Older people often need podiatry attention and predominate in foot clinics. Their management requires special attention to the effects of age on the foot. Good foot care in elderly people demands an awareness of risk, cautious surgical intervention, punctilious hygiene and sterility in procedures, to avoid infection and ensure satisfactory outcome. Professional failure to meet this challenge can result in infection, morbidity and loss of mobility.
The ageing process is associated with physiological changes, increased incidence of comorbidity, iatrogenic illness and functional disability.3,4,5 Changes which occur in cardio-pulmonary and neurological function, cell-mediated immune and metabolic responses, skeleton and skin structure can create foot problems or affect the treatment of foot conditions.


Senescence and function
Atherosclerosis and decreased arterial blood oxygenation brings poorer blood flow to extremities. Impaired renal function, obesity, or sluggish venous circulation can cause peripheral oedema and slow healing. Decline in immunity is associated with increased vulnerability to infectious agents.
Ageing also affects response to inflammation and wound healing proceeds more slowly. Thinning of the skin occurs as the rate of cell production slows in the epidermis. The dermis becomes thinner, and more “papery” with fewer elastin fibres, increasing risk of injury and bacterial skin entry. Loss of subcutaneous fat reduces “padding” with bone protuberances more prominent and subject to trauma if in the feet. Metabolic impairments result in a slower healing process and higher risk of infection in skin lesions affecting feet. Impairment in memory, loss of concentration, impairment in focus and judgment, can affect personal foot care and awareness and the patient may be incapable of giving an accurate clinical history.6-10
Bone formation is affected by reduction of osteoblast differentiation, activity, life span and increased osteoclast activity. Resultant osteoporosis can bring fracture and bone thinning, which can affect feet. Skeletal structure alters with intervertebral discs flattening, cartilage changes, spinal shortening and loss of elasticity in tendons, bringing flattening of the feet with foot-spread. This results in new pressure points and resultant bunions and callosities.
At 70 years, 30% of people have impairment of vision affecting their ability to carry out personal foot care. Neuropathy can diminish the awareness of pain and sensation in peripheral extremities and tenderness and pain may not be experienced. Immobility is not commensurate with ageing, but many older people lose suppleness and mobility, fail to exercise lower limbs and postural fixation impairs circulation to feet. Poor balance and impaired proprioception can result in foot trauma.11-12


Chronic morbidity
Chronic morbidity may impinge upon foot health and management. Cardiac and coronary insufficiency may impair blood flow with cyanosed feet, starved of oxygenated blood resulting in delayed healing and poorer skin protection. Stroke disease can affect limbs, alter balance and walking, and bring changed demands on feet and impaired function.
Lung conditions can reduce oxygenation and impair peripheral tissue response to infection in the feet.


Medications
Routine medication can cause peripheral oedema, impairment of peripheral circulation, or affect immunity and healing. For instance steroid preparations reduce immunity and increase risk of infection. Anti-clotting agents can change bleeding time—a consideration for the podiatrist wielding a scalpel. Podiatric anti-infective and anti-fungal agents can react adversely with conventional systemic drugs.


Management considerations
The aged foot needs an individualised care response
based on:

Risk assessment
• Clinical history of current and past illnesses
• Patient capability and mental status
• Concurrent medications
• Examination of feet and lower legs
• Potential side effects of treatment
• Special attention to diabetics, auto-immune disorders, those on steroids and anticoagulants.13

Foot examination
Examination needs to consider skin colour, temperature, state of toes, nails, inter-digital clefts, tendons and joints, and evidence of foot disorder and disease.
It should also assess whether there is vascular ischaemia or a generalised condition involved. Has the longitudinal and transverse arch of the foot been lost and is there abnormal skin thickening at pressure points?
Other questions include:
• Is there skin infection?
• Are there callosities, corns, bunions, hallux disorder?
• Is there pain on moving the toes, flexing the foot?
• Is the walking gait normal?
• Are there problems with flexion and extension of the ankle?
• Is there tendonitis?14


Foot disorders can affect the skin and this can be local, due to trauma, bacterial or fungal infection. It can also be systemic and reasons include:
• Arteriosclerotic disease
• Soft tissues
• Pressure of nails, shoes, distorted toes, joints causing corns and callosities
• Damage of nail plate eg. onychogryphosis-thickening of the nail and in-growing toe nail
• Bones due to trauma but sometimes from osteoporosis
• Tendons. Often from repetitive strain injury, with strains and sprains of the small muscles and tendons of the foot
• Joints. Due to gout, osteo/rheumatoid arthritis14.15

Corns
Hard and soft corns cause pain, which can interfere with walking. Treatment requires paring of accumulated hard skin with removal of the core nucleus. Soft corns can develop an infected centre and hard skin has to be removed, pus cleaned out and dressing applied.

Callosities
These develop over points on the foot where shoes pinch or toes override. Constant pressure brings thickening and roughening of skin and pain. Removal of offending skin will alleviate the problem if the source of unwanted pressure is removed.

Nail disorders
Inadequate trimming of large toe nails often leaves a small spicule of the lateral border of the largest nail untrimmed. The nail continues to grow and pierces the skin edge to cause pain and infection. Without therapeutic intervention, this will become a chronic low-grade sore and people resort to wearing slippers to alleviate pain with increased likelihood of resultant falls.

