Literature Review


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Literature Review

  1. 1. 1 Best Foot Forward: reviewing the literature on the prevalence of foot pathology in older people Professor Jackie Campbell and Jane Evans, University College Northampton Introduction This literature review is part of a larger research project undertaken by Ray Jones, Jackie Campbell et al from the University of Plymouth and University College Northampton. The project was commissioned by Help the Aged to examine the level of unmet need among the older population and explore innovative methods of providing foot-care services to older people. The full report, Best Foot Forward: older people and foot care, published in August 2005 by Help the Aged, is available from Help the Aged Publishing (tel. 020 7239 1946 for credit card orders) at £8.00 plus £1 postage and packing (cheques payable to Help the Aged should be sent to 207–221 Pentonville Road, London N1 9UZ). 1 Methods To obtain statistics on the prevalence of foot pathology in older people, a search was made of bibliographic databases, and websites for health collections, gateways, organisations and services. Bibliographic databases AMED Ingenta Assianet Kluwer BioMed Central Medline BioMedNet Reviews Recal British Nursing Index Science Direct CINAHL Swetswise Cochrane Library Web of Knowledge Embase Your Journals @ Ovid 1
  2. 2. 2 Emerald Zetoc Highwire Websites for health collections and gateways BUBL National Research Register Health on the Net Foundation NMAP Medline Plus Organising Medical Networked Information MedWeb UK Health Centre National Electronic Library for Health Websites for organisations and services Alberta Podiatry Association American Podiatric Medicine Association Department of Health Foot and Ankle Institute Foot and Ankle Library Institute of Healthcare Management International Working Group on the Diabetic Foot Podiatry Online Society of Chiropodists and Podiatrists The Wellcome Trust World Health Organisation Websites for UK national statistics House of Commons Hansard National Statistics Online 2 Search strategy In the bibliographic databases, the search strategy varied according to the rules for truncation, the existence of a thesaurus, and the size of the database, but broadly the strategy was to search for a combination of the three facets of the topic: • Podiatr? OR chiropod? OR foot • Prevalence OR incidence OR epidemiology OR frequency • Elderly OR geriatric OR aged OR old? Modifications to the strategy had to be made where the number of references retrieved was too great, i.e. sometimes the age facet had to have ‘aged’ removed because it retrieved too many ‘aged 18’ etc. Similarly, sometimes 2
  3. 3. 3 ‘NOT child?’ had to be entered to avoid retrieving the wrong ages. Where too many hits were related to the diabetic foot, ‘NOT diabet?’ had to be entered. 3 Types of literature retrieved The literature contains two types of surveys of the elderly: those covering foot health in general and enumerating the various conditions identified, and those dealing with specific foot conditions. The former are sometimes difficult to compare because (a) the conditions are not described in exactly the same way and (b) the conditions are sometimes clinically observed by a podiatrist and sometimes as perceived by the elderly person. It has also been noticed that many older people may consider foot disorders an inevitable part of the ageing process and therefore do not report them to health professionals (Menz and Lord 1999). The surveys noted have been carried out not only in England, but also in Italy, the Netherlands, Sweden, Australia, Canada and the USA. In the present research into the unmet need for podiatric care of the elderly, it is of course important to consider the predicted growth in the elderly population. The proportion of older people continues to rise, death rates are continuing to fall and the average life span is increasing by an average of two years every decade (UK Central Council for Nursing Midwifery & Health Visiting 1997). Between 1979 and 1994 the number of elderly people over the age of 85 years increased by 50 per cent (Office of Population Censuses and Surveys and General Register Office for Scotland 1993). The number of people over 85 years of age was projected to increase by 15 per cent from 1995 to 2019 (UK Central Council for Nursing Midwifery & Health Visiting 1997). Giving a more European perspective on the issue, Woolf predicts that by 2025 25 per cent of Europeans will be aged over 65 (Woolf and K. Akesson 2003). Menz described the difficulty in establishing the prevalence of foot problems in older people when he referred to the lack of consensus as to what actually constitutes a foot problem, the variations in the populations that have been assessed, and the variety of approaches used to collect the data. Foot problems in older people may result from age-related decreases in joint range of motion, dermatological conditions, detrimental effects of footwear, and systemic conditions such as peripheral vascular disease, diabetes mellitus and arthritis. Furthermore, the definition of a foot problem may also include an individual's inability to maintain basic foot hygiene (e.g. cutting toenails) or [have] difficulty in purchasing comfortable shoes. (Menz and Lord 1999) In order to meet the requirements of the present study, foot conditions were prioritised by a panel of podiatry service managers so that low-risk ones were scored from 1 to 10, 1 indicating where professional interventions are most desirable, 10 where intervention is least indicated. The top five were: Corns 1 3
