Foot Health Training Guide for Long-Term Care Personnel By Arthur E. Helfand, D.P.M. Foreword by Albert J. Finestone, M.D., M.Sc.

Copyright © 2007 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the author.

Introduction

Geriatrics is the branch of medicine that treats the problems of aging. It is more restricted in scope than gerontology, the scientific study of the clinical, biological, historical, and sociological aspects of old age. Podogeriatrics is the special area of podiatric practice that refers to the treatment of foot problems that affect aging individuals. Medical treatment of older adults presents a challenge because many of them have numerous physical problems that complicate and interfere with the diagnosis and treatment of any single illness. Diseases of one organ system place stress on other systems; furthermore, some diseases do not produce in older adults the symptoms that usually are seen in younger individuals. Many older adults also have nutritional deficiencies because of limited incomes, poor oral health, and other problems. In addition, older adults have increased risks for complications from surgery, and convalescence takes longer because damaged tissues recover more slowly. The longer periods of bed rest also can lead to pneumonia, bedsores, and circulatory disorders. Drugs are metabolized more slowly as well, and their effects are prolonged in the body.

EPIDEMIOLOGY

Old age has increasingly significant political, medical, economic, social, and demographic consequences for all nations. Although the percentage of people who are 65 years and older now ranges from approximately 13% to 20% in industrialized countries, these percentages, or the actual numbers that they represent, are expected to increase dramatically in the next few decades. Because of the increase in the number of older adults, gerontologists increasingly call the extremes of this population the "young-old" (65 - 75 years) and the "old-aged" (85 years and older). Although every society seems to have a socially recognized category of "old person," definitions of what old age is can vary depending on time, place, and culture.

Old age increasingly is determined by the reaching of a specific chronological age, usually 65, because this represents the common time of retirement from the work force and the age at which pensions, such as Social Security, usually commence. Aging usually is defined chronologically but may depend on an array of markers, such as physical change, loss of certain abilities, or change in social roles.

DISEASES THAT AFFECT FOOT HEALTH IN OLDER ADULTS

Some diseases that rarely occur in younger people become increasingly common among people who are older than 65 years. Among them are cardiovascular diseases, such as arteriosclerosis, angina, other heart disease, and strokes, which are common causes of disability and death. Older adults also have a higher prevalence of cancer, especially prostate cancer, multiple myeloma, chronic lymphatic leukemia, lymphoma, and basal cell carcinoma. Chronic diseases that develop earlier in life also often present severe health problems in older adults because the metabolism becomes slower with age. For example, gangrene of the foot may occur in older adults with diabetes because of reduced circulation in the extremities. Some diseases are of special concern in older adults, such as bone disorders. Osteoporosis, or decrease in bone mass, mainly affects women after menopause; the bones become brittle, and even minor injuries can produce major fractures.

Also limited to older adults is Paget's disease, the slowly progressive deformation of bone. Osteoarthritis, which affects all older adults to some degree, can cause joint deformities, swelling, and pain. When the weight-bearing joints are affected, instability can result; this may be a cause of falling and fractures. Some degenerative neurological diseases, such as Parkinson's disease, occur almost exclusively among older adults, as does accidental hypothermia, the sudden drop in body temperature in response to cooler air temperatures, which is caused by age-related changes in the nervous system.

Mental disorders of physical or other origin also are a problem of old age. Dementia is a progressive deterioration of personality and intellect that can occur in the seventh and eighth decades of life. Several causes exist, including small vessel hemorrhages in the brain, viral infections of the brain, severe head injuries, tumors, alcoholism, vitamin deficiencies, pellagra, multiple sclerosis, and even lead or carbon monoxide poisoning. Alzheimer's disease, which is caused by deterioration of brain cells, has similar symptoms but usually begins in the fifth or sixth decade of life. In addition, depression in older adults can manifest symptoms that are almost identical to dementia; loss of interest in life, memory lapses, and living in the past are common in both conditions. Problems such as the loss of a spouse and the stress of living on a fixed income account for the high frequency of depression in older adults; the suicide rate among people who are older than 65 years is the second highest of any age group.

PODOGERIATRICS

Podogeriatrics is the special area of podiatric medicine that focuses on health promotion; prevention; and the treatment and management of foot and related problems, disability, deformity, and the pedal complications of chronic diseases in later life. Podogeriatrics is a component of health care for older adults. The Doctor of Podiatric Medicine who provides care for the older adult is trained to prevent and manage the unique and often multiple foot and related problems of older adults. These conditions may be local or the result of complications that are associated with multiple chronic diseases as well as the changes that are associated with the aging process itself.

Given that older adults tend to react to illness, deformity, and disease differently than do younger individuals, care includes an understanding of the specific syndromes that older adults experience and the complexity of being a part of a team that manages multiple diseases. In most cases, podogeriatric care is provided as part of a team approach to patient treatment, which involves many professionals. Under consideration for management is the individual's podiatric and medical history, present problems, the effects of both past illness and conditions and the current problems, and the individual's ability to participate in the development of care plans. Issues that relate to foot complaints also include their relationship to falls, confusion, neglect, and the capacity to perform the simple activities of daily living. Social support also is a consideration in patient care plans.

In many cases, because foot and related problems are the primary complaint, the individual seeks podiatric care initially. This entry into the health care system becomes the starting point for total geriatric care, with appropriate referrals. Comprehensive podogeriatric assessment is a component of this process.

Looking toward the future, there are many projections for the role of the podiatric practitioner. They include the knowledge and the ability to render care that not only is therapeutic in a medical sense but also provides comfort in a social sense. Podiatric practitioners also must recognize the importance of research in the field of aging, particularly as it relates to foot health. Significant areas include care delivery, biomechanics, behavior, and social aspects of immobility and methods to improve access to podiatry services in an attempt to improve the health of older adults.

The purpose of this training guide is to help long-term care (LTC) personnel better understand the need for foot health and podiatric care that is rendered to older adults and those who have ongoing health conditions and reside in LTC facilities. It can be used as a teaching guide for in-service education and as a self-teaching guide for all levels of personnel. This guide provides information on components of care: 1) assessment and 2) skin, nail, musculoskeletal, neurological, vascular, and systemic conditions that involve the foot, toes, and related areas. Some of the objectives of this training guide are to help professionals understand more about the care that is provided by the health care system, what should be considered in relation to the quality of care, and the alternative methods of care programs that are available in LTC. A glossary is included at the end of the book for the reader's reference.