Nail thickening
Nail thickening, onychogryphosis, can lead to walking difficulty if untreated. Damage to the nail plate from repeated hitting of the large toe nail on a shoe obstruction can result in overgrowth of the nail with much thickening. The nail is difficult to clip and is often left to elongate and overgrow the toe and even under-grow another toe. Nail rasps can thin the offending nail and cutters can shorten it closer to the end of the toe. Regular foot care is required to keep the overgrowth within toe limits.
Nails should be cut transversely across the nail just behind the border of the toe. Angles should be rounded and ensure sharp edges do not embed in the nail border. If it does, infection can result in a paronychia, which can be painful, resist treatment and require nail avulsion.15


Nail and web infections
Tinea infections of interdigital toe clefts are common and may result in fulminating tineal infections affecting most of the feet. Untreated, bacterial infection often supersedes. In diabetics this can bring serious consequences. Funguses can cause chronic infection in onychomycosis-resistant to treatment. Poor foot hygiene encourages growth and failure to dry webs of toes after washing helps maintain their presence, which sometimes spreads to the remainder of the foot. The fungus can spread to the nail and gradually discolour and destroy it. Affected nails often become brown and crumbly and erode away—onycholysis. Elderly people can have all toe nails infected.16-18
Antifungal treatment is often prolonged. Oral medication may be required but it can have liver side-effects hazardous to the old and therefore be contraindicated, but antifungal paints can be used in relative safety. Scrapings from nail and infected skin should be taken for culture of the organism in the laboratory to confirm the diagnosis in resistant infections.
Diabetic patients are particularly likely to have monilial infections affecting feet and toe webs. These respond to treatment with antibiotic creams. Scratching and skin breakdown can create ulcers that heal very slowly. Poorly controlled diabetics may develop neuropathic ulcers of toes that are usually painless but dangerous and need prompt attention.18

Toe deformities
Hallux valgus—usually the result of wearing high heeled shoes, results in the big toe being displaced inwards to override nearby toes with marked deformity. This results in callosities, corns, skin abrasions and ulcers. Appropriate foam padding to take pressure of the deformity and wide fronted shoes can alleviate this problem, which is often associated with a bunion.
Lax tendons and arthritis bring joint disturbance with protuberant joints of the small foot bones and misshaping of the foot and toes and bunions. The latter causes much misery and often prevents wearing of conventional footwear and recourse to hazardous soft slippers. Bunions are swellings of the joint between great toe and first metatarsal bone caused by ill-fitting shoes. Protective padding, an anti-inflammatory ointment and wider-toed shoes can improve comfort and reduce pain but sometimes only surgery can improve symptoms. A bursa may develop over the bunion to add to discomfort and deformity and increase shoe pressure further. Additional padding is required to give time for the unwanted fluid protection to be reabsorbed.19
Hallux rigidus—a painful stiffness of the joint between big toe and first metatarsal bone often causes disability. It is associated with arthritis and may benefit from antiarthritic medication.
Gout, osteoporosis and rheumatoid arthritis can affect the feet and need antiarthritic drugs and analgesics therapy.
Prevention of foot disorders20
Meticulous foot hygiene is important in older people. Feet and toe webs especially, should be properly dried after washing. Great care should also be taken by individuals/carers/health professionals when cutting toe nails or paring corns.
Toe nails should be regularly cut and not left with edges which are unseen and grow into surrounding skin. Friction points from bunions and displaced toes should be protected from trauma with padding. Debris should be removed regularly from nail borders and sore or infection of foot/toes should receive prompt attention. Diabetics should have regular foot surveillance.


Summary
Bunions, corns, callosities, oedema and infections of the feet are a burden for older people. Good treatment of the aged foot challenges the doctor, nurse and carer. Geriatric assessment should include a comprehensive examination of feet and appropriate remedial therapy. Good management depends upon recognising need, instituting regular examination and treatment. Good personalised foot care can help the old maintain mobility and enhance personal well-being.


Conflict of interest: none declared


References

1 http://www.statistics.gov.uk. Accessed 01/04/2013
2. Source: Census, April 2001, Office for National Statistics General Register Office, Scotland
3. Cameron J. Functions in the elderly. Ger Med 1991: 29-34
4. Villar P, Wiggins J, et al Structure and function of the ageing lung Care of the Elderly 1991; 3; 129
5. Roffe C. Ageing of the heart. Br J Biomed Sci 1998: 55; 136-48
6. Signola AM, Bousquet J. The Ageing Lung 2001.Current Allergy Reports, 1: 1–2 Current Science
7. Cameron J. Functions in the elderly. Ger Med 1991; 29–34
8. Villar P, Wiggins J, et al Structure and function of the ageing lung. Care of the Elderly 1991: 3; 129
9. Abrams W, Berror R. Manual of geriatrics. 2005 Merck & Co New Jersey.
10. Overstall PW in Medicine. Ed. Souhami R. Moxham 1994 J Churchill Livingstone. Edinburgh.
11. Chan G, Duque G. Age-Related Bone Loss: Old Bone, New Facts. Internat. J Exptl Clin Behave and Tech Gerontology 2002: 48; 2
12. Bergman B. Rosenhall U. Vision and hearing in old age. Scand.Audiol 2001; 3: 255–63
13 McIntosh I. Foot care for the elderly the GPs role. Geriatric Med 1992; 22; 55–8
14 McIntosh I. Good foot care keeps older people mobile. Geriatric Medicine 2004; 34; 44–48
15 Goodfield M. Feet first. Geriatric Med 2000. 57-6
16. Finucane K, Berker D. Management of common diseases of the nail. The Practitioner 2OO4: 61
17. Crawford F, Hart R, et al. Athletes foot and fungally affected toenails Brit Med J 2001; 32; 2288–90
18. Roberts D. Prevalence of dermatophyte infection in the UK Br J Dermatology 1992; 23–7
19. Kent M Ed. Bunion. Sports Science and Medicine 1094 .71 Oxford University Press London
20. McIntosh I. Elderly foot Disorders Podiatry Review 2010; 6-8