  4. 4. 4 Callus/tyloma 2 Plantar neuroma 3 Ganglion/bursa 4 Fissure 4 Abrasions/trauma 5 Symptomatic nail pathology 5 The bottom five were: Heel deformity 6 Mid-tarsal deformity 6 Hallux valgus/rigidus 7 Lesser toe deformity 8 Exostosis 8 Fungal infection – skin 9 Anidrosis/xerosis 9 Hyperidrosis 9 Fungal infection – nails 10 Asymptomatic nail pathology 10 Maceration 10 Medium risk is presented when increasing discomfort or pain are noted in low- risk conditions. High-risk conditions are listed as: ulceration tissue breakdown infection neoplasm inflammation cellulitis gangrene Charcot joint. At any level of risk, the presence of a relevant medical condition may make professional intervention essential. These medical conditions are: neuropathy oedema/edema rheumatoid arthritis osteoarthritis diabetes hypertension (with relevant complications) peripheral vascular disease/peripheral arterial disease cardiovascular conditions malnutrition compromised immunity medication factors scleroderma 4
  5. 5. 5 lupus arteritis gout Raynaud's disease Charcot Marie tooth syndrome cerebral vascular accident. The prioritisation eliminated, from this paper, a certain amount of research found in the original literature review. The studies here are only included because they refer to the top five low-risk and high-risk conditions. The research studies to be considered are described by: researcher – date of research – place researched – no. of subjects – age of subjects – type of residence (i.e. in the community or in care home) – type of assessment. Where necessary, results presented in the original papers by age and sex have been put together to create overall percentage rates for the 65+ age group. The studies are arranged in three sections: • General surveys (of 60+ or 65+ age group) and within that by region (England and Wales, Europe, Australia and USA) • General surveys but with the subjects pre-selected according to a particular criteria, e.g. aged 75+ or living in nursing homes, and within that by region (England and Wales, USA) • Surveys of a specific disease arranged by region (Europe, Australia, USA and Canada). (These are not always restricted to the 60+ age group.) 4 General surveys of 60+ or 65+ age group 4.1 Research in England and Wales Cartwright, A & G Henderson – 1985 – England – 543 – 65+ – in community – self-assessment + by chiropodist In England in 1986 a project was undertaken by the Department of Health and Social Security to do almost precisely what the present project seeks to achieve. A search of the UK Data Archive located a database describing unmet needs of the elderly for chiropody (Cartwright and Henderson 1986). A random sample of people aged 65 and over was selected from the electoral register in ten representative parliamentary constituencies in England. The number of people taking part in the study was 543 (76 per cent of the elderly people identified). Foot examinations were carried out in the participants’ homes by state-registered chiropodists. 5
  6. 6. 6 This study is very significant in any review of podiatric conditions because it has a broad base; the sample was scientifically selected, and 76 per cent of the elderly people approached were willing to take part. The elderly people were a sub-sample systematically selected from a random sample of 1,026 elderly people who had already been identified for the ISSMC Elderly People: their medicines study. The original study was carried out in ten parliamentary constituencies chosen with a random starting point after stratification by the proportion of people of pensionable age, with probability proportional to the number of electors. In each of these areas a systematic sample of 500 people was selected from the registers published in February 1984. The patients were examined by a chiropodist as well as giving a self- assessment, so the results are particularly interesting. They reveal the existence of what is known as 'the iceberg effect' (Hannay 1979) (Lisdonk 1989; Lamberts, Brouwer et al 1991) (Vetter, Jones et al 1986; Kees, Kuyvenhoven et al 2000). Just over half the elderly people (52 per cent) initially reported some trouble with their feet, and more detailed questioning revealed that 86 per cent had some foot condition, problem or deformity. Examining chiropodists assessed that 84 per cent had some foot problems, describing 4 per cent as having major ones, 22 per cent moderate problems and 58 per cent minor ones. Roughly one in seven of the people had feet that were entirely problem-free. These findings bear out the evidence in Menz that elderly people do not always report foot problems (Menz and Lord 1999). The data from this study were released in 1986 and so it is somewhat dated and does not reflect any changes in the health of elderly people's feet which may stem from improved lifestyle or better treatment over the last 20 years. Nevertheless it is a very relevant, useful study for the purposes of this research. Cartwright, A & G Henderson (1986) Initial reports of foot problems 52% Reports after more detailed questioning 86% Reports of difficulty cutting toenails 50% Chiropodists’ assessment of foot problems Major foot problems 4% Moderate 22% Minor 58% None 16% Dorsal corn/callus 33% Apical corn/callus 27% Interdigital corn/callus 9% Ungual corn/callus – definite 10% Ungual corn/callus – possible 28% Plantar corn – definite 20% Plantar corn – possible 12% 6
