Most older people have at least one chronic foot problem, and it’s often up to you to catch them before they become really serious.

Even elderly patients who are able to look after themselves seldom pay much attention to their feet. This assessment needn’t be time consuming. It just requires careful inspection while bathing or turning the patient and noticing whether he favors one foot or limps when he walks.

Take your assessment all the way down to the toes

The problems to watch for

The most common foot problems in the elderly are caused by pressure and trauma.

Corns and calluses are thickened areas of skin caused by a shoe pressing against bone. Corns are raised; calluses are flat. If neglected, either can ulcerate and become infected.

Your patient needs properly fitting shoes that allow his toes to spread. If he does not want to invest in a new pair, perhaps a shoemaker can stretch the ones he’s wearing. Open-toed sandals are another possibility.

To relieve pressure, the patient can put pieces of lamb’s wool between his toes. To reduce calluses, he can rub them with a pumice stone after bathing or soaking his feet in warm water.

Bunions are swellings at the joint of the big toe. They are caused by a deformity, usually congenital, in which this toe bends inward, exposing the joint to friction. The bony prominence becomes enlarged and covered by a bursa-a fluid-filled sac. Shoes that are too tight or have seams that cut across the bony part of the foot may also be at fault.

Suggest well-fitting, low-heeled shoes. Bunion pads may ease discomfort. Walking more slowly appears to keep bunions from getting any larger. In some cases surgery (a bunionectomy) may be called for.

Hammertoe, a flexion-extension deformity of the joints, leaves the toes looking like claws. It is often seen in conjunction with bunions and can cause the formation of corns and calluses. The problem usually results from wearing shoes that are too short. Again, stretching or replacing the shoes for proper fit is in order. Also advise the patient to avoid tight stockings.

If hammertoe is too severe to be accommodated by proper shoes, surgery may be necessary.

Onychauxis is a thickening of the toenails due to aging, nutritional problems, repeated trauma, local infection, or degenerative disease. Because it’s difficult to trim such hard nails, they may grow long enough to cut adjacent toes, causing infection.

Tell the patient to use a nail brush regularly to clean and soften the nails. He should also file them often to keep them short and even. If he can’t manage to do the clipping or filing himself, he should visit a podiatrist.

Onychocryptosis, also known as ingrown toenail, occurs when a portion of the nail penetrates the nail groove. A common cause is cutting the toenails too short or rounded at the corners, not straight across.

Treating this condition involves elevating the foot, cutting off the ingrown portion of the nail, using soaks, and packing the area until the corner of the nail grows beyond the nail groove. The patient may be placed on antibiotics if a secondary infection develops. In any event, he should be taught how to trim his nails so the problem doesn’t recur.

Diseases that endanger the feet

Three types of arthritis can also contribute to foot problems.

Osteoarthritis causes degeneration of cartilage between the bones, resulting in pain when the patient moves his toes. Rest, analgesics, and heat therapy can give relief.

Rheumatoid arthritis, which attacks connective tissue, can cause hammertoe and dislocation of the toe. Symptoms include pain, redness, and heat at the affected joint. The patient may tire easily, run a low-grade fever, and have no appetite. Again, heat therapy and analgesics may be useful, along with anti-inflammatory drugs. Physical therapy may relieve stiffness. The patient should get plenty of rest, especially during the acute phase of the disease. At some point, surgery may become necessary.

Gout is a metabolic disorder that is caused by excess uric acid in the blood. It results in inflammation of the joints-generally those of the big toe or instep. The joint becomes painful, swollen, and very tender, and the patient may have headache and fever as well. During acute attacks he may be bedridden.

Since attacks of gouty arthritis can become chronic and disabling, early diagnosis and treatment are important. A combination of antiinflammatories and medications to promote excretion of uric acid can control the disease. Instruct the patient to eat a balanced diet and drink plenty of fluids.

As troublesome as arthritis can be, peripheral vascular disease is of greater concern. PVD limits the supply of blood to legs and feet. As a result, foot wounds heal slowly.

Pain in a leg or foot is the most common symptom of PVD. Other signs are diminished pulses and changes in skin texture, temperature, and color. For example, the leg may turn pale after it’s elevated for 30 seconds, or deep red-a condition called dependent rubor-when he sits with his feet on the floor. Other symptoms include tingling, burning, or numbness in the foot and hair loss on the leg.

Once a diagnosis of PVD has been made, check the patient frequently for cuts, skin changes, and ulcers. Report any changes to the physician immediately. If a foot infection develops, it will be very difficult to treat, and amputation may be the end result.

Close monitoring for diabetic patients

Diabetes, a chronic condition frequently associated with PVD, can also have a devastating effect on the feet. That’s because hyperglycemia, along with chronic hyperlipemia, reduces blood flow to the small arteries and causes neuropathy. A diabetic patient may not even be aware of a blister, cut, or ingrown toenail. Thus, he’s prone to infection, and if that infection goes undetected for too long, he risks losing his foot.

Teach him to examine his feet every day. If he can’t see well or can’t reach his feet because of obesity or arthritis, he can use a mirror or have someone else cheek for redness, cracks, blisters, and open drainage.

If he develops a foot infection, he must contact his physician immediately. In fact, even if everything is all right he should have a physician or podiatrist cheek his feet at least once a year.

By diligently assessing your elderly patient and teaching him the importance of cheeking his own feet, you can prevent foot problems or detect them before they become serious. If your patient has a chronic foot condition, you may be able to prevent it from becoming worse. By helping him to retain some degree of mobility, you’ll be giving him a chance at a more useful and satisfying life.

Tips on foot care

Give your elderly patient this advice:

  • Wash and inspect your feet daily. Carefully dry between the toes, as wetness in this area can cause infection. If you cannot perform these tasks, get someone to help you.
  • Trim your toenails straight across, never down at the corners. Again, seek help if you are unable to trim them yourself.
  • Soften dry skin with lanolin lotion or vegetable shortening. Always apply such a lubricant after bathing to seal in moisture.
  • Wear clean socks daily.
  • Wear shoes with broad toes and low heels.
  • Avoid garters and tight-fitting shoes or stockings-all of which tend to interfere with the circulation. For the same reason, avoid sitting with your legs crossed.
  • Stop smoking, or at least try to cut down.
  • Exercise If you’re wheelchair-bound, try these exercises several times a day when lying down: Flex and extend your ankles six times; rotate your feet in a clockwise direction six times, then counterclockwise six times.
  • Report foot injuries promptly to your doctor.
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