology, in order to achieve rehabilitation and maintenance of foot health at its maximum level. This also enhances the concept of the secondary prevention of chronic diseases (Centers for Medicare and Medicaid Services 2011, 2010).
Three distinct relationships exist between podiatric medicine and chronic diseases in general: many general pathological conditions can be discovered during the course of a podiatric medical assessment and examination, interview, or treatment program; persons with some chronic disease require podiatric medical and surgical care to control pedal sequelae, as well as the pathologic changes of the feet, ankles, and related structures associated with aging; and many pedal disorders and conditions may become chronic. If untreated, they may result in a loss of ambulation and a furthering disability from other causes.
Although members of the health professions are primarily concerned with the prevention and treatment of disease, the elderly per se concerns are largely those of maintaining the ability to see, hear, eat, and walk. He or she needs to move about to see friends, pursue a hobby, make life more enjoyable, and lead a useful life as a member of his or her community. Foot health is a major catalyst for older individuals to retain their independence.
The treatment of the foot is not usually surrounded by urgency or a matter of life or death. Complaints are usually those that take joy out of living. Many times, moreover, a patient will present himself to a podiatrist with no history of a physical examination during the past several years, and it is in these situations that podiatric medicine can strengthen comprehensive medical care by appropriate referrals and consultations (Centers for Medicare and Medicaid Services, MLN Matters 2010; Conforti 1961).
Systemic Disease of the Feet
A descriptive listing of diseases that manifest themselves in the foot would provide a prohibitively lengthy text. Rather, it is the intention here to identify those that are common and to briefly describe their clinical manifestations and their primary complicating effects.
It should also be recognized that although many diseases and disorders present foot symptoms as initial complaints, the usual response in older adults is toward the most overt abnormality with its varied complaints and symptoms. The individual is often faced with complications arising from various sources which make the podiatric care of older adults anything but “routine,” no matter how common the condition. As an example of this, most older people develop thickened toenails, the treatment of which is considered by regulation to be routine. However, older people also are prone to have some form of cardiovascular disease, and thus, since this is common, its treatment might also be considered routine. But in fact, neither condition should be taken lightly, and both must be managed to maintain the functional activity of the patient.
The initial consideration is one of comprehensive assessment, patient management, and continuing surveillance. The term can mean many things to many people, but in the older individual, it denotes a more serious problem than a behavioral and communication problem because of the real or potential dangers involved. It refers to the fact that elderly patients require care and treatment that is not routine, but has special understanding and special knowledge about unusual conditions. Looking at the elderly patient, it is essential to see him or her as an individual with a probable unusual sensitivity to drugs, a higher susceptibility to infection, a lower threshold to physical and emotional stress, one or more serious systemic diseases and impairments, tissues that do not heal or repair readily, and a tendency to injure their lower extremities, thus reducing ambulation and producing a greater mortality risk (Helfand 1963, 1965).
Foot infection, with or without gangrene, is by far the major local complication in older people related to systemic disease entities and other factors. This situation often results in the necessity for amputation and even in loss of life or the will to live. In general, one can identify the etiologic aspects of foot infection in the aged as those associated with the following (Helfand 1968a, b): trauma, such as a cut, abrasion, or the result of crushing, blistering, or pinching that breaks the intact skin; neglectful acts, such as poor hygiene, particularly poor fitting and/or inappropriate footwear resulting in a foot-to-shoe incompatibility and the production of blisters or raw areas; impaired vision that can turn primary foot care into a need for hospitalization; changes due to the aging process in the skin, such as fissuring, dryness, hyperkeratoses, and atrophy; metabolic changes associated with systemic diseases, such as those seen in diabetes, peripheral vascular disease, patients on dialysis, patients with collagen diseases and compromised immune, mental, and visual status; and primary and secondary skin diseases. Additional factors include the residual result of some surgical procedures; osteoarthritis or degenerative joint disease usually can be identified in the older people in its primary form or as secondary to trauma, inflammation, or metabolic changes.
In addition, the associated relationship between repeutrative and chronic trauma or strain and obesity is well reflected in the weight-bearing joints of the foot. Osteoporosis and postmenopausal syndromes also can be demonstrated often in the same individual. The primary findings in the foot, ankle, and related lower extremity structures include pain, stiffness, swelling, limitation of movement, and deformity. Clinically, diagnostic associations may include plantar fasciitis, calcaneal erosions, and/or spur formation with or without periostitis, osteoporosis, stress fractures, tendonitis, and tenosynovitis. Where osteochondritis was present at an earlier age, the end result is usually an osteoarthritic joint (Helfand 1969a, b).