  7. 7. 7 Plantar callus – severe 3% Plantar callus – moderate 19% Cuts, bruises or abrasions 3% Ingrowing or involuted toenails – severe 9% Ingrowing or involuted toenails – slight 38% Thickened toenails 45% Other nail problems 19% Pain or discomfort with feet Severe 7% Moderate 18% Minor 13% None 62% Foot ulcer – infected or not infected 2% In the low-risk conditions, corns, calluses and symptomatic nail pathology are a significant problem. As the prevalence of corns and calluses are reported by site and severity of the individual conditions, it is not possible to combine these rates to arrive at an estimate of the proportion of older people with these problems. This is because some people will have corns on several sites, for instance. However, other studies have estimated the proportion of people with multiple foot pathologies (e.g. Crawford et al 1993, Sinacore, 2000) and this may be used as a rough guide to the extent of double-counting that may be present in these figures. Moderate or severe pain/discomfort with feet is also surprisingly common at about 25 per cent. Of the high-risk conditions listed, only ulceration and infection were covered in the survey – under the heading 'Foot ulcer – infected or not infected'. The proportion is 2 per cent. Brodie, BS, CS Rees et al – 1983 – Wessex – 200 – 65+ – in community -– self-assessment + by chiropodist Also from the early 1980s, this survey is regionally based in Wessex and involved 700 people randomly selected in seven age groups. For the over- 18s, the sample was based on the electoral register, with 50 males and 50 females from every age band. (These included bands for 65–74 and 75+.) The authors of the study ensured that interviewers were trained to achieve as uniform an examination as possible, and the questionnaires were confined to the general and more obvious conditions which might be found, in order to satisfy the constraints of time and subject co-operation. The interviews were conducted by chiropodists who also investigated the respondents' feet. The results were analysed in fairly general categories, and the ones considered in this paper are listed in the table below. They include only corns, calluses and nail pathologies. The proportions in this study are similar to those in Cartwright and Henderson (1986). It must be noted that the survey involved 100 65–74-year-olds and 100 people aged 75+, hence a higher proportion of those aged 75+ than in the Cartwright study. 7
  8. 8. 8 The authors concluded their study with reference to a subsequent volume in order to report on the implications of the research on chiropody staffing needs and norms. Brodie (1983) 65+ 65–74 years 75+ Men Women Men Women % % % % % Reporting foot problem 62 56 58 58 76 Difficulty in cutting toenails 67 62 48 78 80 Medical conditions predisposing towards need for chiropody 50.5 42 48 56 56 Corns 30 24 36 20 40 Calluses 41.5 42 48 26 50 Nail pathologies 41 38 34 52 40 Elton, PJ & SP Sanderson – 1986 – Manchester – 1,153 (i.e. the 66 per cent who were willing to take part and could be contacted out of potential 1746) – 65+ – in community – self-assessment (154) + by chiropodist (999) This survey, again from the 1980s, is restricted to the population of an urban area. The sample of 1,746 was taken from the GPs' age/sex registers in North Manchester. Of those selected, 66 per cent were willing to take part, but not all were examined by a chiropodist. Those not attending the clinic constituted 9 per cent and, in the main, were just interviewed without being examined. The accuracy of the sampling is therefore flawed because self-assessment is not a reliable measure, as has been suggested by Cartwright, and the fairly high proportion of those unwilling to take part may either reflect reasonable foot health or a dissatisfaction with the service and a consequent reluctance to participate. The survey particularly probes whether patients in need were receiving treatment, and whether need was being properly assessed by GPs. Three low-risk conditions were listed – corns, calluses and nail pathology, and the percentage rates match fairly closely those of the previous two studies. Heel pain was also mentioned, the rate being 4 per cent. 8
