Let’s have a think about our morning routine. It will probably look something like this: Get up, put the kettle on, let the dog out for a pee, get a shower, get ready, walk the dog, boil the kettle again and actually make the cup of tea this time, get your bag and coat and get out and on with your day.
Now ask yourself how much of this could you easily achieve if you have a problem with your foot? It doesn’t have to be a big dramatic foot ulcer (although that is certainly a heck of a challenge to daily living activities) it could be something like an ingrown nail (which anyone who has suffered will tell you hurts like blazes) or maybe you’re a bit unsteady on your feet.
Now add to this everything that we know about what makes living with dementia challenging and it’s not difficult to see why good foot health can play such a central role in living well with dementia.
As a podiatrist my days are hugely varied and I can go from performing MSK (musculo-skeletal) assessments, which is where I look at the way my patients move to determine what I can do to help them to undertaking wound care on patients with a complex medical history. My places of work are also varied and I can find myself in hospital based community clinics, GP surgeries, care homes, acute hospital wards and out on home visits in the community – anywhere people have feet and have a need!
Poor foot health can be extremely isolating for all patients who experience it but in the case of our patients who have a dementia diagnosis this is especially so.
The Alzheimers Society states that “Social isolation and loneliness presents one of the biggest health and social care challenges of the 21st century, increasing one’s risk of dying by 29 per cent.”
Chronic foot pain can lead to a reduction in ability to perform activities of daily living, a reluctance to walk or partake in social events that require patients to walk and can contribute to increased likelihood of falls. In those patients who have long term wounds it can be distressing, painful and there may be an odour which can also add to a reluctance to be around other people.
The risk of social isolation from foot related problems is in addition to the background statistic that a third of people with dementia are lonely or have lost friends since their diagnosis. [1]
In podiatry the work that we do often centres around maximising a person’s ability to take a meaningful part in life. What constitutes “meaningful” is different for every patient and as a department we have really strived over recent years to have good conversations with our patients so that we have a clear idea of what it is they are trying to achieve. We have tools such as Talking Mats available to allow patients with communication difficulties the ability to contribute to the discussion as much as possible. In patients who have advanced dementia we try to involve someone close to the patient in decision making and are working towards making use of ‘getting to know me’ documents so that we can have a clearer understanding of a person’s wishes.
My role can sometimes feel as though I am predicting the future. When I am assessing a patient I am very often looking at the person in front of me and thinking about their circumstances and how to either improve or maintain the situation they find themselves in and looking to determine the possible future risk to their health and social welfare if their situation deteriorates.
How can I keep them going to their day centre or dance class or even just move around their home comfortably? What is my role in helping them to still be able to undertake their activities of daily living to empower them? What are their abilities? What can I build on that they already have so that it works better for them?
Podiatry is seen as a very physical job involving instruments, dressings and physical hands-on assessment. The truth is that all of those elements of the job are secondary to the communication we have with our patients.
The importance of being able to make a connection and understand why a patient might be distressed or anxious, afraid or fed up is fundamental to everything we do. Only by recognising how someone is feeling and being able to speak to them with kindness and patience can any of the other stuff happen. Without it, you cannot set goals, you cannot undertake treatments, you cannot help.
In our patients who have dementia this is of particular importance because a wide range of stages of the disease can come into my clinic on any given day. I think being brave enough to broach the subject with a long-standing patient who you’ve noticed changes in is as important a skill as trying to figure out how to help someone with advanced dementia who may not be able to understand or communicate for themselves. Their diagnosis might be the same on paper but what they need from me is very different. I think for me that this is perhaps the most important thing to bear in mind: the person in front of me is not a diagnosis. They are more than the sum of their morbities and it is very easy, for professionals and patients and families, to get caught up in that trap.
I recently attended a lady in her home who was referred to me for ‘severe neglect, probable dementia’. The patient, following a stroke 2 years prior, had shut herself off from the world. She lived with her husband who, along with her daughter, she allowed to do very limited personal care. She couldn’t get upstairs anymore and would not allow anyone to touch her feet. As time went on and the nails got longer and more painful her position became entrenched. She became unable to walk or put on shoes and was transferring to her commode and back to her chair where she slept, ate and lived. Her GP was eventually called when her family were no longer able to manage and her legs were starting to leak. District nursing were called in for dressings, the GP arranged bloods and reviewed medication and general health and she was referred to a local NHS day centre to try and get her mobilising again.
The major obstacle to being able to get her to the rehab that a day, was that her toenails at the point of referral to me were 2- 3 inches long on 8 out of 10 toes and the big ones were at least an inch thick. She was terrified to let anyone near them because they were so sore. NHS has a policy that we do not undertake nail care as it is considered part of social care. Sometimes though, a situation can be left for so long that it becomes a case of neglect and at that point Podiatry would always intervene. As part of this team of professionals the only way to get this patient anywhere towards getting some mobility back was going to have to start with reducing the nails.
I started as I always do with introductions and started to chat. Through our conversation she told me she wanted to be able to walk a bit more and get shoes on but she was scared of her toes because they were so sore. I talked about why they were hurting and talked to her about what we could do to help make that better so that she could get shoes on. I was in for at least half an hour before I even pulled on a pair of gloves. Talking through what she wanted, what I was going to do and making sure that she felt comfortable with me because I knew how scared she was. Nobody sets out to end up stuck in a chair in their living room, trapped by increasing frailty, confusion and painful feet.
We got her nails sorted. It took a while, some gentle persuasion, a bit of distraction. I told her that I was going to call her twinkle toes once I had finished the treatment which she laughed about. Her husband was by her side all of the time giving her encouragement and I got him to very gently file her nails as well so that he had the knowledge of how to do so effectively. The important part of the conversation was the bit where we spoke about how we can prevent this happening to her again. We agreed that as her husband is there, is would be a good idea to let him file her nails a few times a week. That way her nails can’t get long or thick like they had done. We spoke about how nice it would be to get her feet into a warm footbath and I was able to prescribe her some soap substitute and emollient. I spoke with her husband and her about how to make sure that they dried carefully between the toes and how much cream to use and where.
I left knowing that for that patient I had opened up the possibility of an improved future which had less pain. It wasn’t a complex task. It was about putting in place measures to keep her well and prevent the problem from happening again. Her husband told me he was relieved as he showed me out.
I suppose for me I don’t really do anything different with my patients who have a dementia diagnosis to those who don’t. Everyone needs patience and kindness. Patients with dementia don’t have less choice, opinion or humour because of a diagnosis and even when the dementia is advanced and they aren’t able to communicate verbally, I can still work with those around them to try and come to a plan that respects what their choice might have been. I see the person in front of me and I want to help that person reach their goal.
Contributor
My name is Rebecca Watson. I am a Specialist Podiatrist with NHS Fife where I have worked for 14 years. I have worked in a variety of settings and I am currently between community clinics and community domiciliary service in West Fife.
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