Existing deformities such as pes planus, pes cavus, and digital deformities such as hallux valgus, hallux rigidus, and digiti flexus provide for increased pain, limitation of motion, and a reduction in the ambulatory ability of the patient. The primary factor to consider is that osteoarthritis in the foot is usually secondary to repeated microtrauma and may be precipitated by inadequate foot care at earlier age (Helfand 1971; Helfand et al. 1974).
Traumatic arthritis can be well demonstrated in the foot by the clinical entity of hallux rigidus and its earlier form, hallux limitus. Continued primary trauma to the first metatarsophalangeal articulation provides the etiologic factor. In older adults, the clinical feature resembles a monoarticular osteoarthritic joint. However, the bony bridging provides the need for patient mechanotherapy, as well as surgical consideration (Helfand 1981, 1986).
Neurotrophic arthritis when identified in the older adult patient may be manifested by the atrophic changes seen in diabetes and by the hypertrophic changes seen in tabes. These represent the primary common diseases producing this degenerative form of joint disease (Helfand 1987).
Infectious arthritis can be present in the older adult patient as the end result of a single septic process of the joint and is associated with osteomyelitis. It may also be the residual of tuberculous, gonococcal, or syphilitic joint disease.
Gouty arthritis is a common metabolic arthritic process. Clinically, the disease may provide symptoms in any joint of the foot and should always be suspected where intense pain is present without trauma. The primary manifestations in older adults are related to chronic tophaceous gout and include chronic, painful, stiff joints, soft tissue tophi, and a loss of bone substance (Helfand 1987).
Rheumatoid arthritis in the elderly patient usually is presented as the end result of the disease with exacerbations of pain, joint swelling, stiffness, muscle wasting, and deformity. Residuals in the foot include painful pedal joints, hammertoes, forefoot spreading, progressive hallux valgus, calcaneal erosions, fasciitis, tendonitis, cystic and sesamoid erosions, fused digital articulations, phalangeal reabsorption, extensor tendon displacement with deformities, pedal rigidity, and spurs (Helfand 1987).
Diabetes mellitus is well known to be complicated by many pedal manifestations. Very often foot and ankle symptoms appearing in an individual who is not known to be a diabetic will lead to detection of the disease. The pedal manifestations are related to multiple systems and often are associated with a variety of symptoms and signs such as paresthesias, sensory impairment, motor weakness,
reflex loss, neurotrophic arthropathy, muscle atrophy, absence of pedal pulses, and the clinical findings of peripheral vascular (arterial) impairment. Other common findings are dermatophytosis, chronic inflammation and infection, ulceration, and terminal gangrene (Helfand 1987).
The dread neurotrophic or diabetic ulcer is resistant to treatment and requires a multifaceted approach for management. The best treatment is prevention by the continual management of even minor foot problems. For example, ulcerations can be precipitated by continuous and repetitive microtrauma and pressure causing local vascular ischemia and impairment, penetration of tissue with trauma, and continued friction with thrusting and shearing of the plantar structures. The initial doctrine of prevention must be initiated by recognizing the liability and providing health education to the patient and his or her family. Management must include a multidisciplinary approach (Helfand 1987).
Peripheral vascular insufficiency is present in the older adult patient in varying degrees. Overt indications of decreased arterial supply in the feet and adjacent structures are muscle fatigue, cramps, intermittent claudication, rest pain, coldness, pallor, paresthesias, burning, atrophy of soft tissues, trophic dermal change such as dryness and loss of hair, absent pedal and related pulses, and decreased changes in the various functional tests, such as oscillometric readings, reflex dilation, etc. Many times, calcification can be demonstrated during the course of a radiographic study. Often pain may be mistaken for patho-mechanical faults and blamed on “biomechanical conditions” when the real problem is a lack of oxygenated blood to the extremity (Highmark Medicare Services, LCD P-1N 2006; Highmark Medicare Services, LCD P-3K 2006).
The terminal result of peripheral arterial occlusion, gangrene, can be related to other factors such as smoking, occupation, exposure to cold, and cardiorenal pathology. This may lead to an amputation and a life-changing event that can create a ward of society and eliminate the ability to thrive or lead a life with quality and independence. Edema, either related to cardiorenal disease or dependency, may be the first real sign of impending peripheral arterial complications (Highmark Medicare Services, LCD P-1N 2006; Highmark Medicare Services, LCD P-3K 2006).