  9. 9. 9 Elton (1986) Chiropodial conditions (%) Both sexes Male Female Corns 26 17 31 Hard skin, ball of foot 42 30 49 Nail conditions, first toe Onychauxis 66 65 66 Onychophosis 53 49 56 Nail conditions, lesser toes Onychauxis 57 50 61 Onychophosis 31 25 34 Heel pain 4 4 5 Harvey, I, S Frankel et al – 1988–91 – South Glamorgan – 560 (i.e. the 71 per cent who responded out of potential 792) – 60+ – in community – assessment by chiropodist This study, like Elton's, is predominantly concerned with assessing how chiropody care is rationed out and deduces that foot morbidity is not an independent determinant of receipt of care. The random sample was of 792 patients from GP registers in South Glamorgan in about 1990. The positive response rate was similar to Elton's study, being 71 per cent, and patients were examined by a chiropodist for fairly common low-risk conditions – corns, calluses, symptomatic nail pathology and toe deformities. The proportions for each condition are not given as the authors were more interested in the number of foot problems found in each patient. The table shows that 53 per cent had three or more of these problems. (N.B. The deformities are not included in the top five low-risk conditions in this paper.) Harvey (1997) Foot morbidity score (range 0–5, 1 point scored for each problem present, on either foot) Foot problems examined were for toe deformities (hallux valgus and lesser toe deformities), corns and callosities, in-growing toenails and toenail thickening. Mean foot index scores 2.5 (index 1) and 1.1 (index 2) Three or more foot problems 53% 9
  10. 10. 10 Garrow, P, AJ Silman et al – 2004 – Cheshire – 3,417 – age 18–80 population survey – self-assessed + follow-up interviews and professional examination on 231 respondents with ‘disabling foot pain’ and 50 with no disabling foot pain This very recent study was designed to estimate the prevalence of disabling foot pain, broken down by age and sex, and any associations with foot pathology, regional pain and other general health indicators. It was conducted initially by postal questionnaire to a large random sample (n = 4780) of patients aged 18–80 selected from the lists of two general practices in Cheshire – one from a small market town and the other a commuting suburb of Manchester. There was a very high response rate (84 per cent). The paper does not give information on the age profile of the respondents. Respondents who reported having had foot pain in the last month had foot pain on the day they competed the questionnaire and reported at least one disability arising from foot pain (as measured by the Manchester Foot Pain and Disability Index, Garrow et al, 2000) and were defined as having ‘disabling foot pain’. This group were invited for an interview and professional foot examination, together with a control group of respondents who did not report disabling foot pain. The following prevalence of self-assessed foot problems (not broken down by age) was reported. Self-reported foot problems in the previous six months, by gender Foot problems Total % (n = 3047) Male % (n = 1357) Female % (n=1690) Any foot problem 63.2 57.5 68.0 Corn or callus 30.7 20.2 39.2 Nail problem 23.7 23.5 23.9 Swollen feet 12.0 6.2 16.7 Bunions 8.0 2.6 12.2 Verrucae 4.6 4.0 5.0 Overall, 24 per cent of women and 20 per cent of men reported foot pain during the last month lasting at least one day. The prevalence of disabling foot pain was 11 per cent for women and 8 per cent for men, but increased with age, more steeply for women than for men, reaching a peak at age 55 to 64 (15 per cent women, 12 per cent men) after which it decreased to approximately 10 per cent for both sexes at age 75–80. Only 16 per cent of the overall study population had received foot treatment from a healthcare professional in the last six months (36 per cent with disabling foot pain, 14 per cent with no disabling foot pain). This rate increased with age, with 40.5 per cent of the over-65 age group receiving professional foot care. 10
  11. 11. 11 Those who underwent the professional examination as part of the study showed that, in most cases, the prevalence of clinician-diagnosed problems was greater than the self-assessed rates. This was examined by foot problem and the following sensitivity (proportion of foot problems identified by self- assessment that were also identified by the clinician) and specificity (proportion of absence of foot problem reported by self-assessment that were also reported as absent by the clinician) results were reported. Sensitivity and specificity figures, comparing self-reported with clinician-diagnosed foot problems Foot problem % Sensitivity (95% confidence interval) % Specificity (95% confidence interval) Nail problems 51.7 (44.4–58.9) 79.2 (70.3–85.9) Corns and callosities 47.4 (41.4–53.8) 91.4 (80.1–96.6) Bunions 29.2 (22.9–36.5) 96.3 (90.9–98.6) Verruca 33.3 (13.8–60.9) 97.7 (95.5–98.9) Swollen feet 57.3 (47.9–66.1) 87.5 (81.7–91.7) 4.2 Research in Continental Europe Benvenuti, F et al – 1995 – Italy -– 459 (i.e. the 73 per cent who were willing to co-operate and have medical assessment out of a potential 628. The 73 per cent were similar in age, gender, level of disability to group refusing medical assessment) – 65+ – in community – assessment by physicians Two studies in continental Europe – Italy and the Netherlands – are of interest. Benvenuti in 1995 assessed 459 people over 65 in a small town in Italy. The positive response rate is similar to that in England and Wales, being 73 per cent (out of 628). The group who took part were similar in age, gender and level of disability to the group who refused to participate. The assessment was reliable, being a standardised medical examination by a geriatrician. The particular emphasis in this study was to assess the association between foot pain in older people suffering from pathological conditions of the foot with disability. The list of conditions evaluated is more extensive than in Elton and Brodie. It is not easy to compare the prevalence rate of corns and calluses with the English rate because Benvenuti puts them together in one percentage figure, but if the two English rates are added together, the rates are in fact similar. Benvenuti (1995) Prevalence of foot problems according to gender and age Men Women Prevalence odds-ratio Total population 65–74 yrs 75+ 65–74 yrs 75+ Women vs men 75+ vs 65–74 Variables % % % % % 11
