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Incorporating foot assessment in the comprehensive geriatric assessment

Abstract

Background

Foot problems are common in older adults and associated with poorer physical function, falls, frailty and reduced quality of life. Comprehensive Geriatric Assessment (CGA), a multidisciplinary process that is considered the gold standard of care for older adults, does not routinely include podiatry assessment and intervention in hospitalized older adults.

Aims

To introduce foot assessment to inpatient CGA to determine prevalence of foot disease, foot disease risk factors and inappropriate footwear use, assess inter-rater reliability of foot assessments, determine current podiatry input and examine associations between patient characteristics and foot disease risks.

Methods

Prospective, observational cohort study of older adults on geriatric rehabilitation wards. Foot assessment completed using the Queensland Foot Disease Form (QFDF) in addition to routine CGA.

Results

Fifty-two patients (median age [inter-quartile range] 86.4 [79.2–90.3] years, 54% female) were included. Six patients (12%) had foot disease and 13 (25%) had a ‘high risk’ or ‘at risk’ foot. Foot disease risk factor prevalence was peripheral arterial disease 9 (17%); neuropathy 10 (19%) and foot deformity 11 (22%). Forty-one patients (85%) wore inappropriate footwear. Inter-rater agreement was substantial on presence of foot disease and arterial disease, fair to moderate on foot deformity and fair on neuropathy and inappropriate footwear. Eight patients (15%) saw a podiatrist during admission: 5 with foot disease, 1 ‘at risk’ and 2 ‘low risk’ for foot disease. Patients with an at risk foot or foot disease had significantly longer median length of hospital stay (25 [13.7–32.1] vs 15.2 [8–22.1] days, p = 0.01) and higher median Malnutrition Screening Test scores (2 [0–3] vs 0 [0–2], p = 0.03) than the low-risk group. Patients with foot disease were most likely to see a podiatrist (p < 0.001).

Conclusion

Foot disease, foot disease risk factors and inappropriate footwear are common in hospitalized older adults, however podiatry assessment and intervention is mostly limited to patients with foot disease. Addition of routine podiatry assessment to the multidisciplinary CGA team should be considered. Examination for arterial disease and risk of malnutrition may be useful to identify at risk patients for podiatry review.

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Introduction

Changes to the feet occur with age, leading to high prevalence of foot problems such as foot pain, deformity, muscle weakness and reduced range of motion [1, 2]. This contributes to morbidity in older populations: foot problems have been associated with a higher risk of falls [3], reduced quality of life [4,5,6,7], frailty [8] and lower independence in activities of daily living (ADLs) [9, 10]. Lower independence in ADLs is associated with nursing home admission [11,12,13]. Poor foot care may also be an indicator of self-neglect [14, 15]. Inappropriate footwear is associated with impaired balance with associated risk of falling [16] and foot disease [17]. Foot disease, defined as foot ulceration, infection, critical ischaemia and Charcot neuroarthropathy [18], represents more severe foot pathology. Foot disease is associated with many chronic illnesses and increases in prevalence with age [2, 19], affecting approximately 10% of hospital inpatients [1, 20]. Foot disease usually occurs in people with risk factors such as foot deformity, peripheral arterial disease, peripheral neuropathy, previous ulceration and/or previous amputation [21]. In community dwelling older adults the presence of foot disease is associated with poorer physical function [22].

Despite the impact of foot problems and foot disease on older adults, the foot is frequently neglected by both patients and healthcare providers [23, 24]. The gold standard of care for older adults is the Comprehensive Geriatric Assessment (CGA), a multidimensional, multidisciplinary assessment of medical, social, psychological and functional needs that leads to the development of a coordinated care plan [25]. Podiatry interventional studies have shown reduced risk of falls in community dwelling older adults [26], and integration of a podiatry assessment in the CGA is recommended as part of falls assessment and prevention programs [27]. Inpatient CGA programs, on the other hand, do not routinely include podiatry assessment [28, 29].

The aim of this study was to introduce a standardised foot assessment to older adults undergoing inpatient CGA, to: (1) determine the prevalence of foot disease, foot disease risk factors and inappropriate footwear use; (2) assess the inter-rater reliability of foot assessments; (3) determine the frequency of podiatry assessment; and (4) evaluate associations between patient characteristics and foot disease and foot disease risk factors.