Pedal ulcerations in the aged, associated with arterial insufficiency, are extremely slow healing and are many times complicated by diabetes mellitus, as a result of small vessel occlusion. The loss of collateral circulation and the possibility of occlusion from vasospasm provide an ever-present liability to the patient (Highmark Medicare Services 2008; Merrill et al. 1967).
The peripheral circulation should have adequate support in patients leaving bed following a period of immobilization. Edema of the feet, ankles, and legs, due to a combination of inactivity, dependency, immobilization, pain, muscle inactivity, and venous insufficiency, creates substantial complications. Venous insufficiency, with and without varicosities, may lead to stasis, ulceration, and stasis dermatitis. Topical infections must be considered as serious complications, and early treatment and management must be employed (Riccitelli 1966; Starin and Kuo 1966).
Paresis of the lower extremity, often the end result of a cerebral vascular accident, may result in foot drop, trophic changes, and new weight-bearing areas for which the individual cannot compensate. These changes can turn minor foot lesions into ulcerations (Social Security Amendments 1967, 1971).
Many diseases of the neurologic system can affect the foot, ankle, and adjacent structures and ambulation, such as cerebral palsy with gait abnormalities, post-cerebral vascular accidents, and multiple sclerosis (Tarara 1972; United States Department of Veterans Affairs 1963). However, the primary problems are associated with the coordination of movements as a result of spasticity ataxia, peripheral neuropathies resulting in a loss of position sense, visual defects affecting ambulation, tremor, and rigidity (United States Department of Veterans Affairs 1963, 2009). Patients with mental illness or spastic cerebral palsy present foot defects and problems resulting from their inability to functionally adapt to gait and related system changes (Gabel et al. 2004; Armstrong and Lavery 2016).
A major challenge in addressing the issue of foot care for older people was identified in the Final Report of the 1981 White House Conference on Aging suggesting the implementation of Recommendation #148 that comprehensive foot care be provided for older citizens equal to care provided for other parts of the human body (Dinh 2011; Halter et al. 2003). To permit patients to remain ambulatory, to date, this Recommendation has not been enacted (Helfand 2006b).
In 2000, the Pennsylvania Department of Health provided funding - inding to the Pennsylvania Diabetes Academy and Temple University School of Podiatric Medicine to develop a Comprehensive Podiatric Assessment Protocol (Helfand Index) to assess older citizens and determine risk and to be utilized as a continuing assessment tool to plan individualized prevention and treatment protocols for care (Helfand 2007; Hurwitz and Parekh 2012). The problems have been identified (Luximon 2013; Menz 2008) and management modifications suggested (Positaano et al. 1917, Sinclair et al. 2012). The list of risk diseases or qualifying diseases for care coverage needs to be expanded and enacted so that older individuals and those with physical, mental, and emotional disabilities can be covered for their care. The recommendations need to be enacted.
The attempt has been made to briefly outline the older person’s special foot health needs, particularly those associated with systemic disease (Dinh 2011; Halter et al. 2003). It should be noted that the podiatric management of many of these involves assessment and the management of the pathomechanics related to disease. The prime concern should be the total patient and the utilization of all health professionals as a team if comprehensive care is to be achieved (Arenson et al. 2009; Ham et al. 2014; Helfand 2012).