  12. 12. 12 Corns or calluses 64.8 49.6 65.5 75.9 70.2 2.3 (1.5–3.3) 1.1 (0.8–1.7) Hypertrophic nails 29.6 27,8 35.2 19.9 40.4 0.9 (0.6–1.3) 2.0 (1.3–3.0) Onychocryptosis 5.4 4.0 6.8 6.4 4.8 1.1 (0.5–2.5) 1.1 (0.5–2.5) Pain only when standing 21.8 17.5 23.9 41.1 41.4 2.7 (1.8–4.2) 1.2 (0.8–1.7) Pain also at rest 9.6 3.2 5.5 11.4 18.3 3.8 (1.8–7.8) 3.8 (0.9–3.3) Kees, JG et al – 2000 – Netherlands – 5,689 (i.e. 79 per cent response rate out of potential 7,200) – 65+ – in community – self-assessment by postal questionnaire The Dutch study by Kees et al was conducted in 1997 among a very large random sample of people aged over 65. The selection was based on community registers in an urban district and the positive response rate was very high – 79 per cent. As with Benvenuti, the prime motive was to discover whether foot complaints are risk factors for limited mobility and poor perceived well-being. The response rate may have been particularly good because people who did not reply were sent a reminder after two weeks and if necessary were telephoned two weeks after that. The assessment, however, was possibly not reliable because it was based on a postal questionnaire. Comparisons with the English studies are made difficult because the questionnaire combined common foot complaints together, defining them as complaints not owing to an accident and lasting longer than four weeks. On the face of it, the percentage rates are lower than in England, but this could be a result of the survey being based on self-assessment. Of the 20 per cent of people with non-traumatic foot complaints of over four weeks’ duration, 80 per cent had musculo-skeletal problems related to the forefoot, thus giving an average figure of 16 per cent for musculo-skeletal problems. Foot osteoarthritis is singled out, and the percentage rate is 8 per cent. Kees (2000) General characteristics of the study population (N = 5,689) Characteristic % of respondents Female 58 Age 75+ 38 Foot osteoarthritis 8 Foot complaints, non-traumatic of 4+ weeks duration 20 (men: 14%; women: 24%) Of these, non-traumatic complaints: Foot pain 60 (i.e. 12% of total) 12
  13. 13. 13 Malpositioning of toes or toenail problems 20 (i.e. 4% of total) Numbness or swelling 12 (i.e. 2.5% of total) Skin problems 8 (i.e. 1.6% of total) 4.3 Research in Australia and USA Munro, BJ & JR Steele – 1998 – Australia – 128 (i.e. 46 per cent of the 276 eligible who answered the phone researchers) – 65+ – in community – self-assessment by postal questionnaire A study was conducted in Australia in 1998 to assess the prevalence of foot problems among older people and the rates of utilisation of chiropody services. The random sample comprised only 128 people and was based on a random selection of 1,715 phone numbers which were then narrowed down to those eligible for the survey (276). Two hundred people were willing to participate, but the response rate was in fact only 64 per cent. The assessment was based on a postal questionnaire, and the results were checked against what was expected. The questionnaire was said to be reliable. The categories do not quite fit the ones listed in this paper as priorities, e.g. there is a general category of ‘skin problems’. The purpose of the study was again to provide evidence that elderly people need to be educated about foot problems and the need for foot care in order to maintain their mobility and well-being. So views were also elicited on any treatment sought and received. Specific foot problems reported by respondents Foot problem Total % Men % Female % Corn 17 8 26 Callus 13 11 15 Skin problem 19.5 9 30 Ingrown toenail 13 12 14 Hard, thickened nail 26 28 30 Foot pain 52 45 59 Swollen feet 17 9 25 Arthritis 22.5 23 22 Other 14 13 15 None reported 29.5 40 19 Diagnosed medical conditions reported by respondents Condition Total % Men % Female % Leg circulation problems 20 18 23 13
  14. 14. 14 National Health Interview Survey – 1990 – USA – 119,631 all ages (number of 65+ not known) – 65+ – in community – assessment by untrained observers In the United States the National Health Interview Survey in 1990 is particularly large, covering about 120,000 people within age bands. It is not known how many were in the 65+ age band, and assessment was by untrained observers. Greenberg analyses this survey, comparing it with another one (of 1,000 people aged over 65) run by Bruskin/Goldring Research in 1992 (Greenberg 1994). The tables show how the categories of problems are very broad and limited. Also the latter study made assessments only by telephone interview. The low figures seem a mystery unless they reflect the untrained assessment procedure and a bias in the selection of participants. Foot condition % Corns and calluses 10 Toenail problems in the last year 10 Foot infections 5 With foot problem in the last year 31 14
