Care Of Diabetic Foot: How To Prevent Amputation

Introduction

Diabetes mellitus is defined as a metabolic disorder characterised by chronic hyperglycaemia with metabolism disturbances in carbohydrate, protein and fat because of defects in insulin secretion, insulin action, or both (SIGN 2010).

Diabetes mellitus is one of the main causes of increasing morbidity and mortality in Scotland and worldwide every years (SIGN 2010). Diabetes leads to several problems that begins with many of symptoms and debility on the short term and ending with a wide complications such as blindness, renal failure and amputation. Furthermore, diabetes has a significant impact on increasing the mortality and premature death from cardiovascular disease such as stroke and myocardial infarction (Massi-Benedetti 2002).

Globally, the international diabetes federation (IDF) estimated the number of adults (between 20 – 79 years) with diabetes mellitus disease in 2010 around 285 million in seven regions of the IDF, and estimated the percent of adults with diabetes in 2010 in Europe 8.6%, United Kingdom 4.9%, United States of America 12.3% and similarly at both Jordan and Libyan Arab Jamahiriya 7.5% (IDF Diabetes Atlas 2010). And to the same years, the IDF estimated that the number of deaths due to diabetes mellitus is approximately 3.9 million deaths annually which represents 6.8% of all total global mortality (IDF 2009) . Moreover the number of people who have diabetes were approximately 39 million in 2007 and the expected gradual increase 439 million in 2030 (IDF 2009).Furthermore, in another study the IDF estimated that 23 million years of life are lost due to disability, decrease quality of life and reduce lifespan of person as a result of complications related to diabetes (Egede and Ellis, 2010). The cost of treating and preventing diabetes globally in 2007 was approximately $ 232 billion, this number is expected to increase to over $300 billion in 2025 (Egede and Ellis, 2010).

The United State of America spent in 2002 around $132 billion on diabetes (Egede 2006), and spent around $10.9 billion in 2001 on treating diabetic foot ulceration and amputations (Gordois et al. 2003). Also, The United Kingdom spent in 2001 approximately 5% of the total National Health Service (NHS) expenditure (£3 billion) on diabetes mellitus (Wild et al. 2004). The Diabetic foot complications cost the United Kingdom approximately £252 million each year (Adam et al. 2003).

Every 30 seconds a lower extremity is lost in patients with diabetes due to amputation in the world (IDF 2009). Additionally, around 5% of European population suffer from Type 2 diabetes mellitus (IDF Diabetes Atlas 2007).

India was the country with the highest numbers of patients with diabetes mellitus in Asia (Wild et al. 2004). The complications of diabetes remain very common in the developing countries such as diabetic foot and amputations (IDF 2005) the same as other developing countries in the world. Boulton et al (2005) identified that there are several factors that contribute to the increase complications and incidence of diabetic foot; these include late discovery of the disease and diabetic foot complications; the presence of catalysts such as neuropathy and high infected complications helps, moreover, deficiencies in podiatry service in most countries, barefoot gait which is common in some cultures and some of social beliefs and cultural traditions which are still in control of some communities and drives patients with diabetes to use and to depended on traditional healers, village elders and alternative medicine for treating themselves .

In Sub-Saharan Africa, which contains 33 countries from the list of 50 poorest countries in the world; these countries are facing a significant increase in the rate of diabetes during the next twenty years (Wild et al. 2004). Diabetic foot complications are a major cause of increasing public health problem, leading cause of admissions to hospitals, amputation and increased mortality rate in diabetic patients (Zulfiqarali and Lennox, 2005). The main reasons leading to increase rate of diabetic foot in Africa were the frequency of neuropathy and peripheral vascular disease, unhygienic conditions, poverty, barefoot gait and inappropriate foot wear, low income, urbanisation, frequent co-existing HIV infection, and cultural beliefs and incorrect practices (Boulton et al. 2005).

Risk of developing foot ulcers during lifetime of diabetes patient is approximately as high as 25 % (Singh et al. 2005). The International Diabetes Foundation confirmed that awareness regarding foot complications must be increased between diabetic patients because of its positive impact on personal, social, medical, and economic costs (Boulton 2004).

Implementing screening, educational, and treatment programs globally in every area of the world was the biggest challenge facing the Global Diabetes Community (Boulton et al. 2005).