Methods

Study design

Population

This study is embedded in REStORing health of acutely unwell adulTs (RESORT), an ongoing prospective, observational, longitudinal inception cohort investigating the characteristics and outcomes of geriatric rehabilitation patients at the Royal Melbourne Hospital (Melbourne, Victoria, Australia). Patients included in the RESORT study are assessed within 48 h of admission and discharge with a multidisciplinary, multi-dimensional CGA. Recruitment for wave 1 of RESORT commenced on October 15, 2017. Each annual RESORT wave recruits approximately 600 patients. This sub study, a pilot study adding foot assessment during the geriatric rehabilitation admission, recruited a convenience sample of inpatients from wave 3 between February 12 and March 19, 2020. A power calculation of sample size for foot disease prevalence was 138 patients (based on estimated prevalence of 10%, Z statistic of 1.96 and allowable error of 0.05) [30]. This study was planned to run for 3 months, with an expected sample size of approximately 200 patients, however due to the COVID-19 pandemic recruitment ceased early. Patients were excluded from this study if they were receiving palliative care at admission, transferred to acute care prior to consenting to the study, unable to provide informed consent with no nominated proxy or were discharged prior to foot assessment. The study was performed in accordance with the Declaration of Helsinki and approved by the Melbourne Health Human Research and Ethics Committee (HREC) (approval number 2017.085).

Patient characteristics

Patient demographics, reason for admission and history of falls were collected from medical records and patient surveys. Physical function was assessed with the Functional Ambulation Classification [31], a scale from 0 to 5 recording ambulation ability, and the Short Physical Performance Battery (SPPB) [32], a three component assessment, scored from 0 to 12 points, of balance, 4-m walk and a chair stand test. Functional status was assessed using Katz Activities of Daily Living [33], a 6 item scale of independence in personal ADLs, and Instrumental Activities of Daily Living [34], a measure of independence in domestic and community ADLs, scored from 0 to 8. For the ADL and mobility assessments higher scores indicate greater independence and better physical function, respectively. Nutritional status was assessed with the Malnutrition Screening Tool (MST): a score of 2 or more indicates risk of malnutrition [35]. Pressure injury risk assessment was undertaken using the Braden Scale, which evaluates six domains to determine risk score: scores below 18 suggest increased risk of pressure injury [36]. Medical co-morbidity was assessed with the Cumulative Illness Rating Scale (CIRS) [37], a measure that rates disease burden across major organ groups (higher scores indicating greater severity). Frailty was assessed using the Clinical Frailty Scale, a 7-point scale, with higher scores indicating greater frailty [38]. Discharge destination (community or residential aged care facility) and death during geriatric rehabilitation admission were recorded from the medical history.

Foot risk factors and foot disease assessment

Assessment for foot disease and foot disease risk factors was undertaken by trained clinical researchers using the Queensland Foot Disease Form (QFDF), a 57 item, validated assessment instrument [18] (Additional file 1: Appendix I). The QFDF collects data on demographics, medical co-morbidities, foot disease risk factors and foot disease. Foot disease is defined as foot ulceration, infection, critical arterial disease (toe pressure of < 30 mmHg or Ankle Brachial Index < 0.5) and/or Charcot neuroarthropathy. Foot disease risk factors are deformity (defined as a score of 3 or more on a 6-point scale of deformity), peripheral neuropathy, peripheral arterial disease (toe pressure < 70 mmHg), previous ulceration and previous amputation. Footwear most commonly used indoors and outdoors was classified as appropriate or inappropriate. Inappropriate footwear was defined as footwear that does not have the following components: low heel, non-slip sole, supported heel collar or fastening mechanism [39]. The QFDF assigns a level of foot risk based on presence of foot disease risk factors: low (no neuropathy or PAD), at risk (neuropathy or PAD), high risk (foot deformity with neuropathy and/or PAD; previous foot disease) or acute foot disease.

Standardised training in use of the QFDF was undertaken with the assistance of a podiatrist (EL). A sample of foot assessments was repeated by the second assessor, blinded to the initial assessment, to check inter-rater reliability. The patient’s treating team was notified of the outcome of the foot assessment where previously unidentified foot disease was noted, and recommendation for podiatry referral was made where appropriate. A number of patients also underwent foot assessment by a podiatrist as part of their usual care; this was recorded with the hospital podiatry assessment tool (Additional file 1: Appendix II). Referrals to podiatry were made by clinical staff as needed, usually by nursing staff based on skin assessments. The hospital podiatry assessment tool includes similar data to the QFDF; however, diagnosis of foot deformity and type of footwear are recorded by the podiatrist descriptively rather than using a prescribed format as with the QFDF.

