Incorporating foot assessment in the comprehensive geriatric assessment

Abstract

Background Foot problems are common in older adults and associated with poorer physical function, falls, frailty and reduced quality of life. Comprehensive Geriatric Assessment (CGA), a multidisciplinary process that is considered the gold standard of care for older adults, does not routinely include podiatry assessment and intervention in hospitalized older adults. Aims To introduce foot assessment to inpatient CGA to determine prevalence of foot disease, foot disease risk factors and inappropriate footwear use, assess inter-rater reliability of foot assessments, determine current podiatry input and examine associations between patient characteristics and foot disease risks. Methods Prospective, observational cohort study of older adults on geriatric rehabilitation wards. Foot assessment completed using the Queensland Foot Disease Form (QFDF) in addition to routine CGA. Results Fifty-two patients (median age [inter-quartile range] 86.4 [79.2–90.3] years, 54% female) were included. Six patients (12%) had foot disease and 13 (25%) had a ‘high risk’ or ‘at risk’ foot. Foot disease risk factor prevalence was peripheral arterial disease 9 (17%); neuropathy 10 (19%) and foot deformity 11 (22%). Forty-one patients (85%) wore inappropriate footwear. Inter-rater agreement was substantial on presence of foot disease and arterial disease, fair to moderate on foot deformity and fair on neuropathy and inappropriate footwear. Eight patients (15%) saw a podiatrist during admission: 5 with foot disease, 1 ‘at risk’ and 2 ‘low risk’ for foot disease. Patients with an at risk foot or foot disease had significantly longer median length of hospital stay (25 [13.7–32.1] vs 15.2 [8–22.1] days, p = 0.01) and higher median Malnutrition Screening Test scores (2 [0–3] vs 0 [0–2], p = 0.03) than the low-risk group. Patients with foot disease were most likely to see a podiatrist (p < 0.001). Conclusion Foot disease, foot disease risk factors and inappropriate footwear are common in hospitalized older adults, however podiatry assessment and intervention is mostly limited to patients with foot disease. Addition of routine podiatry assessment to the multidisciplinary CGA team should be considered. Examination for arterial disease and risk of malnutrition may be useful to identify at risk patients for podiatry review.

Foot Problems in Older Adults Presenting to a Falls and Balance Clinic

“…Previous studies have identified foot problems to be of a similarly high burden in outpatient populations, affecting 87% of community-dwelling older adults in one study by Menz and Lord [7]. Both inpatient and outpatient studies have also reported a high prevalence of inappropriate footwear in their respective cohorts [50, 51]. Specific deformities such as hammer and claw toes and hallux valgus were seen in fewer participants in the Falls and Balance clinic when compared to other studies, in which hallux valgus was recognised as the most common foot problem.…”

“…Despite being a less comorbid, less frail, and more functionally independent cohort, foot problems were comparably common in older adults in this FBC when compared to inpatient populations of older adults [50]. Thus, it is likely that podiatry input is equally important in an outpatient cohort of comparably functionally independent individuals as it is in a hospital setting, where the acuity of disease is higher.…”

“…Additionally, the performance of a wide range of statistical tests that explore the associations between foot problems and function may increase the risk of Type 1 error and drawing false positive conclusions. While podiatry assessments were not repeated by a second, independent, and blinded assessor, research has shown fair inter-rater reliability in the assessment of arterial disease, neuropathy, deformity, and footwear appropriateness, which reduces the risk of selection bias in this study [50]. Finally, a validated podiatric screening tool was not used due to the absence of existing, cohort-appropriate validated assessment tools at the time of the study [42, 43].…”

Australian podiatrists’ understanding and current practices of reablement for older people: a qualitative exploratory study

“…Whilst literature on podiatry practice in reablement is limited, evidence suggests that older people represent the largest proportion of care provided by podiatrists in Australia and their attendance at podiatrists tends to be recurrent [20,21]. The link between foot problems in older age which reduce mobility and decrease quality of life has been well established [22][23][24][25][26][27][28][29][30][31]. Therefore, it is reasonable to assume that podiatrists are well placed to be integrated into reablement teams.…”