Nursing Care of the Aging Foot

Article Outline

• Abstract
• Foot Disorders
• Diabetes Mellitus and Foot Problems
• Nursing Assessment
• A Brief Primer on Orthotics
• Nursing Care
• References
• Biography
• Copyright

Feet are not necessarily the most attractive part of the body as it ages, and given the choice, most older adults would rather ignore them. In fact, many older adults cannot even see them, reach them, or care for them properly. And when they ache or look misshapen and oddly colored; well, that's just part of growing old, isn't it? The feet are important for weight bearing, balance, and mobility. Over an average life span, the feet are subject to considerable stress and trauma. Age-related changes of the foot predispose the older adult to discomfort if not pain, fungal infection, reduced range of motion, and itchy dry skin. More than three fourths of older adults (i.e., those age over 65 years) complain of foot pain that is associated with a significant foot problem and have evidence of arthritic changes on x-ray. Impaired ambulation can make the difference between independence versus dependency on others, engagement versus isolation. Assisted living is about choices. Being unable to get where one wants to go or do what one wants to do because of foot problems is a barrier to full enjoyment of the opportunities in assisted living communities. This article describes foot problems associated with aging, diabetes, nursing assessment of the feet, and nursing interventions in the service of accessing and optimizing choices for quality of life.

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• Ethel Mitty

The civilized man has built a coach, but has lost the use of his feet.

—Ralph Waldo Emerson

“Let your fingers do the walking” is perfect for scrolling through a telephone book, iPod, or a personal digital assistant, but it doesn't replace strolling from point A to point B. For that, we need feet. They are not necessarily the most attractive part of the body as it ages, and given the choice, most older adults would rather not discuss them. In fact, many older adults cannot even see them, reach them, or care for them properly. The feet are important for weight bearing, balance, and mobility. Aching feet affect feelings of well-being of self-efficacy. Washing the feet of a revered elder or religious leader is a sign of respect. Feet are part of our proverbial language: someone gets “cold feet”; someone has “both feet on the ground.”¹ The inability to ambulate, whether living at home or in a residential setting such as an assisted living community, can make the difference between independence versus dependency on others, self-determination versus restricted choices, engagement versus isolation.

Considering an average life span, the feet are subject to considerable stress and trauma. Age-related changes of the foot predispose the older adult to discomfort (if not considerable pain), fungal infection, reduced range of motion, and itchy dry skin.¹ More than 75% of older adults (i.e., those aged over 65 years) complain of foot pain associated with a significant foot problem and have evidence of arthritic changes on x-ray.¹ Complaints about the feet include itching, burning, numbness, tingling, resting pain, cramps/claudication, and foot or toenail infections.² Findings of reduced or absent pulses can indicate occlusion located near the foot or in the entire extremity.² Interestingly, foot pulses in older adults with hypertension can be a false indicator of adequate blood supply to the extremity.² Age-related changes in color of the feet can be reddishness and/or blueness (cyanosis). In most older adults, the foot can feel cool even in the presence of superficial infection.²

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Foot Disorders 

Foot disorders can be classified as orthopedic, skin and nails (integument), and systemic.³ Most disorders are the result of years of trauma of various kinds, obesity, osteoarthritis, rheumatoid arthritis, inflammation, gout, and osteoporosis. These processes appear in the feet as stress fracture, tendonitis, joint deformity, bursitis, neuritis, and gait imbalance.³ Unexplained severe foot pain should be investigated as a possible stress fracture.³

Osteoarthritis (OA) usually involves the ankle and big (or “great”) toe and causes stiffness, pain, and limited range of motion. It can be treated with nonsteroidal anti-inflammatory medications (NSAIDS), COX-2 inhibitors (that block prostaglandin production), and corticosteroid injections into the painful joints. Nonpharmacologic interventions that can reduce pain, increase range of motion, and improve ambulation include ankle joint exercise and foot orthotics.¹ Rheumatoid arthritis causes joint stiffening, deformity, and ankylosis and is treated similarly to OA. Periodic non-weight-bearing is highly recommended for both arthritic conditions.