- Alvarez W (1961) The value of foot care to the aged, editorial. Geriatrics 16:104Google Scholar
- American Podiatric Medical Association (1967) Podiatry in Public Health, Council on Public Health, Helfand AE DPM, Chair, Approved January 23, 1965, Board of Trustees and Council on Education, Washington, DC – Published. J Am Podiatr Med Assoc 57(7):338–343, July 1967Google Scholar
- American Podiatric Medical Association (1968) Interpretations and Guidelines for Podiatrists’ Services Under Medicare, January 3, 1968, Washington, DCGoogle Scholar
- Armstrong DH, Lavery LA (2016) Clinical care of the diabetic foot, 3rd edn. American Diabetic Association, AlexandraGoogle Scholar
- Blue Cross and Blue Shield of Greater New York, Medicare Bulletin, For the DPM, the MD, and the DO Concerned with Foot Care, 1971Google Scholar
- Centers for Medicare and Medicaid Services, Billing/Coding Guidelines, Routine Care and Debridement of Nails, 01/01/2010, BaltimoreGoogle Scholar
- Centers for Medicare and Medicaid Services, Foot Care Billing Guide, June 2011, BaltimoreGoogle Scholar
- Centers for Medicare and Medicaid Services, MLN Matters, Foot Care Coverage Guidelines, SE1113, 2010, BaltimoreGoogle Scholar
- Conforti JA (1961) Foot care for mental patients. Ment Hosp 10:42Google Scholar
- Gabel L, Haines DJ, Papp KK (2004) The aging foot – an interdisciplinary perspective. The Ohio State University, Department of Family Medicine, ColumbusGoogle Scholar
- Halter JB, Ouslander JH, Studenski S, High KP, Asthana S, Supiano MA, Ritchie C (2017) Hazzard’s geriatric medicine and gerontology, 7th edn. The McGraw-Hill, New York, 2003Google Scholar
- Ham RJ, Sloane PD, Warshaw Gregg A, Potter JF, Flaherty E (2014) Ham’s primary care geriatrics, A case based approach, 6th edn. Elsevier-Saunders, PhiladelphiaGoogle Scholar
- Helfand AE (1963–1965) Podiatry in a total geriatric health program, and a digest, projects division, Gerontological Society, HHS contracts PH86-63-104 and PH108-65-206, St LouisGoogle Scholar
- Helfand AE (1971) In: Chinn AB (ed) Podiatry and the elderly patient, working with older people – a guide to practice, vol. IV, Clinical aspects of aging. US Department of Health Education and Welfare, Rockville, pp 377–388Google Scholar
- Helfand AE (ed) (1981) Clinical podogeriatrics. Williams and Wilkins, BaltimoreGoogle Scholar
- Helfand AE (1987) Public health and podiatric medicine. Williams and Wilkins, BaltimoreGoogle Scholar
- Helfand AE (1993a) The geriatric patient and consideration of aging, Clinics in podiatric medicine and surgery, vol I. W. B. Saunders, PhiladelphiaGoogle Scholar
- Helfand AE (1993b) The geriatric patient and considerations of aging, Clinics in podiatric medicine and surgery, vol II. W. B. Saunders, PhiladelphiaGoogle Scholar
- Helfand AE (2003) Clinical podogeriatrics: assessment, education, and prevention, clinics in podiatric medicine and surgery. W. B. Saunders, PhiladelphiaGoogle Scholar
- Helfand AE (2006a) Public health and podiatric medicine – principles and practice, 2nd edn. APHA Press/American Public Health Association, Washington, DCGoogle Scholar
- Helfand AE (2006b) Public health and podiatric medicine, principles and practice, 2nd edn. American Public Health Association, Washington, DCGoogle Scholar
- Helfand AE (ed) (2007) Foot health training guide for long-term care personnel. Health Professions Press, BaltimoreGoogle Scholar
- Helfand AE (2012) When routine foot care should not be “Routine” – Part I and Part II, Podiatry Management, October 2012, pp 163–173 and January 2013, pp 189–198Google Scholar
- Highmark Medicare Services, Provider bulletin, routine foot care, 12/30/2008 and LCD L27486 05/11/2011Google Scholar
- Highmark Medicare Services, LCD P-1N, coverage requirements for routine foot care, Camp Hill, 11/29/2006Google Scholar
- Highmark Medicare Services, LCD P-3K, Debridement of Mycotic Nails, Camp Hill, 02/15/2006Google Scholar
- Hurwitz SR, Parekh S (2012) Musculoskeletal examination of the foot and ankle. Slack, Inc, ThorofareGoogle Scholar
- Menz HB (2008) Foot in older people. Churchill Livingstone/Elsevier, Edinburugh/LondonGoogle Scholar
- Positaano RG, DiGiovanni CW, Borer JJ, Trepal MJ (1917) Systemic disease manifestations in the foot, ankle and lower extremity. Wolters Kluwer, PhiladelphiaGoogle Scholar
- Social Security Administration (1971) SSA issues revised medicare regulations and guidelines for routine foot care under SSA – revisions 187, Baltimore, pp 1–2Google Scholar
- Social Security Amendments of 1967, P.L. 90-248, United States Congress, Washington, DCGoogle Scholar
- Tarara EL (1972/1960) Podiatry’s role in the care of the aged. J Am Podiatr Med Assoc 50:57–64Google Scholar
- United States Department of Veterans Affairs, Nursing Care for the Long Term Care Patient, Program Guide, Nursing Services, Department of Medicine and Surgery, G-8, M-6, Part V, Washington, DC, 1963Google Scholar
- United States Department of Veterans Affairs, VHA Directive 2009-030, 16 June 2009Google Scholar