Challenging Patient: Older Patient with Multiple Co-Morbidities

 Know that diabetic foot complications are a significant cause of morbidity  Describe a strategy for preventing diabetic foot ulcers  Know how to perform a diabetic foot exam  Know how to prescribe shoes

 71,000 amputations in 2004 in patients with DM  Prevalence of LEA 2.4% among diabetics  Incidence of LEA (1998) 4.1/1000  Incidence of LEA (2006) 3.5/1000  Healthy People 2000 Goal: 4.9/1000  Healthy People 2010 Goal: 1.8/1000  Health People 2020 Goal: none set Healthy People 2000 Final Review Diabetes in America, 2nd Edition Healthy People 2010 Objectives Health People 2020 Objectives

Can We Prevent Sick Feet?

 Regular foot exams (SORT A) ◦ Deformity, neuropathy, PVD ◦ Examine more often if risk factors 3 to 6 months (SORT C) ◦ Involve podiatry if mult. Risk factors (SORT C) ◦ If prior ulcer or multiple risk factors, every 1 to 3 months (SORT C)  Appropriate footwear (SORT A)  Early referral for vascular disease (SORT C)  Education (SORT C)

 Foot deformities  Protective sensation  Vascular exam

 Callus  Claw toes  Metatarsal heads  Aging Disease Interaction

 Patient’s eyes shut  SWM applied randomly to (4) 6 points  Avoid callus/ulcers  Apply 90° angle until buckles  Patient says “yes” when feels it  Absence of sensation at any site “+” (absence at 4 sites Se, more Sp)

Lavery, Gazewood, 2000

 Absence of pulse more reliable than decreased pulse  Other predictors of PVD ◦ Femoral bruit ◦ Unilateral cool limb  Abnormal finding - consider ABI ◦ asymptomatic; symptomatic;  severe PVD Lavery, Gazewood, 2000

Rith-Najarian, 2000

 Data from RCT’s of educational interventions alone offer weak evidence of effectiveness, esp for high risk patients.  Effective interventions include an education component ◦ Daily foot inspection ◦ Daily foot care ◦ Wear socks/shoes ◦ Report problems Cochrane

 80% of cost - 1 shoe, 3 insoles per year  Part B benefit  LOPS with calluses, deformity, PVD of h/o ulcer  Three step process ◦ See physician for cert of eligibility ◦ See foot care specialist for RX ◦ Therapeutic footwear supplier  SORT A

Left foot Right foot Feet Feet Feet MEET YOUR DIABETICS FEET!