Hyperkeratosis, the thickening of the outer layer of the skin that contains the protein keratin, is considered a normal reaction to soft tissue atrophy, repeat trauma, and pressure. However, it becomes problematic and causes significant foot discomfort related to local ischemia and tissue breakdown when it exceeds its protective function. Corns (heloma) are a result of friction and pressure from shoes on the bony protuberant areas of the toes. They are almost always painful and can become infected (including corns that develop between the toes). The classic over-the-counter remedies are ineffective; they damage healthy skin but have limited effect on the compacted skin that constitutes a corn. Attempts to excise the corn using a scissor, razor, or knife are likewise ineffective and dangerous.¹ Relief can be provided by wrapping moleskin or lamb's wool around the corn to relieve pressure. Debridement is effective, but a long-lasting cure requires ongoing pressure reduction. Calluses (tyloma) have a similar origin to corns, tend to occur on the soles and heels, and can be relieved by applying moleskin or lambskin to the pressure areas. Moleskin should be carefully removed after a few days or when it becomes soiled or wet.

Bunion (or hallux valgus) is a result of (pointy) shoe styles and, for some, genetics. Characterized as a “deviation” in the first joint of the big toe, the sideways (lateral) protrusion of a bunion causes discomfort and can affect walking. A conservative approach is to wear proper shoes, that is, those with a “wide toe box”¹ (p. 186). If the aesthetics of a bunion and/or its discomfort is significantly affecting quality of life, treatment options include corticosteroid injections, anti-inflammatory pain medications, and surgery. Hammertoe is also associated with years of wearing improper shoes and has similar adverse effect on balance and walking. Classic hammertoe is when the second toe is pushed up against, and under, the big toe. Overlapping toes, also known as “rotational toes” due to hallux valgus and OA, are also classified as hammertoe but are due to muscle atrophy and contracture of the long tendons.³ Hammertoe can lead to corn formation if shoes are ill fitting. Less likely to cause pain than the foot conditions just described, hammertoe can be relieved by a special custom-made shoe. Surgery can straighten out the hammertoe, but recovery can be painful and protracted.

Pain in the ball or plantar surface of the foot, metatarsalgia, has multiple causes, some of which can respond to low-tech interventions. Although the primary cause is loss of the fat pad in the ball of the foot, it is associated with obesity, a high arch, flat feet, bunion, and unequal leg length.¹ Primary treatment consists of relieving pressure on the metatarsal head, NSAIDS, and orthotics. Heel pain can be caused by a heel spur and/or loss of the fat pad beneath the heel (calcaneus). It is associated with years of wearing high heels but can also be caused by gout and rheumatoid arthritis. A “pump bump” or Hagland's deformity on the exterior aspect of the heel, is common among older adults and treated similarly as the other foot disorders.

Excessive skin dryness, xerosis, is associated with inadequate hydration and lubrication. Heel fissures are most commonly seen and are associated, as well, with heel stress.³ Because xerosis is considered a keratin disorder, treatment usually consists of application of a keratolytic, for example, a urea or ammonium lactate cream or liquid.

Ram's horn toenail is long and curved, hard and thick. Associated with poor circulation or trauma to the nail bed (matrix), this toenail condition rarely reverts to normal and has to be treated by a podiatrist.

