Prevalence of Foot Problems in Nursing Home Residents With Diabetes Stratified by Dementia Diagnosis

 Longer life expectancies are increasing the prevalence of type 2 diabetes mellitus. In 2010, 8.3% of the US population was affected by diabetes (18.8 million diagnosed and 7 million undiagnosed).¹ Adults aged 65 years and older share a disproportionate amount of the burden of diabetes. In 2010, approximately 42% of the US population with diabetes was aged 65 years and older,¹ and this proportion is projected to increase to 58% by 2050.² The increasing prevalence of diabetes among older adults is alarming, as individuals with diabetes experience greater risks of physical impairment, cognitive decline, and medical complications as they age.^2,3 One common complication is foot problems, which often result from macrovascular disease. This disease is caused by metabolic injury to large blood vessels, including those supplying oxygen to the lower extremities. Decreased circulation to the peripheral nerves results in the damage or death of nerve tissue, which makes it difficult for patients to feel any injuries to their feet. When these foot injuries go untreated, they can lead to ulceration, gangrene, osteomyelitis, amputation, and increased morbidity and mortality. In addition to loss of sensation from nerve damage, diabetes affects the feet in other ways. For example, decreased blood supply and high blood glucose levels are associated with decreased wound healing. In some cases, wound healing does not occur and amputation is required to prevent mortality. In the United States, more than 60% of nontraumatic lower-limb amputations are performed in people with diabetes,¹ but even after amputation, the mortality rate remains high, ranging from 39% to 80% at 5 years.⁴

The increasing prevalence of diabetes and its associated complications have led to increased care burden. Among nursing home residents, the burden is even greater when it is paired with dementia. When patients have both conditions, care challenges are amplified. For example, these patients may have difficulty explaining symptoms related to their foot problems, they may not remember foot education instructions, and they may not agree to take their shoes and socks off while being examined by a healthcare provider. For such reasons, this population requires different medical care strategies compared with cognitively intact persons.

Along with increased care burden, diabetes has a significant impact on healthcare costs. It has been reported that 20% of patients with diabetes are admitted to hospitals because of foot problems.³ In 1998, the average annual acute hospital costs for a diabetic foot ulcer was estimated at $9910, and the direct cost of an amputation resulting from a diabetes-related foot problem was between $30,000 and $60,000.⁴ However, healthcare costs are not just increased when hospitalization occurs. A study from 2004 showed that ulcer-related costs are high regardless of the setting in which they are treated.⁵ In the study, the total ulcer-related costs averaged $13,179 per episode and increased with severity level, ranging from $1892 (level 1 ulcers) to $27,721 (level 4/5 ulcers). An interesting finding of this study was that older adults (>65 years) actually had significantly lower total ulcer-related costs than younger patients, at $11,925 versus $16,390, respectively (P=.02). Costs were also significantly lower for patients with adequate vascular status, with a cost of $5218 compared with $23,372 for those with inadequate vascular status (P<.0001).⁵

Due to the increased risk of foot problems among individuals with diabetes, the American Diabetes Association (ADA) guidelines recommend that persons with diabetes receive a comprehensive annual foot examination by a professional clinician to identify risk factors for ulcers and amputations, test for loss of protective sensation, and assess pedal pulses (Table 1).^6,7 The ADA also recommends that patients with diabetes receive foot self-care education. Although this can be an important measure for cognitively intact residents, those with cognitive impairment may not be able to comprehend or follow through on these recommendations; thus, annual foot examinations are especially crucial for this population, and any educational initiatives should be tailored based on residents’ cognitive abilities. In addition, persons with diabetes who are at higher risk for amputation (eg, history of foot ulcers or amputation), peripheral vascular disease, or neuropathy should receive foot examinations more frequently to prevent foot amputations.⁷ A multidisciplinary approach is recommended for managing foot problems in patients with diabetes,⁸ and this approach may be even more important for residents who have cognitive impairment and other comorbidities to ensure all issues are adequately addressed.

