Foot care for older people – Part 1: Supporting foot health through specific measures

In addition to these physical changes, people often experience not only minor ailments but also – sometimes serious – health problems or even serious illnesses, which then become more pronounced as the years go by.

Conditions that also affect the skin on the feet and lower legs, as well as overall foot health, include, in particular, diabetes mellitus, peripheral arterial disease (PAD), chronic venous insufficiency (CVI) and lymphatic drainage disorders (oedema). Furthermore, as people age, foot and nail fungal infections become more common, which can lead to serious infections. This is usually due to a combination of reduced blood circulation, a weakened immune system, a disrupted acid mantle and, in some cases, declining hygiene.

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What causes us to age?

Whether a person lives to be 70, 80 or 90 years old is essentially determined by their genes. However, whether they actually reach that age – and, above all, how they age – is not determined by their biological heritage alone. This is because the following factors also have a decisive influence:

• diet,
• body weight,
• the extent of chronic stress,
• alcohol and nicotine consumption,
• regular exercise,
• sporting activity,
• any underlying medical conditions.

Furthermore, mental well-being plays an important role. People who keep their brains active throughout their lives are usually more mentally alert and receptive in old age than those who have hardly challenged themselves in this regard. Furthermore, this helps to prevent Alzheimer’s disease or other forms of dementia – as recent studies suggest. Thus, a 70-year-old with a healthy lifestyle – and, of course, ‘good’ genes – may be significantly fitter overall than, for example, someone in their mid-50s who has never looked after their health and has spent many hours of their life smoking and drinking in front of the television. But however fit one may be, the passing years naturally take their toll – and this is often particularly evident on the skin and feet

Even if we think we’ll stay fit for a long time and remain ‘forever young’, so to speak, the ageing process begins earlier than we realise. Here are a few examples:

• The body’s water content in a young person is almost 70 per cent. From around the age of 30, it then decreases steadily to around 55 per cent. If one does not drink enough – which is often the case with older people due to a frequently diminished sense of thirst – the water content can be even lower; and this is also evident in the skin.
• Key factors in the ageing process include messenger substances such as growth hormone (HGH), the precursor to sex hormones (DHEA), as well as progesterone, oestrogen, melatonin, androstenedione and pregnenolone. If hormone production declines, their regulatory function diminishes, and this has consequences. As a result, cells and cell groups no longer work together optimally, and organ systems no longer function smoothly. The best example is DHEA. This hormone, produced by the adrenal cortex, is almost an all-rounder. Not only does it provide energy, motivation and mental performance, but it also promotes muscle growth, influences fat metabolism, thereby protecting against atherosclerosis, and reduces stress hormones (particularly cortisol). At the same time, it strengthens the immune system. From our mid-20s onwards, however, DHEA levels decline steadily, so that by old age, production of this hormone is down to only around 10 to 20 per cent. The consequences include, amongst other things, muscle loss, a decline in physical and mental performance, fatigue and susceptibility to infection.

• The changes in the skin are also complex: for example, the fat cells in the subcutis decrease, as do the collagen and elastin fibres in the dermis. Production by the sebaceous and sweat glands declines; in addition, fewer natural moisturising factors are produced in the epidermis. As a result, the epidermis not only lacks lipids and moisture, but is also less able to retain moisture, and the protective hydrolipid film is similarly compromised. All of this contributes to the typical dry, hydrolipid-deficient condition of ageing skin. Added to this is reduced blood flow, which – alongside the overall reduction in cell division and renewal – limits the skin’s ability to regenerate. Whilst the skin of young people renews itself on average every 28 days, this process takes around 60 to 70 days in 60-year-olds. Due to reduced cellular metabolism, injuries also heal more slowly, whilst the risk of infection increases as the immune system weakens.
• As a result of the natural ageing process, peak bone mass – and thus bone strength – also decreases. This process begins in one’s mid-thirties and amounts to around 0.5 to 1.5 per cent annually. This means that with age – and the associated decline in muscle strength and disturbances in the sense of balance – the risk of bone fractures increases.
• As respiratory volume and the number of alveoli decrease, the oxygen content of the blood falls. At the same time, the tissues increasingly lose their ability to absorb oxygen. As a result, the supply to the cells diminishes.
• The heart muscle gradually loses its pumping power. At the same time, the elasticity of the blood vessels decreases. This affects blood circulation throughout the body and, consequently, the supply of oxygen (and nutrients).