Fungal infections, commonly of the toenails (onychomycosis), is evidenced by a dry scaly foot and brittle, thickened toenails. This condition represents 20% of all nail disease and is almost always found only among adults.³ It is caused by dermatophytes (a fungus that infects keratinized tissue) as well as some yeasts and molds. Infected nails have a white or brown-yellow discoloration with hyperproliferation of the nail bed and brown-yellow “debris” under the nail bed. A culture of the nail bed debris will be confirmative, but observation of these signs is somewhat conclusive even without culture. This condition is difficult to treat in the presence of peripheral vascular disease and diabetes. Medications such as Griseofulvin is associated with significant systemic effects and is not recommended for older adults.¹ More recently, newer agents such as fluconazole, itraconazole, and oral terbinafine (Lamisil) are reportedly effective and safe for older adults.³ However, itraconazole interacts with digoxin and warfarin sodium (Coumadin). Terbinafine is the only antifungal that can be taken orally but has reported interaction with tricyclic antidepressants, takes 3 to 4 months to be effective, and has a high relapse rate.³ A topical antifungal can prevent fissures between the toes but is marginally effective as a cure. Scrupulous drying of the feet and exposure to the air must be instituted.

Athlete's foot (or tinea pedis) is another common fungal infection of the foot that develops in the moist areas between the toes.⁴ The skin appears thick and scaly; complaints include burning, itching, and stinging. Thick, tight shoes and plastic shoes are predisposing risk factors. It can appear in combination with onychomycosis, or alone. The treatments described earlier can be used, as can clotrimazole (Lotrimin) and miconazole (Monistat-Derm); the oral medications carry the same risks.

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Diabetes Mellitus and Foot Problems 

Among all the diseases to which flesh is heir, diabetes mellitus is the most important—and quality-of-life-threatening chronic illness—that affects the feet of older adults. Data indicate that 50% to 75% of lower limb (including toe) amputations could have been prevented by comprehensive assessment, treatment, and patient education.², ³ Given the vision problems of those with diabetes which curtails their ability to see their feet and toes, reduced wound-healing process and time, neuropathy and sensory impairment, vascular insufficiency, and skin and muscle changes, the risk of foot problems is significant and can be life threatening.

Older adults with diabetic neuropathy affecting the feet are afflicted with paresthesia (defined as abnormal skin sensations such as burning, tingling, itching, and usually associated with peripheral nerve damage), reduced sensitivity to pain and heat or cold, reduced Achilles' reflex, skin color and hydration changes, loss of proprioception (defined as awareness of body/parts position, location, orientation, and movement), reduced ambulatory capacity, lessened sense of vibration, and a measurable difference in the size of their two feet.² Hyperkeratotic lesions are common, as are claw toes (i.e., hammertoes).² These lesions can cover or mask an ulceration below it, leading to infection and gangrene.² It is strongly recommended that older adults should be examined at least twice yearly to screen them for foot problems. Assisted living nurses can and should be part of an ongoing assessment and management strategy.

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Nursing Assessment 

Neurological assessment by a nurse should include the older adult's response to sharp and dull pressure points, their Babinski (superficial plantar) response, their Achilles' reflex, and complaints of burning and pain.² The Achilles' reflex, also known as the ankle-jerk reflex, is a test of the S1 and S2 (sacral spine) nerve roots and could be an indicator of sciatic nerve problem. It is delayed in hypothyroid disease. Holding the foot in dorsi-flexion (a right angle), the foot moves downward (it extends) when the Achilles' tendon is tapped. The Babinski response or sign is not a positive or negative finding; it is either present (the big toe points upward when the plantar surface is stroked) or it is absent. It is elicited by stimulating the outer portion of the sole (known as the plantar surface of the foot) by running a pin or needle along the surface from the heel to the toes. A firm stroke in the same direction using the thumb can also be done. The presence of the Babinski response in other than newborns (normal in the first few months of life) can be a sign of central nervous system disease.

Assessment of the feet and legs includes the following:

Comprehensive foot assessment can include gait and mobility assessment (as well as balance), heel strike, calf girth, leg length (are they the same?), and whether varicosities are present. Any positive findings should be recorded and reported, but absent or unequal pulses should be reported immediately to the primary care provider because it could indicate a life-threatening event, such as an arterial embolus or clot.

