The initial evaluation of the older patient should include a comprehensive assessment and risk stratification process. A comprehensive podogeriatric and chronic disease assessment protocol (Helfand Index),⁵ developed for the Pennsylvania Department of Health, enables practitioners to initiate a diagnostic and risk stratification procedure that includes multiple elements. The comprehensive assessment tool can be used to assess both pathology and risk factors. These elements include demographics, history of present illness, and past medical history. Current prescriptions and over-the-counter medications should be noted.⁶

The dermatologic evaluation should include but is not limited to the following: hyperkeratosis, bacterial infection, ulceration, cyanosis, xerosis, tinea pedis, verruca, hematoma, rubor, discoloration, and preulcerative changes. The foot orthopedic assessment includes but is not limited to the following: hallux valgus, hallux rigidus limitus, anterior imbalance, Morton’s syndrome, digiti flexus (hammertoes), and bursitis.7–9

The peripheral vascular evaluation should include but is not limited to the following: coldness, trophic changes, palpation of the dorsalis pedis and posterior tibial pulses, the history of night cramps and/or claudication, edema, atrophy, varicosities, atrophy, and other findings. Amputation or partial amputation should be noted. The neurologic evaluation should include but is not limited to the following: Achilles and superficial plantar reflexes, vibratory sense (pallesthesia), response to a loss of protective sensation, sharp and dull reaction, joint position, burning, and other findings.¹⁰

Identifying complicating foot problems

The primary manifestations in the foot include but are not limited to the following: plantar fasciitis, spur formation, periostitis, decalcification, stress fractures, tendonitis, tenosynovitis, residual deformities, pes planus, pes cavus, hallux valgus, digiti flexus (hammertoe), rotational digital deformities, joint swelling, increased pain (podalgia), limitation of motion, and pain and a reduced ambulatory status (pododynia dysbasia).¹¹

Diabetes and foot care

The older diabetic patient presents a special problem in relation to foot health.¹² It has been projected that 50% to 75% of all amputations in the diabetic can be prevented by early intervention where pathology is noted, by improved foot care health education, and by periodic assessment prior to the onset of symptoms and pathology (secondary and tertiary prevention). The elderly diabetic is a patient with all of the problems related to the disease itself. These include vascular impairment, the degenerative changes of aging, neuropathy, dermopathy, and marked atrophy and deformity related to both diabetes mellitus and aging. These factors are also complicated by the social restrictions related to these multiple pathologies.¹³^,¹⁴

The older diabetic patient presents a special problem in relation to foot health. It has been projected that 50% to 75% of all amputations in the diabetic can be prevented by early intervention where pathology is noted, by improved health education, and by periodic evaluation prior to the onset of symptoms and pathology (secondary and tertiary prevention).

The older diabetic patient with neuropathy has insensitive feet that will usually exhibit some degree of paresthesia, sensory impairment to pain and temperature, motor weakness, diminished or lost Achilles and patellar reflexes, decreased vibratory sense, a loss of proprioception, xerotic changes, anhidrosis, neurotrophic arthropathy (Charcot), atrophy, neurotrophic ulcers, and the potential for a marked difference in size between two feet. There is a greater incidence of infection, necrosis, and gangrene.¹⁵ Vascular impairment adds pallor, a loss, or decrease in the posterior tibial and dorsalis pedis pulse, dependent rubor, a decrease in the venous filling time, coolness of the skin, and trophic changes. Numbness and tingling as well as cramps and pain can be demonstrated. There is usually a loss of the plantar metatarsal fat pad that predisposes the patient to ulceration in relation to the existing bony deformities of the foot and repetitive microtrauma.^15–17

Hyperkeratotic lesions form as space replacements and provide a focus for ulceration because of increased pressure on the soft tissues with an associated localized avascularity from direct pressure and counterpressure. Tendon contractures and claw toes (hammertoes) are common. A warm foot with pulsations in an elderly diabetic with neuropathy is not uncommon. When ulceration is present, the base is usually roofed by hyperkeratosis that retards and many times prevents healing. Necrosis and gangrene are associated with infection with eventual occlusion and gangrene. Foot drop and a loss of position sense may be present. Pretibial lesions are indicative of this change as well as microvascular infarction. Arthropathy gives rise to deformity (Charcot), altered gait patterns, and a higher risk for ulceration and limb loss.

Risk assessment models similar to one used in the Department of Veterans Affairs Prevention of Amputation and Treatment Program can identify patients at risk for foot wound and amputations and those at high risk. It involves assessment for disease procurers, in this case peripheral vascular disease, loss of protection sensation, and foot deformities, and assigning a risk level to each patient. A management and referral algorithm is used to quickly refer those patients at high risk for care and schedule those at lower risk for ongoing surveillance. This is always coupled with foot care health education and follow-up on adherence of those behaviors.18–20

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