Inter-rater reliability was assessed using percentage agreement overall and Cohen’s Kappa co-efficient was calculated for 5 patients comparing researcher assessments and 8 patients comparing researcher to hospital podiatrist assessment. Agreement based on Kappa values was defined as: > 0.8 excellent; 0.61–0.80 substantial; 0.41–0.6 moderate and < 0.40 fair to poor [40, 41].

Assessments were captured on paper forms and then de-identified and managed using the Research Electronic Data Capture (REDCap) [42] tool. Data was exported to SPSS for Windows version 26 (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp) for analysis.

Statistical analysis

Descriptive statistics were used to summarise the patients’ baseline characteristics. Data with a normal distribution is presented as mean and standard deviation; data with a non-normal distribution is presented as median and interquartile range; and categorical variables are presented as proportions. The baseline characteristics of the foot risk groups were compared using the Kruskal-Wallis H test (for more than 2 groups) or Mann-Whitney U test (for 2 groups) for nonparametric continuous and ordinal data and Fisher’s exact test for categorical data. To reduce type 1 error, the level of significance for all analyses was set at p < 0.05.

Results

The baseline characteristics of the 52 included patients are given in Table 1: median age was 86.4 [IQR 79.2–90.3] years, 54% were female. The median values for admission Katz ADL, iADL, SPPB, FAC and CFS demonstrate low independence, impaired mobility and moderate frailty in the cohort. A majority of patients (69%) had fallen in the last year. Diabetes mellitus was diagnosed in 15 (29%) patients.

Table 1 Characteristics of included geriatric rehabilitation inpatients at admission

Foot disease, foot disease risk factors and inappropriate footwear

Six patients (12%) had foot disease (pressure injury (4/6), neuroischaemia (1/6) and trauma (1/6)). The prevalence of foot disease risk factors was: mild to moderate peripheral arterial disease 9 (17%), neuropathy 10 (19%) and foot deformity 11 (22%). Reported footwear was inappropriate in 41 patients (85%, n = 48): the most commonly worn footwear indoors and outdoors was slippers (34%) and moccasins (33%) respectively. Thirteen (25%) patients were assessed as having an ‘at risk’ or ‘high risk’ foot. Eight patients (15%) saw a podiatrist during their hospital admission: 5 had foot disease, 1 was at risk and 2 were low risk of foot disease. All patients that were seen by a podiatrist required an intervention, which included advice, nail care, debridement and wound dressings.

Patient characteristics with and without foot disease

Differences between patients based on risk foot or foot disease are summarised in Table 2. Patients with foot disease were significantly more likely to have podiatry assessment during hospitalisation. There was a trend towards an association between age and foot risk (p = 0.08). When risk category was dichotomised (low risk patients versus at risk, high risk and foot disease patients), patients with higher foot risk or foot disease had significantly longer median length of hospital stay (25 [13.7–32.1] vs 15.2 [8–22.1] days, p = 0.01) and higher median MST scores (2 [0–3] vs 0 [0–2], p = 0.03) than the low-risk group.

Table 2 Patient characteristics stratified by foot disease risk

Inter-rater reliability

There was substantial to excellent agreement on presence of foot disease (Cohen’s kappa 0.75–1; percentage agreement 92%), moderate to substantial agreement on presence of arterial disease (Cohen’s kappa 0.5–1; percentage agreement 92%), fair to moderate agreement on foot deformity (Cohen’s kappa 0.33–0.5, percentage agreement 63%) and fair agreement on neuropathy (Cohen’s kappa 0–0.3, percentage agreement 63%) and inappropriate footwear (Cohen’s kappa 0–0.2, percentage agreement 67%).