  15. 15. Systematic Review of the Literature: General Surveys of 60 or 65+ age group 15 Bruskin/Goldring Research – 1992 – USA – 1,003 – 65+ – in community – assessment by telephone interview Foot condition % Corns and calluses 12 Toenail problems in the last year 8 Foot infections less than 1% With foot problem on any occasion in whole life 38 Helfand, AE et al – 1998 – USA – 417 – 60+ – in community – method of assessment unclear This American study was far more precise and scientific than the two previous large-scale ones mentioned above. It was conducted between 1995 and 1998 among 417 people over 60 years old, living in the community in the city of Philadelphia. It is not clear how they were selected. Helfand writes that higher- risk patients tend to be receiving care already so it was not expected that the number of such patients in the study would be significant. He thus indirectly suggests that the selection process was for volunteers from those who were not receiving care. The results will therefore be affected by a prevalence of low-risk conditions. The assessment is so precise that the observers must have been trained, although it is not stated whether they were podiatrists. Assessment is made even more reliable because the participants were educated in some depth about foot health. The results show the widespread prevalence of foot problems among older people, and are quite similar to the findings of Cartwright. Helfand (1998) Prevalence of foot conditions Condition % Heloma (corns) 33 Tyloma 26 Hyperkeratosis 48 Prominent plantar metatarsal heads, with soft-tissue atrophy 24 Onychauxis 28 Onychodystrophy 31 Painful toenails 28 Clinical hallux limitus 17 Painful feet 45 Cold feet 12 Bacterial infection 2 Foot ulcerations 2 15
  16. 16. Systematic Review of the Literature: General Surveys of 60 or 65+ age group 16 Sinacore, DR – 2000 – USA – 81 (19 men, 62 women) – 51+ – in community – assessment by podiatrist The study by Sinacore is much smaller than Helfand’s and the sample was self-selected, being in response to requests for volunteers. Of the 81 participants (over 50 years old), 62 were women. Women have been shown to be more prone to foot problems than men, so the results of the study will be biased. Asking for volunteers is likely to have attracted those with problems, so with the sexual bias as well, the results are not very reliable. The categories are very broad, e.g. ‘skin and callus’ and ‘foot deformities’, so comparisons with other studies are difficult. Prevalence of most common foot impairments in the elderly Foot impairment % Skin and callus 46 Foot deformities 36 With 2 or fewer impairments 45 With 3–5 impairments 53 With 6+ impairments 2.5 5 General surveys with specified sub-populations (i.e. not just 60 or 65+) Research in England and Wales Campbell, J et al – 2002 – Cambs & Hunts – 343 (assessed as low-risk and discharged from NHS podiatry service) – 65+ – in community – assessment by podiatrist This study took place in Cambridgeshire in 2002 to assess the effect on older people who were discharged from NHS podiatry services in two health authorities because they were assessed as low-risk during a disinvestment programme. The 343 patients included were therefore not a totally random sample, having had low-risk foot problems within the past one to three years. The authors made a random selection within this group of people and after encountering anger in the responses on account of reaction to the cutbacks, they had to reword their letter of invitation to assure patients of the independence of the study. Every effort was made to ensure uniformity of assessment, which was carried out by two podiatrists. Sometimes the same patient was assessed by both to check the validity of the results. The purpose of the study was to find out how much foot health deteriorated after discharge and what factors were involved. The results are in broad categories. Their fairly high percentage rates may reflect the fact that all patients had been assessed as low-risk within the previous three years. 16
  17. 17. Systematic Review of the Literature: General Surveys of 60 or 65+ age group 17 Campbell (2002) Percentages of moderate/severe pathologies receiving only home care 12–18 months after discharge Moderate/severe nail pathology 30 Moderate/severe hyperkeratosis 42 Moderate/severe pain 49 Moderate/severe inflammation 40 Unilateral/bilateral oedema 37 Insensitivity to touch 26 Insensitivity to vibration 33 Crawford, VLS et al – 1993 – South Belfast –248 – 75+ – in community – assessment by podiatrist. NB Foot problem percentages are based on the 128 (52 per cent) needing treatment This study is similar to Campbell’s in that the prevalence rates of foot conditions are based on a sample who are currently receiving podiatry treatment. (Campbell’s sample had been receiving treatment within the previous one to three years.) Therefore the rate may be higher than in a normal population. On the other hand, some surprisingly low prevalence rates such as those for ingrowing toenails (7 per cent) may be owing to the fact that appropriate podiatry treatment was being received. The group is aged over 75 and living