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Addressing Lower Extremity Wounds in Residents With Diabetes


Annals of Long-Term Care: Clinical Care and Aging. 2014;22(7-8):9.


Gregg Warshaw, MD Medical Editor

According to the Centers for Disease Control and Prevention, 10.9 million Americans aged 65 years and older (27%) have diabetes.1 The condition is associated with numerous complications, including delayed wound healing, and is the seventh leading cause of death in the United States.2 One of the most common complications leading to hospitalizations among persons with diabetes is a foot-related injury, such an ulcer, infection, or gangrene. Among those with diabetic foot ulcers, the American Podiatric Medical Association estimates that 14% to 24% will ultimately require an amputation.3

Elderly persons residing in nursing homes are at particularly high risk of amputations and other diabetic complications due to their high prevalence of comorbidities, functional impairments, and frailty, making prevention and timely management of diabetic complications essential to reduce morbidity and mortality in this population. This issue of Annals of Long-Term Care: Clinical Care and Aging®  includes two articles that offer insights on how to improve the management of lower extremity wounds in residents with diabetes.

In the first article, “Diabetes Foot Education: An Evidence-Based Study in Long-Term Care”, the authors report the results of their pilot study, which sought to educate long-term care (LTC) staff about foot health and how to prevent diabetic foot complications by conducting more comprehensive foot inspections. Their training module consisted of a 45-minute presentation by a physician and a trained diabetes educator, which was followed by a short video that demonstrated components of the foot examination, such as checking pedal pulses. The authors carried out the training in three LTC facilities, and they collected pre- and post-training surveys to assess for changes in staff knowledge. Although the staff of only one facility demonstrated a significant increase in knowledge following the training, chart reviews completed 3 months after the training showed clinically and statistically significant practice changes in all three facilities, as compared with chart reviews completed 3 months before the training. As the pilot study demonstrates, specialized training programs may be effective for improving the care of persons with diabetic foot complications, even if post-training assessments do not necessarily demonstrate an increase in knowledge. Time constraints and staffing shortages are often cited as reasons for not providing such specialized training to staff, but as this study shows, the sessions do not need to be long or taxing to have a meaningful impact.

In the second article, “Hyperbaric Oxygen Therapy: A Brief History of its Benefits and Indications in the Older Adult Patient”, the authors provide an overview of hyperbaric oxygen (HBO2) therapy. Historically, HBO2 has been used to successfully treat decompression sickness. Its use for other conditions has shown mixed results; however, it is covered for reimbursement by the Centers for Medicare & Medicaid Services (CMS) for a variety of acute and chronic conditions where the results have been more favorable, including for diabetic wounds of the lower extremity. In such cases, patients need to meet the following three criteria: (1) the wound is due to their type 1 or type 2 diabetes; (2) the wound is classified as Wagner grade III or higher; and (3) the wound has been refractory to standard wound therapy. In LTC settings, such criteria may be met more frequently than in the community-based setting; thus, this treatment should be considered for residents who are suitable candidates (eg, those who can tolerate being transported to facilities that provide HBO2).

In this issue, you will also find a Diabetes Spotlight in our LTC Bulletin Board, which outlines three new developments that have the propensity to change diabetes care. We also encourage you to visit our online Diabetes Medical Resource Center at, where you will find diabetes news, feature articles, images, guidelines, and more.

This issue also introduces The Pulse, a new department that features reader insights on a hot topic in LTC. This month’s Pulse examines the issue of aging in place, which has become more feasible as the CMS has shifted funding favoring home- and community-based LTC over institutionalized care.

We hope you enjoy the articles in this month’s issue. As always, we appreciate your feedback. Please e-mail your comments to our associate editor, Allison Musante, at

Thank you for reading!


1.    Centers for Disease Control and Prevention. Diabetes research and statistics. Accessed August 6, 2014.

2.    American Diabetes Association. Overall numbers, diabetes and prediabetes. Accessed August 6, 2014.

3.     American Podiatric Medical Association. Diabetic wound care. Accessed August 6, 2014.

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