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A Brief Primer on Orthotics 

An orthotic is any device specifically fashioned to support or correct a musculoskeletal deformity.⁵ Various sciences and specialties come together to create orthotics: materials engineering, physiology, gait assessment and anatomical measurement, and psychology. Special shoes and orthotics (e.g., brace, arch support, bar) can relieve foot pain, stress, and trauma by weight diffusion and weight dispersion.³ Weight diffusion occurs by increasing the thickness of the sole of the shoe. Weight dispersion occurs by adjusting the insole or by using a specific orthotic to divert pain away from the area. Various kinds of padding, wedges, or bars are used to relieve discomfort and to restore or maintain balance and ambulation. Special shoes can provide extra depth, transfer weight-bearing pressure points, change gait pattern and stride, restrict joint motion, limit flexion and extension, and so on.

Medicare reimburses for depth-inlay and custom-model shoes and for “inserts” for beneficiaries with Part B Medicare. An MD or a DO (doctor of osteopathy) has to certify in writing that the individual has diabetes, suffers from a specific diabetes-related condition (e.g., poor circulation, history of leg/foot ulcers), and has a comprehensive illness management plan. Clearly this is a critical area for nursing assessment and documentation.

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Nursing Care 

Normal nails should be cut straight across and aligned with the end of the toe. If the nails are hard or brittle, soak the feet in warm water (15–20 min) before attempting to cut the toenails, or do it immediately after the bath or shower. Leg elevation and foot exercises can reduce edema, especially if done several times daily. Gentle reminding and learning by example—encourage your staff to put up their feet up periodically—is person-centered caring for both the residents and staff members.

A simple foot exercise consists of curling and uncurling the toes (known as “toe bends”) followed by ankle rotation, 5 to 10 times clockwise and then 5 to 10 times counterclockwise.¹ Foot massage is relaxing for the feet as well as the entire body, can reduce pain and edema, and can improve foot circulation and flexibility.¹ However, massage should not be instituted without checking with the resident's physician/primary care provider because some vascular issues might be a contraindication to foot massage. Space does not permit inclusion of the steps of a foot massage procedure, but several Web sites provide safe instruction. It always starts with warm, slightly lubricated hands and a warm heart—just like a back rub.

Good foot care includes daily inspection. A lotion or oil (e.g., cocoa butter, aloe, lanolin, vegetable oil) should be applied after the skin has been blotted, not rubbed, dry but should not be applied between the toes. A daily foot soak is pleasant but not recommended for residents with diabetes. As noted earlier, a foot soak might be needed to soften the toenails so that they can be trimmed (straight across). A podiatrist should be involved in toenail care if they are thick, appear infected, and so on. The old adage “breaking in my new shoes” was more likely that the shoes were breaking in the feet of the wearer. It is suggested that new shoes should be worn just for an hour for the first few days, increasing the time slowly.¹ Good-quality athletic shoes (“sneakers” or gym shoes) with some degree of support are recommended, as are shoes with broad toe space and low heels.¹ They enhance balance and gait stability.

Paraphrasing Charles M. Schulz (the creator of the comic strip Peanuts) and in the interest of continuing engagement with the natural and constructed environment: “Walking is very beneficial. It's good for your legs and your feet. It's also very good for the ground. It makes it feel needed.” The feeling is mutual.

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References 

1. Ebersole P, Hess P, Luggen AS. Toward healthy aging. Human needs and nursing response. 6th ed.. Amsterdam: Mosby/Elsevier; 2004;
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2. Helfand AE. Foot problems. Peripheral arterial, sensory and diabetic problems. In:  Capezuti EA,  Siegler EL,  Mezey MD editor. The encyclopedia of elder care. 2nd ed. New York: Springer Publishing Company; 2008;p. 316
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3. Helfand AE. GNRS. Geriatric nursing review syllabus. 2nd ed.. New York: American Geriatrics Society; 2007;
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4. Mayo Clinic. www.mayoclinic.com/health/athletes-foot/DS00317. Accessed July 1, 2009.
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5. Wikimedia Foundation, Inc. http://en.wikipedia.org/wiki/Orthotics. Accessed July 1, 2009.
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