The prevalence of foot problems among persons with diabetes treated in a variety of settings, including outpatient clinics, community clinics, and diabetes clinics, have been examined, but the prevalence of foot problems among nursing home residents with diabetes remains largely unknown. Yet knowledge of the prevalence rates of foot problems in nursing home residents is important to design evidence-based programs that effectively identify and manage foot problems in frail, older persons who are at higher risk of foot problems and their associated complications. The purpose of this cross-sectional study was to understand the prevalence of foot problems among persons with diabetes in three nursing homes in southern Florida, and to examine the nature of the documentation of foot problems and follow-up treatment by the nursing home staff in these facilities.

We retrospectively reviewed the medical charts of 103 patients with type 2 diabetes mellitus with and without dementia from three nursing homes near Fort Lauderdale, Florida, to assess the prevalence and types of foot problems in these facilities. We stratified the charts by dementia diagnosis to examine whether the residents with dementia experienced any differences in foot problems compared with residents without dementia. During the medical chart review, we extracted detailed information that included the patients’ demographics (Table 2), cognitive function, history of foot problems, and resolution of foot problems.

Almost 70% of the total patient population had foot problems, ranging from dry red skin to amputation. Overall, patients with and without dementia had comparable types and frequencies of foot problems (Table 3); however, patients with dementia had a higher percentage of calluses (12%) than patients without dementia (6%), but they had a significantly lower prevalence of ulcers (14% vs 48, respectively). We found a total of four amputations, three (7%) in the dementia group and one (3%) in the cognitively intact group. Of these amputations, two involved toes and two were of feet. One of the foot amputations occurred in the cognitively intact patient. Edema was documented in 32% of the total patient population. Approximately 28% of patients with foot problems with and without dementia had a history of foot ulcers, and most of these patients also had a history of dry flaky skin and edema.

In each of the three facilities, the residents had a complete foot examination upon nursing home admission and at every readmission; however, specialist referral and documentation procedures differed across the nursing homes. Almost 90% of patients from site 2 had documented specialist referrals, if required. We could not establish these percentages for sites 1 and 3 due to difficulties deciphering the medical records. Site 2 had better follow-up and overall chart documentation as compared with the other two nursing homes; foot examinations, including assessment of foot structure, visual examination, palpitation, documentation of wounds and calluses, skin check, appropriate follow-ups, and specialist referrals (eg, to podiatry and wound care) were consistently documented in the medical charts of this nursing home. Comparatively, in the other nursing homes (sites 1 and 3), documentation of calluses, wounds, and pedal pulses was inconsistent and scattered in the patient charts. Even though foot assessment and nail care were part of the routine examination in these nursing homes, follow-up examinations were rarely documented.

The charts at all three sites were paper-based and the handwriting in the charts was difficult to read. We observed that the documentation of patient education regarding foot care was missing in the patient charts from all three nursing homes. Even though all of the charts were paper-based, there was no specific form in the charts in which the nurses could document patient education about foot self-care.

Our study suggests that incomplete documentation of foot assessments can pose a significant risk to residents, especially because a history of foot problems is an important factor for determining the risk of future foot problems. Although it is unclear exactly why there were incomplete assessments in our study population and a lack of documentation, we suspect the following factors may have contributed: (1) lack of clinical expertise to guide a systematic approach to foot problems; (2) lack of time from staff who can help with documentation; and/or (3) lack of continuous education on the importance of foot assessments and foot care education.

The ADA requires the use of the monofilament examination and a tuning fork in foot assessments^6,7; however, in all of the three nursing homes included in our study, we did not find documentation that any of these methods was used. In addition, the facilities did not have a podiatrist see all patients with diabetes; only those who were referred saw this specialist. Yet a podiatrist can help identify patients who are candidates for and might benefit from diabetic shoes and insoles (eg, persons with peripheral arterial disease or neuropathy), both of which are covered by insurance. They can also help establish footwear policies, which are lacking in most nursing homes, but can help keep at-risk feet healthy while preventing other common problems, such as falls.