in the community. The sample was based on a random selection of one in ten of those eligible and living in south Belfast – i.e. 730 individuals. The number was reduced to 248 on account of various factors, e.g. being institutionalised or not traceable. Only 52 per cent of these were studied because the study required them to be in contact with podiatrists. The assessment was by a podiatrist. The prevalence rates of corns and hard skin are surprisingly high considering that podiatry treatment was being received, but the age band (75+) would account for this. As mentioned above, the rate of ingrowing toenails is unusually low. Crawford points out, however, that a similarly low prevalence rate was found in a study by Salvage of a group of over-75s in South Glamorgan in 1988 (see below). No present contact with podiatrist 48% Needing treatment 52% (males 26; females 102) % based on those needing treatment Having 1 foot problem 23% Having 2 foot problems 48% Having 3 foot problems 23% Having 4 foot problems 6% Foot problem treated Hard skin 36% males: 35% females: 36% Corns 48% males: 39% females: 51% Infections 2% males: 0% females: 2% Nails – cutting 96% males: 96% females: 96% 17
  18. 18. Systematic Review of the Literature: General Surveys of 60 or 65+ age group 18 Nails – thinning 6% males: 8% females: 5% Nails – ingrown 7% males: 4% females: 8% Salvage, AV et al – 1988 – South Glamorgan – 251 (i.e. the 69 per cent who were willing to participate and could be contacted out of potential 362) – 75+ – in community – assessment by interview In a South Glamorgan community, 370 subjects over 75 were randomly selected. Of these, 69 per cent (251) could be contacted and were willing to participate. In the last year, 37 per cent had seen a podiatrist, which may explain the low rate of ingrowing toenails. Assessment was by a podiatrist. Foot condition % Ingrowing toenails 7 Unable to cut own toenails 38 Able to cut own toenails with difficulty 19 White, EG & GP Mulley – 1989 – Leeds – 96 (i.e. the 95 per cent who were willing to be examined out of potential 101) – 80+ – in community – assessment by chiropodist This group was also quite narrow, covering people over 80 and living at home. From a GP’s age/sex register in Leeds, 106 people were selected and of these 96 were willing to participate. As with all these studies, the proportion currently receiving podiatry treatment (in this case nearly 50 per cent) affects the reliability of the figures, as foot health may be better in those who are being treated and the level of podiatry care varies from health authority to health authority. Assessment was by a podiatrist. The study is also similar to other research cited in that the effects of not being able to cut one’s own toenails is seen as a source of potential nail pathology and foot pain. The prevalence rates seem high but can be accounted for by the high age group. White (1989) With foot problem 94% With foot pain 30% Difficulty in cutting own toenails 77% Corns or calluses 68% (men: 44% women: 76%) Nail pathology 56% (men: 68% women: 52%) 6 General surveys with groups pre-selected (i.e. not just 60 or 65+) Research in USA Black, JR & W Hale – 1987 – USA – 733 – 72+ – in community – self- assessment by questionnaire with nurse or technician 18
  19. 19. Systematic Review of the Literature: General Surveys of 60 or 65+ age group 19 It is not stated how the sample was selected in this study. It took place in a community in Florida in 1987 with a high proportion of retired people. The number of people who participated was 733, and the youngest was 72. Assessment may have been flawed because it was done by the participants on the basis of a questionnaire with a nurse or technician subsequently helping to complete any questions that had presented difficulty. The low prevalence rate for corns may reflect the difficulty in distinguishing between calluses and corns experienced by the older participants. Black (1987) Frequency of foot problems Foot problem Total % % Men % Women Toenail problems 22.5 17.3 25.1 Calluses 20.2 9.8 25.7 Corns 16.1 4.7 22.1 Swelling 9.8 5.1 12.3 Decreased activity 9.1 5.2 11.2 Burning spells 5.4 2.4 7.1 Loss of feeling 3.7 2.4 4.4 Hannan, MT et al – 2001 – USA – 56 – 65+ – in nursing home and ambulatory – assessment by podiatrist The group studied in this research were residents of a nursing home. The study took place in 2001 in the USA. The number of participants was quite small – 56. They were all ambulatory, and assessment was by a podiatrist. The choice of categories seems odd because there is no mention of corns or calluses. The list provided covers the eight most frequent foot problems, only one of which comes in this paper’s list of priorities. Hannan (2001) Prevalence of most frequent foot problems Dystrophic nails 78% Foot vibratory lack of sensation 57% Varicosities 25% Ankle edema 9% 19