Discussion

Foot disease risk factors and foot disease were common in this cohort. Podiatry assessment and intervention was undertaken for most patients with foot disease but for few patients with an at risk or low risk foot. Inter-rater reliability testing confirmed that there was substantial agreement on presence of foot disease and arterial disease, however agreement was poorer for neuropathy, deformity and inappropriate footwear. Presence of peripheral arterial disease may therefore be a useful indicator for podiatry referral for patients with an at risk foot. Inter-rater reliability for footwear and neuropathy may have been impacted by high rates of cognitive impairment in older adults on sub-acute wards [43]. Differences in training and clinical experience, the small sample size and the use of different assessment forms by researchers and hospital podiatrists may also have contributed to these findings. Nevertheless, the poor inter-rater reliability for these risk factors highlights the difficulty for non-podiatrist clinicians identifying at risk patients.

Risk of malnutrition was higher and length of stay on the Geriatric Rehabilitation ward was longer for patients with foot disease, at risk and high risk feet. There was no difference in Cumulative Illness Rating Scale or Clinical Frailty Scale between the groups, suggesting that this is not due to overall ill-health. The difference in length of stay may be explained by differences in nutritional status, as malnutrition is associated with longer length of hospital stay [44]. Malnutrition is a risk factor for pressure injuries, and nutritional interventions are recommended in prevention and treatment of pressure injuries [45]. Although two thirds of cases of foot disease in this cohort were pressure injuries, there was no difference in Braden scale between the foot disease group and other groups. A previous study also noted that the Braden scale under-estimates risk of foot pressure injury [46]. Risk of malnutrition may be useful to identify at risk patients for podiatry assessment. Although previous studies have shown associations between foot problems (particularly foot pain) [2, 47] and foot disease [48] and poorer physical function, this study did not identify any differences in physical function based on foot disease or foot disease risk factors.

The rate of foot disease in this cohort is similar to other studies in sub-acute populations in Scotland and Australia that reported prevalence rates of 15% [17] and 12% [20] respectively. Diabetes-related foot disease is well recognised and improved outcomes have been achieved in recent years with interdisciplinary care [49], however in this cohort a minority of patients with foot disease and foot disease risk factors were diagnosed with diabetes. This is consistent with other studies of older adults [1, 17, 50]. Numerous other chronic medical conditions are associated with foot disease, such as osteoarthritis [51], chronic renal failure [52], gout [53] and rheumatoid arthritis [54]. Changes to the foot in addition to increased prevalence of chronic medical conditions with age [2, 55] are the likely cause of high rates of non-diabetes related foot disease in this population.

Use of inappropriate footwear was very common in this cohort and similar rates have been reported by other inpatient and outpatient studies of older adults [17, 56, 57]. Footwear interventions have been shown to improve foot pain and function [58, 59]. Multifaceted podiatry intervention, including footwear advice and provision of orthotics, has been shown to reduce the risk of falls, however footwear advice alone has not [26]. Improving footwear is recognised to be a difficult task: low adherence rates for recommended footwear have been reported, mostly due to the cost and aesthetics of appropriate footwear [60].

Given the high prevalence of foot disease, foot disease risk factors and inappropriate footwear, as well as evidence for reduced falls [26] and foot pain [61, 62] from outpatient podiatry intervention in older adults, routine podiatry assessment and intervention should be considered as part of the CGA in geriatric rehabilitation inpatients. An alternative approach to increase the rate of podiatry assessment and intervention in this population, based on this study’s findings, would be to include peripheral arterial disease and risk of malnutrition as indicators for podiatry referral.

Limitations

The pragmatic approach of comparing researcher foot assessments using the QFDF with podiatry assessments using the hospital assessment tool may have affected inter-rater reliability measures due to differences in documentation of foot deformity and footwear. Use of the QFDF for foot assessments may have underestimated the prevalence of foot problems, given that single foot deformities and integumentary problems are not captured with this assessment. The study was conducted in late summer, which may have impacted the prevalence of foot disease: studies of diabetes related foot disease have found higher rates of infection and amputation in warmer months, whilst amputations in people without diabetes are most common in winter [63, 64]. The study sample size is also a limitation, particularly for examining associations between foot disease, foot disease risk factors and patient characteristics.

Conclusion

Foot disease, foot disease risk factors and inappropriate footwear are common in older adults admitted to geriatric rehabilitation wards although podiatry assessment and intervention is mostly limited to patients with foot disease. Assessment for peripheral arterial disease and risk of malnutrition may help to identify at risk patients for podiatry input. Interventional studies incorporating podiatrist assessment and intervention into CGA are needed.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

References

  1. Lazzarini PA, Hurn SE, Kuys SS, Kamp MC, Ng V, Thomas C, et al. The silent overall burden of foot disease in a representative hospitalised population. Int Wound J. 2017;14(4):716–28. https://doi.org/10.1111/iwj.12683.

    Article  PubMed  Google Scholar 

  2. Rodriguez-Sanz D, Tovaruela-Carrion N, Lopez-Lopez D, Palomo-Lopez P, Romero-Morales C, Navarro-Flores E, et al. Foot disorders in the elderly: a mini-review. Dis-a-Month: DM. 2018;64(3):64–91. https://doi.org/10.1016/j.disamonth.2017.08.001.

    Article  Google Scholar 

  3. Menz HB, Auhl M, Spink MJ. Foot problems as a risk factor for falls in community-dwelling older people: a systematic review and meta-analysis. Maturitas. 2018;118:7–14. https://doi.org/10.1016/j.maturitas.2018.10.001.

    Article  PubMed  Google Scholar 

  4. Katsambas A, Abeck D, Haneke E, van de Kerkhof P, Burzykowski T, Molenberghs G, et al. The effects of foot disease on quality of life: results of the Achilles project. J Eur Acad Dermatol Venereol. 2005;19(2):191–5. https://doi.org/10.1111/j.1468-3083.2004.01136.x.

    Article  CAS  PubMed  Google Scholar 

  5. López DL, Callejo González L, Losa Iglesias ME, Canosa JL, Sanz DR, Lobo CC, et al. Quality of life impact related to foot health in a sample of older people with hallux valgus. Aging Dis. 2016;7(1):45–52. https://doi.org/10.14336/AD.2015.0914.

    Article  PubMed  PubMed Central  Google Scholar 

  6. López-López D, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, Palomo-López P, Rodríguez-Sanz D, Brandariz-Pereira JM, et al. Evaluation of foot health related quality of life in individuals with foot problems by gender: a cross-sectional comparative analysis study. BMJ Open. 2018;8(10):e023980. https://doi.org/10.1136/bmjopen-2018-023980.

    Article  PubMed  PubMed Central  Google Scholar 

  7. López-López D, Martínez-Vázquez M, Losa-Iglesias ME, Calvo-Lobo C, Rodríguez-Sanz D, Palomo-López P, et al. Foot health-related quality of life among elderly with and without lesser toe deformities: a case-control study. Patient Prefer Adher. 2018;12:251–5. https://doi.org/10.2147/PPA.S152269.

    Article  Google Scholar 

  8. Muchna A, Najafi B, Wendel CS, Schwenk M, Armstrong DG, Mohler J. Foot problems in older adults (associations with incident falls, frailty syndrome, and sensor-derived gait, balance, and physical activity measures). J Am Podiatr Med Assoc. 2018;108(2):126–39. https://doi.org/10.7547/15-186.

    Article  PubMed  Google Scholar 

  9. Griffith L, Raina P, Wu H, Zhu B, Stathokostas L. Population attributable risk for functional disability associated with chronic conditions in Canadian older adults. Age Ageing. 2010;39(6):738–45. https://doi.org/10.1093/ageing/afq105.

    Article  PubMed  Google Scholar 

  10. Benvenuti F, Ferrucci L, Guralnik JM, Gangemi S, Baroni A. Foot pain and disability in older persons: an epidemiologic survey. J Am Geriatr Soc. 1995;43(5):479–84. https://doi.org/10.1111/j.1532-5415.1995.tb06092.x.

    Article  CAS  PubMed  Google Scholar 

  11. Thorpe ER, Garrett KB, Smith AM, Reneker JC, Phillips RS. Outcome measure scores predict discharge destination in patients with acute and subacute stroke: a systematic review and series of meta-analyses. J Neurol Phys Ther. 2018;42(1):2–11. https://doi.org/10.1097/NPT.0000000000000211.

    Article  PubMed  Google Scholar 

  12. Cai Q, Salmon JW, Rodgers ME. Factors associated with long-stay nursing home admissions among the U.S. elderly population: comparison of logistic regression and the cox proportional hazards model with policy implications for social work. Soc Work Health Care. 2009;48(2):154–68. https://doi.org/10.1080/00981380802580588.

    Article  PubMed  Google Scholar 

  13. Gaugler JE, Duval S, Anderson KA, Kane RL. Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatr. 2007;7:13.

    Article  Google Scholar 

  14. Chang P, Meaux T. Onychogryphosis: a report of ten cases. Skinmed. 2015;13(5):355–9.

    PubMed  Google Scholar 

  15. Möhrenschlager M, Wicke-Wittenius K, Brockow K, Bruckbauer H, Ring J. Onychogryphosis in elderly persons: an indicator of long-standing poor nursing care? Report of one case and review of the literature. Cutis. 2001;68(3):233–5.

    PubMed  Google Scholar 

  16. Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR. Effects of footwear features on balance and stepping in older people. Gerontology. 2008;54(1):18–23. https://doi.org/10.1159/000115850.

    Article  PubMed  Google Scholar 

  17. Burns SL, Leese GP, McMurdo ME. Older people and ill fitting shoes. Postgrad Med J. 2002;78(920):344–6. https://doi.org/10.1136/pmj.78.920.344.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Lazzarini PA, Hurn SE, Kuys SS, Kamp MC, Ng V, Thomas C, et al. Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study. BMJ Open. 2016;6(6):e010811. https://doi.org/10.1136/bmjopen-2015-010811.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lazzarini PA, Hurn SE, Fernando ME, Jen SD, Kuys SS, Kamp MC, et al. Prevalence of foot disease and risk factors in general inpatient populations: a systematic review and meta-analysis. BMJ Open. 2015;5(11):e008544. https://doi.org/10.1136/bmjopen-2015-008544.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Earl BJ, Lazzarini PA, Kinnear EM, Cornwell PL. Prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility: a cross-sectional prevalence study. J Foot Ankle Res. 2014;7(1):41. https://doi.org/10.1186/s13047-014-0041-x.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lazzarini PA, Hurn SE, Kuys SS, Kamp MC, Ng V, Thomas C, et al. Foot complications in a representative Australian inpatient population. J Diab Res. 2017;2017:4138095.

    Google Scholar 

  22. Iseli RK, Lee EK, Lewis E, Duncan G, Maier AB. Foot disease and physical function in older adults: a systematic review and meta-analysis. Australas J Ageing. 2021;40(1):35–47.

  23. Oh-Park M, Kirschner J, Abdelshahed D, Kim DDJ. Painful foot disorders in the geriatric population: a narrative review. Am J Phys Med Rehabil. 2019;98(9):811–9. https://doi.org/10.1097/PHM.0000000000001239.

    Article  PubMed  Google Scholar 

  24. James K, Orkaby AR, Schwartz AW. Foot examination for older adults. Am J Med. 2020;134(1):30–5.

  25. Tuttle CSL, Maier AB. Towards a biological geriatric assessment. Exp Gerontol. 2018;107:102–7. https://doi.org/10.1016/j.exger.2017.09.017.

    Article  PubMed  Google Scholar 

  26. Wylie G, Torrens C, Campbell P, Frost H, Gordon AL, Menz HB, et al. Podiatry interventions to prevent falls in older people: a systematic review and meta-analysis. Age Ageing. 2019;48(3):327–36. https://doi.org/10.1093/ageing/afy189.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Hatton AL, Rome K. Falls, footwear, and podiatric interventions in older adults. Clin Geriatr Med. 2019;35(2):161–71. https://doi.org/10.1016/j.cger.2018.12.001.

    Article  PubMed  Google Scholar 

  28. Parker SG, McCue P, Phelps K, McCleod A, Arora S, Nockels K, et al. What is comprehensive geriatric assessment (CGA)? An umbrella review. Age Ageing. 2018;47(1):149–55. https://doi.org/10.1093/ageing/afx166.

    Article  CAS  PubMed  Google Scholar 

  29. Welsh TJ, Gordon AL, Gladman JR. Comprehensive geriatric assessment--a guide for the non-specialist. Int J Clin Pract. 2014;68(3):290–3. https://doi.org/10.1111/ijcp.12313.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Arya R, Antonisamy B, Kumar S. Sample size estimation in prevalence studies. Indian J Pediatr. 2012;79(11):1482–8. https://doi.org/10.1007/s12098-012-0763-3.

    Article  PubMed  Google Scholar 

  31. Holden MK, Gill KM, Magliozzi MR. Gait assessment for neurologically impaired patients. Standards for outcome assessment. Phys Ther. 1986;66(10):1530–9. https://doi.org/10.1093/ptj/66.10.1530.

    Article  CAS  PubMed  Google Scholar 

  32. Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2):M85–94. https://doi.org/10.1093/geronj/49.2.M85.

    Article  CAS  PubMed  Google Scholar 

  33. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. Jama. 1963;185(12):914–9. https://doi.org/10.1001/jama.1963.03060120024016.

    Article  CAS  PubMed  Google Scholar 

  34. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist. 1969;9(3):179–86. https://doi.org/10.1093/geront/9.3_Part_1.179.

    Article  CAS  PubMed  Google Scholar 

  35. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458–64. https://doi.org/10.1016/S0899-9007(99)00084-2.

    Article  CAS  PubMed  Google Scholar 

  36. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden scale. Nurs Res. 1998;47(5):261–9. https://doi.org/10.1097/00006199-199809000-00005.

    Article  CAS  PubMed  Google Scholar 

  37. Linn BS, Linn MW, Gurel L. Cumulative illness rating scale. J Am Geriatr Soc. 1968;16(5):622–6. https://doi.org/10.1111/j.1532-5415.1968.tb02103.x.

    Article  CAS  PubMed  Google Scholar 

  38. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. Cmaj. 2005;173(5):489–95. https://doi.org/10.1503/cmaj.050051.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR. Optimizing footwear for older people at risk of falls. J Rehabil Res Dev. 2008;45(8):1167–81. https://doi.org/10.1682/JRRD.2007.10.0168.

    Article  PubMed  Google Scholar 

  40. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb). 2012;22(3):276–82.

    Article  Google Scholar 

  41. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74. https://doi.org/10.2307/2529310.

    Article  CAS  PubMed  Google Scholar 

  42. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010.

    Article  PubMed  Google Scholar 

  43. Clark AB, Reijnierse EM, Lim WK, Maier AB. Prevalence of malnutrition comparing the GLIM criteria, ESPEN definition and MST malnutrition risk in geriatric rehabilitation patients: RESORT. Clin Nutr. 2020;39(11):3504–11. https://doi.org/10.1016/j.clnu.2020.03.015.

    Article  PubMed  Google Scholar 

  44. Leiva Badosa E, Badia Tahull M, Virgili Casas N, Elguezabal Sangrador G, Faz Méndez C, Herrero Meseguer I, et al. Hospital malnutrition screening at admission: malnutrition increases mortality and length of stay. Nutr Hosp. 2017;34(4):907–13. https://doi.org/10.20960/nh.657.

    Article  PubMed  Google Scholar 

  45. Eglseer D, Hödl M, Lohrmann C. Nutritional management of older hospitalised patients with pressure injuries. Int Wound J. 2019;16(1):226–32. https://doi.org/10.1111/iwj.13016.

    Article  PubMed  Google Scholar 

  46. Scheepers J. Assessment and consideration of foot risk factors is essential for proactive prevention of hospital-acquired foot pressure injuries. Wounds Int. 2018;9(1):29–34.

    Google Scholar 

  47. Menz HB. Biomechanics of the ageing foot and ankle: a mini-review. Gerontology. 2015;61(4):381–8. https://doi.org/10.1159/000368357.

    Article  PubMed  Google Scholar 

  48. McDermott MM, Greenland P, Liu K, Guralnik JM, Celic L, Criqui MH, et al. The ankle brachial index is associated with leg function and physical activity: the walking and leg circulation study. Ann Intern Med. 2002;136(12):873–83. https://doi.org/10.7326/0003-4819-136-12-200206180-00008.

    Article  PubMed  Google Scholar 

  49. Barshes NR, Sigireddi M, Wrobel JS, Mahankali A, Robbins JM, Kougias P, et al. The system of care for the diabetic foot: objectives, outcomes, and opportunities. Diab Foot Ankle. 2013;4(1). https://doi.org/10.3402/dfa.v4i0.21847.

  50. Schwarzentraub PH, Raymond GA, Ball MJ, Bizzoco DL. Foot ulcers: a 54-month retrospective study. J Foot Surg. 1991;30(5):437–42.

    CAS  PubMed  Google Scholar 

  51. Roddy E, Menz HB. Foot osteoarthritis: latest evidence and developments. Ther Adv Musculoskelet Dis. 2018;10(4):91–103. https://doi.org/10.1177/1759720X17753337.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Otte J, van Netten JJ, Woittiez AJ. The association of chronic kidney disease and dialysis treatment with foot ulceration and major amputation. J Vasc Surg. 2015;62(2):406–11. https://doi.org/10.1016/j.jvs.2015.02.051.