As previously stated, we found that patient education, specifically for those without dementia, was missing from the documentation, yet this is an integral part of foot care practice. Additionally, certified nursing assistants who function as important personnel in the daily care of persons with diabetes have no systematic process to document their work on foot assessment or foot care education. One possible explanation for this is that the documentation system of the facilities is lacking. All three facilities still used paper-based charts for documentation, and with such systems, adding more forms or assessments would increase the burden of reporting.

Implications for Practice

Preventing diabetic foot complications and providing treatment for foot problems requires an interprofessional, team-based approach^8-10; however, coordination between team members can be difficult, particularly in the long-term care setting where many healthcare providers from outside facilities may be involved. There are also the competing demands of each staff member’s tasks to contend with. For example, long-term care facilities are often understaffed and have high turnover, requiring more inexperienced staff to be hired. As a result, staff may be burdened just by addressing patient care demands, and increasing documentation requirements may place even more strain on already thin resources. At the same time, not documenting foot examinations and other important clinical data can compromise patient care and lead to complications that can ultimately increase patient care demands.

One opportunity to improve documentation is to adopt electronic health records, an important health information technology. Electronic health records have shown promise to support quality improvement initiatives in other healthcare settings,¹¹ and adoption in nursing homes would strengthen the identification of patients with diabetes who are at risk of developing foot problems and may require immediate treatment. This could be accomplished through the development and use of a detailed foot care assessment template, such as provided by the US Department of Health and Human Services.¹² The use of technology could further support the ongoing quality of care of foot problems through user alerts for annual foot examinations for patients with diabetes, and by generating user-friendly management reports to support follow-up treatments and resolve foot care problems.

In the absence of using electronic health records and foot assessment templates in the nursing home, nurses can document foot assessments through their weekly notes. When doing so, nurses should print their names along with their initials in the charts, rather than signing them, as it is difficult to analyze, update, or follow patients when signatures cannot be deciphered.

Comprehensive interprofessional foot care training sessions should be reinforced to minimize the research and knowledge gap of healthcare professionals. These training sessions can improve regular foot examinations, lead to more effective foot care education, increase the likelihood of detecting wounds early, ensure appropriate referral of patients, and prevent amputations. These training sessions can be provided as an in-service in nursing homes every 3 months or upon new staff being recruited. Training formats, structure, and content can vary, depending on the learning needs of the staff.

Patient education is an important component of proper foot care, but because nursing homes house people with different cognitive and physical abilities, patient education needs to be tailored to work within a patient’s capabilities. While handouts or videos may be helpful for individuals who are cognitively intact or only minimally impaired, they are unlikely to be useful for persons with more profound cognitive impairment, as these patients’ ability to communicate and process educational materials may be limited. In such persons, ongoing foot assessments are paramount to ensuring any foot problems are identified before they become life-threatening.

With the rise in the prevalence of diabetes complications among older adults, it becomes imperative to prevent foot problems at an early stage. Several prevention strategies, including frequent foot examinations, appropriate patient education, and timely referrals, can help ensure early diagnosis and treatment to prevent foot complications and lower-extremity amputations. Such strategies can be aided through the development and adoption of health information technologies and user-friendly foot assessment templates embedded within electronic health records, as well as interprofessional foot care training for nursing home healthcare professionals.

Authors: Sweta Tewary, PhD, MSW^1,2 • Naushira Pandya, MD, CMD^1,2 • Nicole Cook, PhD, MPA³

Affiliations:

¹Geriatric Education Center, College of Osteopathic Medicine, Nova Southeastern University, Fort-Lauderdale-Davie, FL

²Department of Geriatrics, College of Osteopathic Medicine, Nova Southeastern University, Fort-Lauderdale-Davie, FL

³Masters of Public Health Program, College of Osteopathic Medicine, Nova Southeastern University, Fort-Lauderdale-Davie, FL

Disclosures: The authors report no relevant financial relationships.

Address correspondence to:
Sweta Tewary, PhD, MSW
3446 South University Drive
Fort Lauderdale, FL 33328
st813@nova.edu