CLINICAL PODOGERIATRICS: ASSESSMENT, EDUCATION AND PREVENTION

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1 CLINICAL PODOGERIATRICS: ASSESSMENT, EDUCATION AND PREVENTION Dedication iii Foreword Vincent J. Mandracchia xiii Foreword Norman Klombers xv Preface xvii Overview of Geriatrics 373 Karen D. Novielli and Christine A. Arenson America is an aging nation. In 2000, 13% of the population was 65 years old or older. By 2020, that number will rise to 20%. Podiatrists fill a pivotal role in maintaining the health and independence of older adults. Chronic disease may first manifest itself as abnormalities of the feet. Perhaps even more important from the perspective of most aging Americans, major disability, functional impairment, and morbidity may be avoided by excellent preventive and restorative foot care. This article discusses the many ways that health care professionals, including physicians, nurses, podiatrists, and therapists, can address the special issues facing the elderly. Nursing and Long-Term Care Concerns of Foot Care in the Elderly 383 Ilene Warner Long-term care can no longer be thought of simply in terms of nursing homes. Rather, home health care, adult day care, and assisted VOLUME 20 NUMBER 3 JULY 2003 vii

2 living, in addition to nursing homes, encompasses the full spectrum of the delivery of long-term care services. Great variability is seen not only in the regulation of these industries but in reimbursement of the service providers. The nursing assessment of the geriatric foot, too, is dictated in some measure by the type of setting, the regulatory requirements, and the standards of care for that health care setting. Foot care of geriatric patients is examined in this article through the regulatory framework of long-term care providers. Foot Pain in Later Life: Some Psychosocial Correlates 395 Keeping patients walking has been a goal of the podiatric profession since its inception over a century ago. With the extremely high prevalence of foot problems in the elderly, and especially in those with chronic disease and mental impairment, the needs for the future are significant. To achieve the desired outcome of having podiatric services available to all aging patients, foot care must be integrated into all comprehensive forms of health care delivery, so that podiatric care becomes a primary service, thus permitting patients to maintain an optimal level of foot health and general health. We describe in this article a collection of problems that mark our aged of today and clearly indicate that primary foot care should be provided as a primary health service for the elderly, the mentally ill, the emotionally ill, the retarded, the blind, and others with chronic diseases. Podiatric Assessment of the Geriatric Patient 407 Given the high prevalence of foot problems in the elderly, especially in those patients who have chronic diseases and mental health problems, foot care is essential. Keeping patients walking is a goal that needs to be met if older persons are to maintain a high degree of quality in their lives. Foot health, care, and foot health promotion should be a part of comprehensive health care for older Americans. This article addresses the many foot health problems facing the elderly population and provides recommendations for providing foot care as a part of comprehensive health care. Assessing Onychial Disorders in the Older Patient 431 Disorders and diseases of the toenails (onychial) in the older patient are often the focus of the primary foot complaints. They may be a result of the aging process, the end result of repetitive microtrauma or historical major trauma, a complication or related clinical change associated with a multiple system disease or condition, or a localized foot problem. This article details the symptoms of and problems associated with onychial disorders in the elderly. viii

3 Assessing Hyperkeratotic Lesions in the Older Patient 443 Hyperkeratotic lesions in the older patient create pain and deformity, limit ambulation, and may predispose the patient to ulceration. These lesions have multiple etiologies, particularly in the older patient, including the normal physiological changes of aging, disease, deformity, changes in balance, shoe last incompatibilities, and inappropriate footwear. This article outlines the signs, symptoms, and management of hyperkeratonic lesions. Skin Disorders 453 Francine G. Schiraldi-Deck The purpose of this article is to provide a simple overview of skin disorders to help in assessing podogeriatric foot problems. In most cases, podogeriatric care is provided as a team approach to patient management. Health care providers have a combined responsibility to keep aging patients in good walking condition, pain-free, and mobile so they can be as independent as possible and have a high quality of life. Arthritis and Related Diseases of the Foot and Ankle: Rehabilitation and Biomechanical Considerations 469 James B. McGuire Arthritis and other rheumatic conditions are among the most common disabilities in the United States. Although arthritic conditions affect the knee and hip joints more frequently than the joints of the foot, disorders of the foot are particularly disabling. This article outlines the types of arthritis conditions affecting the foot and discusses strategies for management and rehabilitation. Foot Deformities: Biomechanical and Pathomechanical Changes Associated with Aging, Part I 487 Mark A. Caselli and David H. George This article reviews the most common foot deformities and pedal pathomechanical conditions that often result in pain and disability in the elderly. A description of the deformity or condition, its etiology, presenting symptoms, and various nonsurgical approaches to treatment are explored. The primary goal in all cases is to maintain or improve the patient s ability for comfortable, independent ambulation. ix

