Diabetic Foot Ulcers in the Homeless Population

Diabetic Foot Ulcers in the Homeless Population

            Diabetic foot ulcers (DFU) are a serious and common complication of diabetes mellitus. Individuals with diabetes have a 15-25% lifetime risk of developing a lower extremity ulcer (Braun, Fisk, Lev-Tov, Kirsner, & Isseroff, 2014). The treatment of DFU is intense and may require frequent outpatient visits or admission for inpatient treatment. Therapy often involves offloading excess pressure on the extremity and may require casting or cumbersome boot orthotics (Figure 1). The United States Department of Housing and Urban Development (2014) estimated that 1.42 million individuals experienced homelessness in 2013. Bernstein, Meurer, Plumb, and Jackson (2015) estimated the prevalence of diabetes among the homeless at 8%.

            These individuals are at increased risk of developing diabetic foot ulcers because of their circumstances. Environmental exposure, injuries, ill-fitting footwear, and difficulty with glycemic control all contribute to an elevated risk (Bernstein et al., 2015; Muirhead, Roberson, & Secrest, 2011). Foot care for homeless individuals is further complicated by difficulty accessing care, difficulty with adherence to treatment, under or un-insured status, and competing priorities such as finding food and shelter (Muirhead et al., 2011).

            The homeless population in the United States is a complicated population. Homeless diabetic individuals are at increased risk for developing chronic lower extremity wounds compared with diabetic individuals who are not homeless. Once present, these wounds are especially difficult to treat in this population. One significant barrier to treatment is the presence of competing priorities: individuals may have to choose between attending a foot clinic and finding food and shelter. One way to improve care of this population is to make foot clinic available at a range of times to increase the chances that individuals will not be forced to make such a choice (Muirhead et al., 2011). What other specific challenges face this population and how can they best be addressed?

Figure 1. A removable cast walker. Adapted from “Best practice guidelines: Wound management in diabetic foot ulcers,” by Wounds International. Copyright Wounds International 2013.

References

Bernstein, R. S., Meurer, L. N., Plumb, E. J., & Jackson, J. L. (2015). Diabetes and hypertension prevalence in homeless adults in the United States: A systematic review and meta-analysis. American Journal of Public Health, 105(2), e46-e60. http://dx.doi.org/10.2105/AJPH.2014.302330

Braun, L., Fisk, W., Lev-Tov, H., Kirsner, R., & Isseroff, R. (2014).  Diabetic foot ulcer: An evidence-based treatment update.  American Journal of Clinical Dermatology, 15(3), 267-281.  http://dx.doi.org/ 10.1007/s40257-014-0081-9.

Muirhead, L., Roberson, A. J., & Secrest, J. (2011). Utilization of foot care services among homeless adults: Implications for advanced practice nurses. Journal of the American Academy of Nurse Practitioners, 23(4), 209-215. http://dx.doi.org/10.1111/j.1745-7599.2011.00598.x

U.S. Department of Housing and Urban Development. (2014). The 2013 annual homeless assessment report (AHAR) to Congress: Part 2, estimates of homelessness in the United States. Retrieved from https://www.hudexchange.info/onecpd/assets/File/2013-AHAR-Part-2.pdf

Wounds International. (2013). Best practice guidelines: Wound management in diabetic foot ulcers. Retrieved from http://www.woundsinternational.com/media/issues/673/files/content_10803.pdf