Diabetes Foot and Skin Care. Diabetes and the feet. Foot problems: Major cause of morbidity and mortality

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1 Session # 11 Diabetes Foot and Skin Care Betty Harvey, RNEC BScN MScN Amanda Mikalachki, RN BScN CDE Diabetes and the feet Diabetes affects circulation and immunity. Over time, the sensory nerves in the hands and feet may be damaged. The person with diabetes may not feel a foot injury, blister or cut. Small sores, ulcers or wounds may then become infected leading to serious complications that can result in amputation. Foot problems: Major cause of morbidity and mortality Amputation rates for people with diabetes remain exceeding high 23 times more likely than someone without diabetes. 85% of all amputations are the result of a nonhealing foot ulcer. statistics

2 Screening and assessment Foot examinations by both the individual and healthcare providers should be an integral component of diabetes management. Foot examinations should be performed: at least annually at more frequent intervals in those at high risk Elements of a foot assessment Assessment for structural abnormalities: Range of motion of ankles and toe joints Callous pattern Bony deformities Skin temperatures Consider fit and condition of shoes Evaluation for: Neuropathy using a monofilament Ulcerations Evidence of infection Peripheral arterial disease Peripheral arterial disease

3 Assessments for PAD The distribution of PAD is greater in the arterial tree below the knee than in patients without diabetes Non-invasive assessments include: Ankle-brachial blood pressure index (ABI) Determination of systolic BP by: Photoplethsymography Transcutaneous oximetry (tcpo 2 ) Doppler arterial flow studies Tests and methods used to assess the presence of PAD Test/Method Clinical History Criteria Assess Risk Factors: Smoking Poor glycemic control Hypertension Dyslipidemia Obesity Family hx Sedentary lifestyle Increased coagulation Symptoms of exercise-induced claudication 1,2 (calf or muscle pain that improves with rest) Previous vascular studies or surgical procedures must be noted. 1. American Diabetes Association. Diabetes Care. 2003;26: Diabetes Australia Guideline Development Consortium; Tests and methods used to assess the presence of PAD Test/Method Criteria Visual Skin colour, hair distribution and nail growth 1 examination Ulcerations and infections Dependent rubor Pallor on elevation Pulse palpation Pulse palpation of pedal and post tibial 3,4 Should pulses be impalpable, or there is an ulcer present, test arterial vessels, 1 i.e. an ankle brachial index may provide further information. 2 Skin temperature 3-second capillary refill 1. Frykberg RG, J Foot Ankle Surg. 2006;45(Suppl 5):S1-S Norgren L, et al. Eur J Vasc Endovasc Surg. 2007;33(Suppl 1):S1-S American Diabetes Association. Diabetes Care. 2003;26: Diabetes Australia Guideline Development Consortium; 2004.

4 Neuropathy Detectable sensorimotor polyneuropathy will develop within 10 years of the onset of diabetes in 40% to 50% of people with diabetes. The loss of sensation and neuropathic pain (burning, pins and needles) is frequently bothersome. One of the most common and hardest to treat complications Neuropathy Risk factors for neuropathy are: exposure to higher levels of glycemia elevated TG high BMI smoking Hypertension Screening for peripheral neuropathy should begin at diagnosis of type 2 diabetes and occur annually thereafter. Simple screening questions 1. Do your feet ever feel numb? 2. Do your feet ever tingle? 3. Do your feet ever burn? 4. Do your feet ever feel like they have insects crawling on them?

5 The 10-g Semmes-Weinstein monofilament How to use the monofilament 1. Show monofilament to patient. 2. Instruct patient to say yes every time monofilament stimulus is perceived. 3. With patient s eyes closed, apply monofilament to four sites on each foot. Use a smooth motion 4. Perform this stimulus 4 times per foot in an arrhythmic manner. 5. Add up all correct stimuli for a score out of 8. A score of 7 or 8 correct responses likely rules out the presence of neuropathy. How to mark the foot on the flowchart + If positive response - If negative response

6 Management of neuropathy Intensified glycemic control Pharmacologic agents and other approaches alone or in combination Insufficient studies to recommend which medications to use first Few patients have complete relief of painful symptoms with any treatment Management of neuropathy Class Agents Considerations Anticonvulsants Gapapentin (Neurotin, generics) Pregabalin (Lyrica, generic) Valproate (Depakene, generic) Antidepressants Amitryptiline Duloxetine (Cymbalta) Venlaxafine (Effexor XR) Usual first-line therapy Opiods Dextromethorphan Morphine sustained release (MS Contin, generic) Oxycodone CR (OxyNEO, generics) Tapentadol ER (Nucynta ER) Tramadol (Raliva ER, generics) Use caution due to potential for: - dependency - tolerance, and - dose escalation Feet factoids Of the ~2.3 million Canadians with DM, 345,000 will develop a foot ulcer In 2006, >4000 Canadians with diabetes had a limb amputated 30% of Canadians with limb amputation will die within 1 year, and 69% will die within 5 years Canadians with DM who visit a doctor or healthcare team at least 3 times/year have a 33% lower risk of amputation that those who do not.

7 Foot ulcers: A major healthcare cost Diabetic foot ulcers cost our healthcare system >$150 million annually. Total estimated cost to treat chronic leg ulcers in Ontario alone: $15,564,000 (2005) Average cost of treating a diabetic foot or leg ulcer: $8,000 (2007) Average cost of treating infected diabetes ulcers or wounds: $17,000 Average cost of treating a chronic wound: $10,376 Average cost of acute wound (no complications): $11,840 Risk factors for foot ulceration Peripheral neuropathy Previous ulceration or amputation Structural deformity Limited joint mobility PAD Microvascular complications High A1C levels Onychomycosis (fungal nail infection) Loss of sensation to 10-g monofilament Management of foot ulcers Requires an interdisciplinary approach that addresses: Glycemic control Offloading of high-pressure areas Lower extremity vascular status Local wound care Smoking cessation

8 General principles of wound management Provision of a moist wound environment Debridement of nonviable tissue (nonischemic Did wounds) you know? Antibiotic therapy is not generally required for neuropathic Average time foot to ulcerations closure of acute that wound show no (no complications) evidence of infection = Serious infections 165 in chronic days foot ulcers tend to be polymicrobial and require broadspectrum antibiotics asap. >50% of amputations may be preventable by appropriate footwear and more effective nail and foot care. Patient self-care education and advice Stand Up To Diabetes Avoid foot trauma Routine-ize foot care, just like brushing teeth Check feet daily, using a mirror if necessary to see bottom of feet Soaking feet is not recommended Best soap: Dove (lowest ph, so least drying to skin) Daily application of lotion for diabetic dry feet Best creams: Atractain; Sween 24; Uremol 10 Smoking cessation strategies

9 Rally the Troops! What can you delegate? Consider your team Your literal team of allied health professionals who may work directly with you in your practice Nurse, dietitian, pharmacist Community resources DEC, dietitians, retail pharmacists, YCMA, physiotherapists, social workers etc Colleagues and other experts Know your community resources Know when and to whom to refer VON Podiatrist / chiropodist Wound care specialist Specialized shoe stores Type a list with locations and phone numbers as a resource for all team members Summary Neuropathy is a frequent complication of type 2 diabetes. Screening for neuropathy at least annually is crucial. Assessing patients feet is a routine component of diabetes management. Individuals who develop a foot ulcer should be managed by an interdisciplinary healthcare team, to avoid recurrence or amputation. Know your community resources Know when and to whom to refer