A diabetic patient faces many problems caused by diabetic foot such as pain, morbidity and substantial economic consequences. The infection rate by diabetic foot differs between developing and developed countries and between European countries. Globally 25%-90% of all amputations were caused by diabetes (Boulton et al. 2005). The cost of treating diabetic foot ulcers was affected by the implementations of some interventions to prevent the development of foot ulcers, care strategies to heal ulcers or wound to prevent inflammation and amputation, shorten period of wound healing, and by frequent care necessary for disability after amputation (Tennvall and Apelqvist, 2004).

In Europe and North America 7-20% from of the total expenditure is spent on diabetes and more precisely on the diabetic foot care (Boulton et al. 2005). In a Swedish prospective study it was estimated that diabetic patient with foot ulcers cost around 37% of the total costs on foot ulcers care until healed without amputation but if the patient needs amputation the inpatient care will cost up to 65% of the total costs, and also costs around 45% of the total costs using topical treatment of wounds but this percentage changes to 13% in patients with amputation (Boulton et al. 2005). The economic costs of minor lower limb amputation (foot level) such as toes around $43,800 and for main lower limb amputation (above ankle) such as all foot around $66,215, of which 77% of the costs comes post-amputation (Boulton et al. 2005).

Applying foot-care services such as screening, education, treatment can effectively the rate of amputation among diabetes patients (Boulton et al. 2005). Furthermore, treatment of diabetic patients with or without diabetic foot according to the present management guidelines would result in enhanced survival and significantly reduced number of diabetic foot complications. Furthermore, it leads to significant reduction of up to 25-40% from the total economic costs of treating ulceration and amputation (Ortegon et al. 2004). Also, the adherence of diabetes patient to education and treatment is very important, effective and playing important role to prevent diabetes complication and improvement of patient health (Boulton et al. 2005).

Aims and objectives

Aims:

To create more awareness of diabetic foot complication and foot care.

To promote foot health in individual with diabetes and minimise the risk of foot complication.

To identify major causes that lead to foot ulcers and how to prevent them.

To inform people with diabetes about the actions and measures they can take to prevent occurrence of foot complications, provide diabetes self care education and encourage patients to change their behaviours to enhance foot hygiene and appropriate foot wear.

To inform patients how to look after their wounds or ulcers.

To reduce risk of lower extremity complication and amputation between diabetic patients.

To try and improve the flow of information and intervention between patients and health care specialists.

To enhance communication between diabetic patients and multidisciplinary care team.

Objectives:

Educate diabetic patient about good foot hygiene, diabetes risk factors, wound care, and about appropriate foot wear.

Provide education about foot care by regular monitoring – identification and early detection of ulcers, determination of risk factors such as (Neuropathy, Ischemia, Deformity, Callus, Oedema).

Educate patient about the risk factors that can are increase diabetic foot complications such as poor fittings shoes, smoking, obesity, blood pressure, high lipids, aging and positive history to ulcers or amputation.

Educate patient about proper footwear, nails care and wound care.

Outcomes:

Patient will have good circulation to feet.

Patient will identify and take action when injury occurs.

Patient will know how to take care of his feet.

Patient will be able to determine the risk factors to diabetes ulceration and lower limb amputation.

Patient will identify and select appropriate foot wear.

Patient will be able to identify the importance of wound care, early detection of ulcers, good diet and exercise, regular monitoring and assessment of foot, adjust the level of sugar in the blood and stop smoking.

Interventions

Worldwide, 3.2 million deaths reported in relation to diabetes complications every year, also one in twenty deaths in the world due to diabetes resulting in 8700 deaths daily, this is equivalent to 6 deaths every minute (Unwin and Marlin, 2004). Study was estimated incidence of foot ulcers each year to diabetes patient around 2-6%, a prevalence of 3-8%, also estimated recurrence rates of ulcers within 5 years approximately 50-70%, the average of healing ulcers of 11-14weeks and the rates of incident of amputation after a one year estimated by 15%. However, the cost of diabetic foot include direct costs related to foot complications and also indirect costs related to loss of productivity, patient and family economic costs and loss of quality of life (Boulton et al. 2005). In a prospective study following up patients after foot ulcer healing, explained the return ulceration rates to patient after 1 years was 34%, at 3 years was 61% and at 5 years 70%. The diabetic patients with recurrent ulcers, the highest costs were for hospitalise care, social services, and self care in home (Boulton et al. 2005).