  20. 20. 7 Surveys on specific diseases/foot problems The literature review listed several foot diseases and related medical conditions on which research had been carried out, but only one area falls within the list of priorities to be discussed in this systematic review – ulceration. Leg and foot ulcers Research in Europe Ebbeskog, B et al – 1996 – South Stockholm, Sweden – 241,804 – all ages, with age bands – in community – questionnaire for clinical staff Four very large studies have been reported in Sweden – in South Stockholm (1996), Malmo (1992), Skaraborg county (1991) and Blekinge county (1998). The populations studied ranged from 151,610 to 270,800. Assessment was done by a questionnaire sent to clinical staff, and the response rate was high at over 90 per cent. The prevalence rates cover anyone with leg or foot ulcers undergoing treatment, but the vast majority (85 per cent and 92 per cent in two of the studies) are elderly patients. The rates of 0.12 per cent, 0.19 per cent and 0.33 per cent are better than the 2 per cent rate reported in Cartwright’s and Helfand’s studies. One of the Swedish studies was by Oien, and he makes the interesting suggestion that the ulcers were being treated more successfully since the annual questionnaire was introduced in 1986. (The annual questionnaire was the basis for his research in Blekinge county.) It encouraged staff to make more accurate diagnoses of ulcer aetiology and he presumes, therefore, that they give more effective treatment. Ulcers with a duration of over two years decreased from 44 per cent to 27 per cent and treatment time per ulcer from 2.1 to 1.7 hours per week. Ebbeskog (1996) Prevalence of leg and foot ulcers Age % All ages 0.12% Over 65 92% Commonest cause Venous insufficiency 42% Pain reported with venous ulcer Pain 47%
  21. 21. Lindholm, C et al – 1992 – Malmo, Sweden – 264,959 (i.e. circa 95 per cent response rate) – all ages – all types of residence – questionnaire to clinical staff Prevalence of leg and foot ulcers With leg or foot ulcer 0.12% Nelzen, O et al – 1991 – Skaraborg county, Sweden – 270,800 (with response rate of 92 per cent) – all ages, with age bands – all types of residence – questionnaire for clinical staff Prevalence of leg ulcers With active leg ulcers 0.33% Median age of patients with leg ulcers 76.5 years Patients with leg ulcers over 65 85% Oien, RF – 1998 – Blekinge county, Sweden – 151,610 – all ages – all types of residence – questionnaire for clinical staff Prevalence of chronic leg and foot ulcers With chronic leg or foot ulcer 0.19% Commonest cause Venous ulcers 38% Leg and foot ulcers Research in Australia Johnson, M – 1995 – Australia – 1,050 – 65+ – in community – method of assessment not given, with mention of studies in Sweden and North America No source for prevalency rates given. A study in Australia found slightly higher prevalence rates (1 per cent) than those in Sweden, based on a population group of 1,050 in a large city. Johnson points out that despite low prevalence rates, the condition involves major health costs with frequent nursing visits, therefore preventive measures and screening for venous and arterial vascular disease are cost-effective. Johnson (1995) Prevalence of chronic leg ulcers All ages in an Australian town 1% Over-60s in Swedish survey 1% Over-60s in North American survey 1%
  22. 22. Leg and foot ulcers Research in USA and Canada Harrison, M et al – 1999 – Canada – total number not given – all ages, with age bands – all types of residence – clinical assessment The research by Harrison in 1999 covered a whole region in Canada and used clinical staff as a source of information on prevalence. Harrison mentions a study by Nelzen in 1996 which suggests that a significant proportion of people with leg ulcers may be self-managing their condition. (Nelzen 1996) Harrison’s study therefore also includes a mechanism for self- referral (advertisements in 15 local and community newspapers). She does not give details of the response rate to these advertisements. The prevalence rate of 1.8 per cent is similar to that in Cartwright and Helfand. Nearly 75 per cent of the cases were in people over 65. Harrison (1999) Prevalence of leg and foot ulcers With leg or foot ulcer 1.8% Within this patient group, % of over- 65s nearly 75% Within this patient group, with a leg ulcer (all ages) 50% Within this patient group, with both leg and foot ulcer 15% Within this patient group, with a foot ulcer 35% Within this patient group, with history of leg or foot ulcers 45% Within this patient group, with 2 or more leg or foot ulcers over 40% Within this patient group, with moderate to severe pain from ulcers over 35% Paletta, C, Professor, Dept. of Plastic Surgery, St Louis University, USA – in eMedicine 2003 Review of research in Ireland, Australia and Sweden No source for prevalence rates given. This review by Paletta (2003) reports that the prevalence rate of ulcers in the USA is not known. He refers to studies in Ireland and Australia, finding the prevalence rate of chronic leg ulcers to be about 1 per cent. He also mentions a telephone survey in Sweden which shows that over time, in people over 70, the prevalence rate for both healed and non-healed ulcers is 9.8 per cent. No
  23. 23. further details are given, although he suggests that 80 per cent of leg ulcers are caused by venous disease and 20 per cent by arterial disease. Current chronic leg ulcers in Ireland and Australia 1% Healed & non-healed ulcers over time in over-70s in Sweden (telephone survey) 9.8% Copyright © Help the Aged 2005 All rights reserved Registered charity no 272786 Help the Aged, 207–221 Pentonville Road, London N1 9UZ Tel. 020 7278 1114 Email: