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

Regular exercise benefits the heart, circulation and lungs, which in turn improves the supply of oxygen and nutrients to the whole body. Regular, moderate physical exercise also strengthens the muscles, which in turn benefits bone health. For this reason alone, it is important that older people are (once again) able to walk well. Adequate skin care is just as important as appropriate protection against pressure and friction. Of course, advice and fitting of orthopaedic footwear should never be overlooked where necessary.

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

Practical aids

Older people often suffer from limited mobility. The following items, for example, can provide assistance in everyday life:

• Shower stools
• Telescopic shoe horns
• Telescopic mirrors for checking diabetic feet, for example
• Dressing aids for compression stockings

Targeted skincare for older people

Extremely dry skin has numerous consequences that are not merely unpleasant. It can also restrict mobility and increase the risk of infection. This is because extremely dry skin – known in medical terms as xerosis cutis – is associated with:

• Itching,
• Skin lesions (including those caused by scratching),
• Hyperkeratosis (including painful clavus and pressure-induced plantar callosities) with, in some cases, deep, painful, dry rhagades.

Important!
As a general rule, older people are advised to drink more to prevent dry skin. However, in the case of certain medical conditions, such as heart or kidney failure, the daily fluid intake must not be increased!

To avoid stripping the skin of even more lipids and moisture, the following is recommended for daily body care:

• Shower or bathe for no more than 15 minutes, and no more than two to three times a week, at a water temperature of no more than 39 °C.
• Use only cleansing lotions for dry skin or moisturising ‘soap-free’ and ‘pH-neutral’ shower gels and bath additives, preferably without preservatives, colourings or fragrances.
• Avoid rubbing alcohol – for example, on the legs – as alcohol dries out the skin.

Discover skincare products

For these reasons, regular and appropriate skincare is essential, particularly for older people. To stabilise the hydrolipid content of the epidermis and the skin’s acid mantle, and to allow the skin to regenerate, products that provide both lipids and moisture are required. However, a balanced ratio is key here. Thus, water-in-oil (W/O) emulsions with a fat content of over 50 per cent are recommended, as they provide the skin with sufficient lipids. At the same time, the light, breathable film that such skincare products form on the skin protects the epidermis from excessive transepidermal water loss.

Above all urea-containing skincare products with a urea content of five to 10 per cent are particularly suitable here. This is because urea helps to retain moisture, supports the regeneration of the epidermis, keeps it supple and protects it from drying out and irritation. At a concentration of 10 per cent, urea also has an anti-itching effect and promotes the skin’s natural shedding process. Urea is generally well tolerated. However, it should not be used on weeping or bleeding rhagades, inflammations or injuries. Products containing urea should be avoided on sensitive skin. In the case of atrophic or poorly perfused skin, a urea concentration of 10 per cent or higher is contraindicated, as it then has a keratolytic (i.e. skin-exfoliating) effect.

Other nourishing ingredients for mature skin include, for example, anti-inflammatory jojoba with its moisturising and hydrating properties. Allantoin also has moisturising, soothing and regenerating properties,  Aloe vera, Panthenol and shea butter.& nbsp;Vitamin E promotes moisture retention in the stratum corneum and also has regenerative properties. Furthermore, it has anti-inflammatory and wound-healing properties. Skincare products containing borage seed, hemp or evening primrose oil also have anti-inflammatory effects. Skincare products with a high fat content or containing mineral oil, on the other hand, are unsuitable. This is because they have a pore-clogging (occlusive) effect, which hinders the natural transepidermal water exchange.

The treatment of patients with peripheral arterial disease (PAD) or skin that is otherwise highly sensitive and at risk of injury and infection should be carried out with the utmost care in every respect – and, where necessary, with brief breaks to alleviate pain. The following points should be observed:

• The feet should be prepared using only a mild, alcohol-free disinfectant.
• In the case of an incipient ingrown toenail without tissue defect, gentle correction is recommended, for example using non-woven pads, Smig or Sulci protectors. If there is a lesion in the nail fold or if hypergranulation tissue has already formed, the patient must be referred to a doctor and further podiatric treatment should be carried out in consultation with them.
• Caustic agents such as alum, Albothyl or silver nitrate are absolutely contraindicated here due to the fragility of the tissue and impaired wound healing. For this reason, even Clavi should only be treated manually and with the utmost caution. Warts should always be removed by a dermatologist.
• It is also important to prevent and treat fungal infections of the feet promptly, as any infection can lead to a lesion. The patient must be advised to use the product regularly (in accordance with the package leaflet). Fungal nail infections should not be treated by the patient themselves, but by a podiatrist, as filing down the nail poses a risk of injury to the surrounding tissue.

In addition to daily care of the skin on your feet, we also recommend regular use of nail oil containing an antifungal active ingredient. These oils not only keep the nail plate elastic and the surrounding skin supple, but also protect against fungal infections.

A visit to a dermatologist is definitely recommended if itching and/or inflammation persist despite adequate skin care, or if an unexplained skin change occurs or spreads. In the event of a purulent paronychia, older people – particularly those with diabetes or peripheral arterial disease – should also see a doctor immediately!

To prevent excessive callus formation and the associated discomfort, protection against pressure and friction on exposed areas of skin is just as essential as corrective measures for toe deformities. The range of ready-made products made from fixation fleece, moleskin fabric, leather, polyurethane or latex foam, tricot fleece, wool felt, silicone foam and gel is extensive. It ranges from ball-of-foot, forefoot and heel pads or cushions, toe separators and protective rings, to corn-protection rings, gel tubes, cut-to-size padding sheets, as well as thin, self-adhesive, elastic latex and silicone sheets – to name but a few of the options.

In addition, the market offers pressure-relief products made from polymer gel. These are not only particularly supple, elastic, skin-friendly and hypoallergenic, but they also release paraffin oil, which prevents excessive hyperkeratosis and keeps the skin supple. However, although ready-made products often alleviate discomfort, their fit is not always perfect; furthermore, their durability is limited. Regular, close monitoring is therefore often essential when using them.

Discover suitable pressure protection products

If the ready-made products do not deliver the desired results, a custom-made silicone orthosis the solution. However, a long-term corrective or pressure-relieving measure by an orthopaedic shoe technician may also be required. In this case, the patient should consult an orthopaedic surgeon, who will prescribe the appropriate pressure-relieving or corrective measure.

Where does it hurt?

A foot scan and pedography ensure the optimal fitting of insoles or shoes.

The foot scan provides a digital representation of weight distribution and pressure patterns on the sole of the foot whilst standing, as well as the length and width of the feet. Pedography is a dynamic foot pressure measurement in which the patient walks across a pressure measurement plate fitted with sensors. The resulting data is analysed using a specialised computer programme. The examination is used for dynamic and static foot pressure measurement as well as gait analysis. The rolling motion of the feet, along with their pressure distribution and the resulting individual loads, is displayed graphically in colour.

Money spent on comfortable, well-fitting shoes that are easy to put on and have non-slip soles is money well spent, as the right footwear helps to prevent pressure sores and falls.

• Older people in particular should take their time when buying shoes: this means trying them on in the shop for at least ten minutes. The best time to do this is in the afternoon, as feet are usually slightly swollen then.
• Shoes with Velcro fastenings not only make it easier for people with limited mobility to put them on and take them off. They also allow the width of the shoe to be easily adjusted to the correct fit if the feet swell or oedema develops.
• Shoes should be as flat as possible (with a heel no higher than four centimetres) and wide enough for the toes.
• PU soles with a tread pattern are not only non-slip, they also cushion each step, thereby relieving pressure on the joints.
• Furthermore, the shoes should provide sufficient space to protect against pressure and friction.
• If orthopaedic insoles are required, shoes with removable insole pads are recommended.

For people with diabetes, appropriate footwear tailored to the stage of the condition is essential to prevent lesions. For example, in risk groups 0 and I (according to Wagner) – that is, diabetes without peripheral polyneuropathy or peripheral arterial disease (PAD) and with only a minor foot deformity such as a splayfoot – a ready-made shoe that fits the foot properly is recommended. Here, for example, a continuous, seamless, soft inner lining protects the skin of the foot, a soft toe cap protects the toes, a padded tongue protects the instep, and a long, padded heel counter ensures pressure-free support for the heel.

Depending on the other risk groups, which extend up to Group IV (this includes diabetes with loss of sensation, significant peripheral arterial disease, and severe toe and foot deformities), options may include, for example, orthopaedic shoe modifications such as sole stiffening, widening of the sole and/or the upper, as well as a bunion, midfoot or heel roll, may be required. These improve the foot’s rolling motion and thereby relieve pressure on the joints, amongst other things. In some circumstances, it may be essential to provide diabetic safety shoes or custom-made orthopaedic shoes extending above the ankle – both with a footbed adapted for diabetes – as well as a custom-made inner shoe. In addition to a doctor’s prescription, advice and support from an experienced orthopaedic shoe technician are required here, who will also regularly check the fit.

Captions
Image 1: Typical dry, scaly skin associated with aging.
Images 2–3: This 88-year-old patient suffers not only from peripheral arterial occlusive disease but also from severe chronic venous insufficiency (CVI). In the second image, skin atrophy and venous markings are clearly visible. The third image shows complete brown discolouration due to haemosiderin deposits, as is typical of CVI.
Image 4: A nail growth disorder caused by PAD. Such a finding is often mistaken for onychomycosis. To be on the safe side, a dermatologist should carry out the appropriate diagnostic tests in such cases.

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