Diabetic foot complications are very common worldwide; it leads to social, political and economic impacts on society, patients and their families (Boulton et al. 2005). When Paul Brand was asked to suggest a recommendation to reduce amputations and foot complications in diabetes patient to the US Department of Health conference, most of the attendees were probably expecting an answer of both either promoting vascular surgery or modern medications, but they were surprised to hear that his answer was the recommendation to encourage health care professionals and caregivers to remove patient’s shoes, socks and after that examine and assess feet, many countries in the world ignored these recommendations. Although, the assessment of foot does not require expensive equipment for example a tuning fork, pin, tendon hammer and 10g monofilament these are cheap and suffice(Boulton 2004; Singh et al. 2005).

The education should be focused on the diabetic patients with high risk feet. Furthermore, when planning an educational programme the caregivers should not forget that many patients donated are unable to understand what neuropathy, nephropathy, ischemia or risks of foot ulcers means (Vileikyte et al. 2004). Because of that the education should be simple, easy to understand by patients and suitable for the culture and social background of the patient (Boulton et al. 2005).

First: Risk Factors

One amputation occurs every 30 seconds worldwide between diabetic patients (Bakker et al. 2005). Approximately 15% of diabetic patients develop foot ulcers (Edmonds 2008). Amputation occurs more with diabetes patient than patient without diabetes (SIGN 2010). Three main pathologies factors must be met for the beginning and stimulation development of diabetic foot complications: neuropath, ischemia and infection. Furthermore, People with diabetes mellitus are higher to develop lower limb amputation between 15-46 times more than people without diabetes mellitus (Wilson 2005).

Neuropathy is the most frequent and common complications in diabetic patients. It affects around 50% from all diabetic patients (Wilson 2005). The danger lies in the loss of protective sensation to pain, thus patient feel or recognise the pain or any discomfort in the lower extremity (Urbancic-Rovan, 2005).

Ischaemia is four times more common in people with diabetes than in people without diabetes. Some of the factors that lead to increased occurrence of ischaemia were smoking, hypertension and hyperlipidaemia. Usually it develops gradually and slowly in diabetic patients, but in the end leads to a severe decrease in arterial perfusion and results in compromising vascular supply of the skin, and most often leads to a minor or major trauma in the lower extremity (Wilson 2005). Ischaemia and neuropathy are mostly associated together in diabetic patient (Edmonds and Foster, 2005)

Infection of wound or ulcers in diabetes patient is the main reason for admission to hospital, and also increasing the incidence of amputation, when the infection is associated with neuropathy and ischaemia it leads to higher incidence of infection without pain, furthermore, leads to the loss of some of the inflammatory response such as increased temperature and white blood cell count (Wilson 2005).

Additionally risk factors identified by (Urbancic-Rovan, 2005) that can effect diabetes patient and lead to ulceration and lower extremity amputation includes:

Foot deformity because of motor neuropathy and muscle atrophy.

Callus growth and formation.

Disability in joint mobility.

Reduced metabolic control leading to impaired wound or ulcer healing.

Positive history to foot ulcer or lower limb amputation.

Autonomic neuropathy that leads to gradually decreased sweating and dry fissured skin in foot.

Obesity.

Retinopathy.

Inappropriate footwear.

Smoking.

Older people.

Socioeconomic status.

Interventions:

Early detection and screening in addition to appropriate management of these ulcers can lead to preventing up to 85% of amputation (Edmonds and Foster, 2005).

To provide effective treatment and management the patient should know and understand the major causes and risk factors for ulceration and amputation, meticulous treatment plan and should have frequent routine screening (Wilson 2005). Moreover, regular screening and assessment for feet of diabetes patient give the patient the opportunity of up to 99.6% to keep his feet free from ulcerations (follow up at 1.7 years) and were 83 times less probable to incident ulcers than the high- risk group (SIGN 2010).

Teaching patients about the metabolic management, such as the control of blood glucose by regular diet, exercise, insulin and medication to protect neurological function. Patient should be educated on how to treat blood pressure, high lipids and should be encouraged to stop smoking to preserve cardiovascular function, prevent the occurrences of ischemia and enhance blood supply to lower extremity (Edmonds 2008).

Encourage diabetic patient to daily foot examination and inspection, full monitoring of his feet by specialist diabetes doctor or nurse every 4 months and full screening and examination test every 6 month (Michael et al. 2005).