    Article  PubMed  Google Scholar 

  53. Rome K, Erikson K, Otene C, Sahid H, Sangster K, Gow P. Clinical characteristics of foot ulceration in people with chronic gout. Int Wound J. 2016;13(2):209–15. https://doi.org/10.1111/iwj.12262.

    Article  PubMed  Google Scholar 

  54. Firth J, Waxman R, Law G, Nelson EA, Helliwell P, Siddle H, et al. The predictors of foot ulceration in patients with rheumatoid arthritis. Clin Rheumatol. 2014;33(5):615–21. https://doi.org/10.1007/s10067-013-2428-7.

    Article  PubMed  Google Scholar 

  55. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743–800.

    Article  Google Scholar 

  56. Jessup RL. Foot pathology and inappropriate footwear as risk factors for falls in a subacute aged-care hospital. J Am Podiatr Med Assoc. 2007;97(3):213–7. https://doi.org/10.7547/0970213.

    Article  PubMed  Google Scholar 

  57. O'Rourke B, Walsh ME, Brophy R, Vallely S, Murphy N, Conroy B, et al. Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study. BMC Geriatr. 2020;20(1):55. https://doi.org/10.1186/s12877-020-1448-9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Menz HB, Auhl M, Ristevski S, Frescos N, Munteanu SE. Effectiveness of off-the-shelf, extra-depth footwear in reducing foot pain in older people: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2015;70(4):511–7. https://doi.org/10.1093/gerona/glu169.

    Article  CAS  PubMed  Google Scholar 

  59. Frecklington M, Dalbeth N, McNair P, Gow P, Williams A, Carroll M, et al. Footwear interventions for foot pain, function, impairment and disability for people with foot and ankle arthritis: a literature review. Semin Arthritis Rheum. 2018;47(6):814–24. https://doi.org/10.1016/j.semarthrit.2017.10.017.

    Article  PubMed  Google Scholar 

  60. Menz HB, Spink MJ, Landorf KB, Hill KD, Lord SR. Older people's perceptions of a multifaceted podiatric medical intervention to prevent falls. J Am Podiatr Med Assoc. 2013;103(6):457–64. https://doi.org/10.7547/1030457.

    Article  PubMed  Google Scholar 

  61. Araguas Garcia C, Corbi SF. Effect of debridement of plantar hyperkeratoses on gait in older people - an exploratory trial. Arch Gerontol Geriatr. 2018;78:7–13. https://doi.org/10.1016/j.archger.2018.05.017.

    Article  PubMed  Google Scholar 

  62. Balanowski KR, Flynn LM. Effect of painful keratoses debridement on foot pain, balance and function in older adults. Gait Posture. 2005;22(4):302–7. https://doi.org/10.1016/j.gaitpost.2004.10.006.

    Article  PubMed  Google Scholar 

  63. Leung HB, Ho YC, Wong WC, Guerin J. Seasonal variations in non-traumatic major lower limb amputation in Hong Kong Chinese diabetic patients. Hong Kong Med J. 2007;13(5):379–81.

    CAS  PubMed  Google Scholar 

  64. Armstrong DG, Lavery LA, van Houtum WH, Harkless LB. Seasonal variations in lower extremity amputation. J Foot Ankle Surg. 1997;36(2):146–50. https://doi.org/10.1016/S1067-2516(97)80062-2.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The authors thank the multidisciplinary team members involved in the RESORT cohort for their clinical work and the @AgeMelbourne team for their role in data collection.

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Study concept RKI, GD, ABM; Data collection RKI, EKL, EL; Manuscript development led by RKI with input from all authors. The authors read and approved the final manuscript.

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Correspondence to Rebecca K. Iseli.

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This study was conducted in accordance with the Declaration of Helsinki and approved by the local ethics committee.

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Supplementary Information

Additional file 1: Appendix I.

The Queensland Foot Disease Form [18]. Appendix II. Hospital specific podiatry assessment form (2 pages).

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Iseli, R.K., Duncan, G., Lee, E.K. et al. Incorporating foot assessment in the comprehensive geriatric assessment. BMC Geriatr 21, 223 (2021). https://doi.org/10.1186/s12877-021-02164-3

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