The signs of ageing are most evident on the skin; and not just on the face, neck and hands – the epidermis of the lower legs and feet also changes. Here, the skin is often very dry, rough and slightly flaky. A hydrolipid deficiency can also lead to redness, a feeling of tightness, a burning sensation and itching. It is not uncommon for this to develop, for example, into eczema with papules and inflammation, or into intensely itchy desiccative eczema. Typical of this desiccative eczema are net-like cracks in the stratum corneum, particularly on the lower limbs.

Furthermore, as we age, the epidermis becomes significantly thinner, particularly on the shins and the tops of the feet, making it more susceptible to both irritation and injury. If this is compounded by a lack of blood supply to the tissue caused by arteriosclerosis, the result is atrophy. In this case, the skin is as thin as parchment, glossy and highly vulnerable, and wounds heal with great difficulty.

Another sign of ageing on the lower legs – as, incidentally, on the backs of the hands and the extensor surfaces of the forearms – is often ‘purpura senilis’: slight pressure, or even for no apparent reason, causes pinpoint or patchy haemorrhages in the skin. These may fade within weeks or months, or they may remain permanently. In the latter case, they take on a brownish colour over time. This is caused by the breakdown of blood, which produces haemosiderin, a complex of iron and proteins.

Further changes, usually occurring after the age of sixty, include pigmentary disorders (‘age spots’) and benign skin growths such as the non-contagious verrucae seborrhoicae. In the early stages, these ‘age warts’ appear as matt, flat, skin-coloured or light grey-brown spots or plaques. Over time, they then develop into black-brown, round or oval warts of varying sizes with a fissured, keratinised surface. These warts often form on the back, chest and the front of the arms and legs, but never on the palms of the hands or the soles of the feet.

Almost everyone is born with healthy feet. However, as we get older, foot and toe deformities become more common. The reason is usually a combination of genetic predisposition, ‘foot-unfriendly’ footwear, excess body weight and prolonged strain.

It is therefore no surprise that around 70 per cent of adults are affected by, for example, sagging, buckled, splayed or flat feet. As muscle mass decreases with age and the tension in ligaments and tendons continues to weaken, these changes and the associated symptoms become more pronounced. It is therefore typical for the longitudinal and transverse arches to sink further, causing the feet to widen and lengthen – and meaning that shoes now need to be one size larger. This sinking also places excessive plantar pressure on the metatarsal heads. The consequences are calluses and pain.

A fallen flat foot can also lead to the development of hammer toes and claw toes or a hallux valgus or exacerbate them. It is also important to note that toe deformities may, under certain circumstances, occur in cases of diabetic polyneuropathy! Due to incorrect weight-bearing and dry skin, there is also an increased formation of hyperkeratosis such as calluses and corns in areas subject to pressure and friction. The toes from D2 to D5 – on the dorsal side at the middle joints and at the apex – as well as the plantar forefoot and the heels are particularly frequently affected.

In cases of very severe callus formation, fissure-like rhagades may develop on the heels, which are particularly prone to stress; these may, under certain circumstances, become infected deep down. However, severely dry skin and hyperkeratosis can also be additional symptoms of chronic conditions that become more prevalent with age. These include, in particular, diabetes mellitus with disease-related arterial insufficiency and peripheral neuropathy, as well as peripheral arterial disease (PAD).

The feet are often not spared from the signs of wear and tear on the joints that frequently occur in old age. In addition to hallux rigidus – osteoarthritis of the metatarsophalangeal joint of the big toe – osteoarthritis of the metatarsal bones and the ankle joint are particularly noteworthy. Of course, the joints of the individual toes can also be affected by this painful wear and tear.

Read Part 2: Foot care for older people – Part 2: Helpful tips for healthy feet

Captions:
Figure 1: Abnormal nail growth in old age.
Figure 2: The benign ‘senile wart’ is initially rather flat and skin-coloured to light grey-brown.
Figure 3: Over time, the verruca seborrhoicae develops into a black-brown wart with a fissured and keratinised surface.
Figure 4: Hallux valgus frequently leads to misalignment of the neighbouring toes. Not only are these toes particularly close together, but as ‘hammer toes’, their distal phalanges are severely bent.

Author: Barbara von Wirth M.A., specialist journalist
Images 1–4: @Barbara von Wirth M. A.

About the journal PODOLOGIE

The specialist journal PODOLOGIE is one of the leading publications for podiatrists and medical foot care specialists in German-speaking countries. With in-depth specialist articles, practical case reports and the latest information from the worlds of science, law and clinical practice, it supports its readers in their day-to-day professional lives and offers a valuable platform for professional exchange. Those interested can choose from a range of subscription options – from the print edition to digital access. Further information on subscriptions can be found at:  www.podologie.de/abos