All diabetes patients when diagnosed with diabetes mellitus should be educated and encouraged to be screen and examine his foot regularly or at least annually to detect any risk factors for foot ulcers as early as possible (Edmonds 2008). And to assess their risk of beginning a foot ulcer complication (SIGN 2010). patients should be screened for the main risk factors which include:

Neuropathy, which is the most common complication of diabetes mellitus and begins to produce primitive signs that emerge within 5 years of the onset of the disease (Hampton 2006). The neuropathy can be assessed by the use simple techniques such as 10g monofilament to assess pressure sensation in patient. On the other hand, the use of vibration perception threshold by using a neurothesiometer to assess patients (Edmonds 2008). Because the vibration perception threshold is more sensitive than the 10g monofilament especially in persons at risk for foot ulcers (Miranda-Palma et al. 2005).

Ischaemia assessed by palpation of the dorsalis pedis or posterior tibial pulse, if it cannot be felt it is unlikely that there is significant ischaemia. So the significant factor indicating ischaemia is the reduced Doppler arterial waveform. But the American Diabetes Association (ADA) recommended that the ankle-brachial pressure index (ABPI) should be measured for all diabetic patient especially patients above 50 years of age (Edmonds 2008). Faglia et al (2005) showed in his study that 21% of the occurrence of peripheral arterial disease was indicated by a low ABPI in recently diagnosed diabetic patients.

Deformity such as claw toes, pes cavus, hallux valgus, hallux rigidus, hammer toe, Charcot foot and nail deformities; these deformities lead to bony prominences and causes high mechanical pressures on the skin surface, thus leads to ulceration, especially in the absence of protective pain sensation and feeling, and when wearing inappropriate shoes. Thus any diabetes patient, who has any deformities, should be educated how to care for his feet (Edmonds 2008).

Callus and Oedema: the presence of callus leads to ulceration because of the high pressure and friction on it. Also the oedema is the main factor causing ulceration, and often produced when patient is wearing inappropriate and poorly fitting shoes (Edmonds 2008).

Diabetic patient should be educated about signs of infection. Swelling, redness and hotness, all of this are present with signs of systemic infections. Patient must visit a medical clinic immediately (Michael et al. 2005).

Second: Foot care

Diabetic foot complications are common complications between United Kingdome populations, according to statistics, 23-42% related to neuropathy, 9-23% vascular disease and 5-7% foot ulceration (SIGN 2010). Diabetic foot care guideline is very important and should be the main part of basic diabetic patient education programs and workshops (Michael et al. 2005).

Interventions:

Diabetes patient and caregivers’ nurses or physician should be taught the nail cutting techniques (Michael et al. 2005). Nails of diabetes patient should be cut when they are softer and flexible, therefore, the patient should cut his nails after a bath or shower; the patient should never try to cut the whole nail as one piece, cut out the corner of the nail or more down the sides of nail (Edmonds 2008). Patient should be educated to use the soft brush to clean about the nails and if the nails become thick, the nails care should be performed by a professional nurse or physician (Michael et al. 2005).

Patient education regarding foot hygiene, nail care, general assessment of foot care and patient should know when and how to ask for help when having any symptoms, problems or any suspicions around his foot (Wilson 2005).

Encourage patient to wear natural fibre socks, it is better to be white to simply detect any derange or bleeding from foot (Michael et al. 2005).

Footwear may reduce the rate of amputation by 50% when it is used perfectly (Bloomgarden 2008). Footwear (shoes) should be padded with soft leather from the inside and have a broad rounded toes, with an elevated toe box, the heels must be low to prevent excessive pressure on toes, and they must be the appropriate size to prevent movement and friction within the shoe (Edmonds 2008).

If the diabetic patient has any deformity in his foot it should be detected early and appropriate shoes selected before any complication occurs. The diabetes foot wear included to three main types:

Sensible shoes it is used to protect diabetic patient with partial loss of sensation (low risk to develop foot ulceration).

Readymade stock shoes it is used to patient who has few deformities, neuroischaemic feet and that needs to be protected almost all the time (moderate risk to develop foot ulceration).

Customized shoes it is made specifically for patients with deformities and contains appropriate insoles to relieve pressure on the foot (Edmonds 2008). The custom-built footwear should be used to decrease callus severity and reduce ulcer repetition (SIGN 2010).

Diabetic patient who have lost protective sensation and cannot feel normally in lower extremity should be protecting their feet from any mechanical, thermal, chimerical injury because of that they should be encouraged to develop a habit of regularly examining and inspecting their feet to detect any problem or complication early. In addition should be educated about type 2 diabetes to protect themselves as far as possible to avoid the occurrence of any injury (Edmonds 2008). If patient have lost their sensation in the lower extremity, recurring trauma, limited joint mobility, poor healing and have ischaemia in lower limb, all of this lead to increased incidence of ulceration and in addition amputation (Bloomgarden 2008).

