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Best Foot Forward: rReviewing of the literature: data on the prevalence of foot pathology in older people
July 2004
Professor Jane Evans and 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
/ IngentaAssianet / Kluwer
BioMed Central / Medline
BioMedNet Reviews / Recal
British Nursing Index / Science Direct
CINAHL / Swetswise
Cochrane Library / Web of Knowledge
Embase / Your Journals @ Ovid
Emerald / Zetoc
Highwire
Websites for health collections and gateways
BUBL / National Research RegisterHealth on the Net Foundation / NMAP
Medline Plus / Organising Medical Networked Information
MedWeb / UK Health Centre
National ElectronicLibrary 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 ‘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
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 – nails10
Asymptomatic nail pathology10
Maceration10
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
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.)
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group 1
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.
This study is very significant in any review of podiatric conditionsbecause 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%
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.
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.
Elton (1986)
Chiropodial conditions (%)Both sexes / Male / Female
Corns
/ 26 / 17 / 31Hard skin, ball of foot
/ 42 / 30 / 49Nail conditions, first toe
Onychauxis
/ 66 / 65 / 66Onychophosis
/ 53 / 49 / 56Nail conditions, lesser toes
Onychauxis
/ 57 / 50 / 61Onychophosis
/ 31 / 25 / 34Heel pain
/ 4 / 4 / 5Harvey, 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%
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 genderFoot 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.