Preventing Limb Loss Among Aging Patients Living With Diabetes & DFUs

The prevalence of foot ulcers among aging diabetes patients is not expected to improve any time soon. What can wound care providers in the outpatient clinic do to help their patients avoid limb loss?

As of 2012, 29.1 million people in the United States are living with diabetes and eight million people among this cohort are living with the disease undiagnosed, according to the American Diabetes Association. When considering those who are living with prediabetic conditions, this number increases to include nearly half of the U.S. population.¹ Also, recent data by the Centers for Disease Control and Prevention show 4.3 million people ages 20-44 are living with some type of diabetes and about 208,000 people younger than 20 have been diagnosed with diabetes today. But this is not strictly a “young person’s disease.” Unfortunately, the number of patients within the Veterans Health Administration living with diabetes is high — 25%, according to the U.S. Department of Veterans Affairs (VA). 

As wound care clinicians well know, diabetes is a chronic condition that comes with a host of complications requiring daily management that very often lead to the development of chronic wounds — namely diabetic foot ulcers (DFUs) — particularly when patients do not effectively manage their disease on a daily basis. Nearly 25% of all patients living with diabetes will develop a DFU, an open sore, or wound on the foot, and 14-24% of patients living with a DFU have already undergone an amputation of a toe, a foot, or more, according to the Amputee Coalition, a nonprofit organization based in Manassas, VA, that seeks to empower people affected by limb loss to achieve education, support, and advocacy. In fact, DFUs are the leading cause of nontraumatic lower limb amputations in this country, according to the Amputee Coalition. If there’s a silver lining to these unsettling statistics, however, it’s that the majority of lower extremity amputations are preventable. 

The challenge for today’s practitioners caring for patients in the outpatient clinic setting has become providing appropriate care of DFUs, as well as patient education on self-care and prevention, in an attempt to keep DFUs from leading to actual limb loss. As Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure,” and that couldn’t be more true than when it comes to diabetes, DFUs, and preventing amputations. This article will help wound care clinicians establish a basic set of everyday steps with their patients to collaboratively prevent DFUs from leading to amputation as well as to potentially prevent these wounds overall.

Recommendations for DFU Prevention² 

What follows is an outline for wound care providers to communicate to their patients that will also assist in monitoring their progress during clinic visits.² Patients should be taught to: 

• Conduct daily inspections of their feet. (Encourage patients to look at the entire foot, the sides of their feet, the heel, the toes, and the skin between their toes. The use of mirrors with extensions to assist in these inspections is also suggested.).
• Clean and dry their feet daily, including between the toes. (Instruct patients to use mild soap and water, making sure they are in a stable position while in the shower or bathtub to avoid slips or falls. A clean, dry towel to pat — not rub — feet dry is also advised.) 
• Bathe their feet in room temperature water — not hot water.
• Wear clean (preferably white) socks that are not too tight each day.
• Avoid walking barefoot.
• Always let their healthcare providers know immediately if a cut or foot problem (such as pain, swelling, foul odor, numbness, etc.) occurs.
• Attempt to stay off their feet if they have a cut and to seek their podiatrist’s advice as to how much walking can safely be done.
• When purchasing new shoes, do so late in the day or early evening because feet tend to swell during the day.

Considering VA Strategies

Breaks in the skin of one’s feet can lead to gangrene and/or amputation and, unfortunately, all types of foot ulcers are associated with high morbidity and high mortality. One study found patients living with a DFU that led to an amputation had a five-year mortality rate of 47% while patients who had an ulcer that healed fared only slightly better with a five-year mortality rate of 43%.³

The VA is a unique system and is especially equipped to engage in preventative medicine. Clinicians are trained to identify patients at risk based on electronic health records (EHRs) and diagnosis codes already in the system. For example, when a patient is diagnosed with diabetes or end-stage renal disease, the EHR notifies the primary care doctor that the patient needs a foot evaluation.  

Once patients are identified as “at risk,” clinicians take steps to ensure their disease is controlled properly. In the case of diabetes, some of these steps include glycemic control, smoking cessation, and regular podiatric care. Once patients are under the care of the podiatrist, they are examined at each visit in an effort to re-identify the risk level to ensure proper documentation occurs in the patient’s medical chart. Then, a list of educational steps is displayed by the EHR so that self-care behaviors and communication from the doctor can be reinforced for what’s required at home. 

That said, an assessment as to whether or not patients will be able to complete their at-home care routine is also part of the clinical agenda. Simply providing self-care education once has not been found to be effective. As medical professionals, wound care providers must assess whether or not patients can be expected to take the proper steps to care for themselves. For example, a question to always consider asking is, “Are you or your caregiver having any difficulty examining your feet and, if so, why?” This allows the clinician to know if, perhaps, patients cannot see their feet due to vision impairment or are having difficulty maneuvering their feet to see them properly. These specific questions can help to intervene and provide the necessary tools for proper foot care at home. 

Jeffrey Robbins is the director of podiatry service, Veterans Affairs Central Office, Washington, DC, and chief of the podiatry section, Louis Stokes Cleveland VA Medical Center.

References 

1. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the united states, 1988-2012. JAMA. 2015;314(10):1021-9.

2. Department of Veterans Affairs Expert Holds Diabetes Awareness Month Educational Webinar for Veterans on Diabetic Foot Care and Limb Loss Prevention. Amputee Coalition. Accessed online: www.amputee-coalition.org/preventing-secondary-limb-loss-webinar

3. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003; 26(2):491-4.