Should educate diabetic patients how to prevent dry skin to prevent ulceration, by applying emollient or lotion such as E45 cream on a daily basis (Reckitt Benckiser, Slough) or Calmurid cream (Galderma, Watford) (Edmonds 2008). Patient should be encouraged to use daily oil, lotion and lanolin cream to prevent dryness of skin (Michael et al. 2005).

If patients have callus they should be educated not to cut their callus or use any product to remove it. Also the callus should be removed gradually by podiatrist to prevent ulceration (Edmonds 2008). Patient should not use any removers to remove corns or callus (Michael et al. 2005). The podiatrist can reduce effectively the number and size of foot calluses and enhance self care (SIGN 2010).

Should be encouraged to do path to his foot daily with mild soap to promote blood circulation. Furthermore, patient should dry the feet carefully and use lamb’s wool between the toes if the skin stays moist or become macerated (Michael et al. 2005).

The occurrence of foot wounds is 2-7% per year among diabetes patient (Bloomgarden 2008). Also the patient and caregivers should be educated about sterile dressing’s technique, the dressing should be covering all wound or ulcers to prevent infection, protect patient foot from any trauma, and promote wound healing (Edmonds 2008).

Patient with wound or ulcers should be frequently assessed and inspected specially if the patient has lost protective pain sensation to early detect any development of complications or problems, because of this the dressing should be characterized by: uncomplicated and speed lifting, The ability to walk by without any trouble or suffering disintegration, good ability to monitor and evaluate the secretions and abscess (Edmonds 2008).

Action plan:

Agreed strategy for foot care such as protocol or guideline driven care of the patient.

Involvement of a multidisciplinary foot team to include: diabetic nurse specialist, podiatrist, vascular and orthopaedic surgeon, diabetes physician, orthotist and radiologist.

Education for staff and all caregivers looking after the feet of diabetic patients.

Establishment and enhancement of good communication between the diabetic patient and multidisciplinary foot team and the primary medical doctor.

Reinforcement using appropriate foot wears.

Encouragement of diabetic patients to effectively liaising with the podiatrist.

Maintain wound care by using appropriate and sterile dressings.

Encouragement of community nurses to educate people, especially about diabetes mellitus, diet, insulin, diabetes medication and the risk of complications.

Activate discussion groups and workshops for patients with diabetes in primary medical centres.

Facilitating the knowledge, skill and human resources for the promotion of diabetes self care.

Conclusion and recommendations

Diabetes mellitus is defined as a metabolic disorder characterised by chronic hyperglycaemia with metabolism disturbances in carbohydrate, protein and fat because of defects in insulin secretion, insulin action, or both (SIGN 2010).

Approximately 39 million person in 2007 diagnosed with diabetes and an expected gradual increase to 439 million in 2030 (IDF 2009). The diabetes Cost in 2007 worldwide was approximately $ 232 billion and expected to increase to over $300 billion in 2025 (Egede and Ellis, 2010). Every 30 seconds, a lower extremity is lost to diabetes due to amputation in the world (IDF 2009).

Diabetic foot complications very common worldwide, also leads to big social, political and economic impacts to both society and to the patient and their families. Paul Brand, suggest a real recommendation to reducing amputations and foot complications to the US Department of Health conference that is to encourage multidisciplinary foot team to remove patient’s shoes, socks and after that examine and assessment patient feet.

The diabetic foot is a significant healthcare problem worldwide and inadequate appropriate therapy may lead to the spread of serious complications such as amputation, disability and increase morbidity and mortality rate each year globally. Therefore, careful monitoring, regular assessment, patient education and education for the specialist team caring for diabetic foot ulcers are very important and significant. Furthermore, early detection and specialized treatment of any risk factors plays significant part to prevent foot complications and reducing the amputation rate.

Diabetes leads to dramatically increased risk of diabetic foot and amputation, but available evidence based guidelines or protocols that this risk may be significantly reduced by effective screening and intervention. The multidisciplinary foot team should screen all diabetic patients regularly to early detect those at risk for foot ulceration and this screening should include all risk factors and all assessment procedure.

Educating patients and caregivers about foot care and risk factors, full examination every 6 month or at least annually, appropriate footwear, daily self foot examination, wound care, smoking cessation, control of blood glucose level, activation of community nurses, enhance communication between diabetic patient and multidisciplinary foot team. All of these measures should be applied and adhered by patient firstly, and by all caregivers secondly to reduce diabetic foot complication and prevent amputation.