4 Foot Deformities, Biomechanical and Pathomechanical Changes Associated with Aging Including Orthotic Considerations, Part II 511 Kendrick A. Whitney As Americans above the age of 65 have become healthier and remain physically active, we are seeing an increase in lower extremity and foot problems. As life expectancy has increased in this fastest growing segment of the population, so have serious agerelated problems such as injuries from falls. Periodic lower extremity evaluations and appropriate therapeutic intervention may help to prevent many of these serious and debilitating conditions and injuries. An important aspect of the treatment plan for older adults may include the use of foot orthoses and optimal shoewear. Peripheral Vascular Considerations 527 Arlene F. Hoffman Arterial pathology of the lower extremity is common in the elderly. It has been the author s experience that most arterial pathology affecting the foot is caused by peripheral arterial occlusive disease, emboli, or infection. One of the most important factors determining whether healing will take place is the adequacy of the arterial blood supply. It is essential that health care providers be able to recognize whether the patient s blood flow is sufficient to maintain tissue nutrition or heal an ischemic ulcer, whether signs or symptoms presented by the patient are a result of an arterial system disorder, and, if arterial blood flow is compromised, whether the patient should be referred to a specialist. Lower Extremity Neurological Evaluation of the Older Patient 547 Samuel J. Spadone The phrase lower extremity neurological evaluation is a misnomer. The evaluation focuses on deficits that manifest in the lower extremity, but the expert knowledge of the competent examiner may indicate that the cause is remote from the lower limbs. Moreover, the skilled examiner must evaluate the patient in toto to determine the etiology of any abnormalities manifesting in the lower extremities. For these reasons and others, the neurological evaluation of the older patient is of particular importance and should be performed routinely. Assessing and Preventing Foot Problems in Older Patients Who Have Diabetes Mellitus 573 Foot problems in the older patient who has diabetes presents special challenges because of comorbid conditions and the aging process. The key to management is to prevent foot ulcers, infections, and x

5 other associated foot problems, thus permitting the older patient to remain a vital and independent member of society. We describe in this article a process and guidelines for proper referral for care and management that can be employed by all health care providers of the patient who has diabetes. Geriatric Primary Podiatric Medicine 583 The management of foot care for older patients, or podogeriatric care, is often provided as part of a team or interdisciplinary approach. The individual s podiatric and medical history, present problems, the effects of past illnesses and conditions, and the individual s (or their family s) ability to participate in the development of care plans should be taken into consideration. This article discusses various podogeriatric foot care issues and their effective management. Basic Considerations for Geriatric Footwear 593 Proper and appropriate shoes that fit well can help keep elderly patients walking. Footwear is needed for protection and should permit the patient to function as normally as possible. The shoe must function as a unit with the patient and be compatible with and supportive to the patient s functional requirements and ambulatory needs. Though selecting shoes for older patients should always place comfort and function above style, patients also need to function in society, making intelligent compromise a consideration for the patient s overall welfare. Surgical Considerations in the Geriatric Patient 607 Ellen Sobel and Renato J. Giorgini The geriatric patient has a high incidence of foot deformities and may be considered a good surgical candidate if healthy and psychologically ready for the surgical procedure. Foot problems in the geriatric population that may require surgical intervention can be grouped into approximately five categories, including (1) localized orthopedic disorders (ie, bunions, hammer toes, and so on); (2) skin and nail problems (ie, onychomycosis); (3) degenerative and inflammatory arthritis; (4) diabetic foot disorders; and (5) neuromuscular disease. Octogenarians undergoing major surgery enjoy long-term survival rates that equal or exceed those of the general elderly population. The reported mortality of patients over age 90 undergoing elective surgery is 2.3%. Index 627 Subscription Information xi