NAILS talked with respected podiatrist Dr. Godfrey Mix about the adjustments needed in procedures of foot care and the elderly.
NAILS: How do the skin and nails change with age?
Dr. Mix: with an elderly client, the vascular status, or circulation system of blood, is usually going to be diminished. The older we get, the poorer our circulation becomes, particularly in our hands and feet. The skin starts to get thinner; it’s easily nicked or injured, so we [nail technicians and podiatrists] have to be a lot more careful in handling the skin. The nails, just from wearing shoes, seem to become much more tough and brittle, and they get thickened from shoe injuries or just minor injuries over a lifetime. They start to curl in at the corners, and a lot of debris accumulates along the nail margins.
NAILS: As people get older, do they start developing foot disorders or medical problems that a nail technician needs to consider when evaluating the best service for her elderly client?
Dr. Mix: You need to have the client’s medical history prior to doing any service on her. Find out about medications she is taking.
NAILS: Which medications or disorders might a client have that should raise red flags for a nail technician?
Dr. Mix: Insulin, of course, for your diabetic clients. There are also a number of oral medications for diabetes. One of them is Glucatrol; the names of others usually have something to do with glucose. You want to watch for those because a diabetic client has poor circulation (see “A Pedicurist’s education in Diabetes” in the March 1996 issue). If your client is taking high blood pressure medications (Verapamil is one of them) and she is elderly, you know that her circulatory status is going to be diminished.
NAILS: What precautions should be taken on a client with poor circulation?
Dr. Mix: Just be very careful and gentle. You probably are going to find more swelling around the ankles and in the feet because of the vascular status. Never cut cuticles or calluses!
NAILS: Opinions differ as to whether heat or cold should be applied to reduce the swelling from injuries. When you’re doing a pedicure on swollen feet, should they be soaked in warm water or cooler water?
Dr. Mix: Do a normal soak in warm water. I recommend keeping the water temperature under 100° on the elderly when you’re soaking their feet. In warm water, the tissues also warm up, requiring more oxygen. If these tissues also suffer from poor blood circulation, oxygen [carried by blood] can’t get to those tissues. If there is swelling as well as poor circulation, it causes increased pressure on the blood vessels in the feet and around the ankles. So the circulation of the blood to these areas slows down. If the water is too hot, the tissue requires more oxygen but can’t get there because of swelling.
For some reason, people generally think it is best to boil our feet. In reality, the rule of thumb is if you wouldn’t put the rest of your body in water that is too hot, don’t put your feet in it. I think it’s an old wives’ tale that tells us to soak our feet in hot, hot water to “boil out” any infection. I don’t know where it came from, but my patients will come into my office after soaking their feet in extremely hot water, and it’s almost like they burned their feet from it.
NAILS: Should the nail technician do a standard massage on swollen feet, or a lighter massage?
Dr. Mix: The most important thing is make sure your massage technique pushes the fluids up the leg toward the heart; that will help make the circulation a bit better. You don’t want to overdo the massage. Again, gentleness is important.
NAILS: Are there any lotions or sloughing treatments that shouldn’t be used on elderly clients’ feet?
Dr. Mix: It depends on the skin type. If the skin is very thin and dry, like paper, then you have to be very, very careful with it. Abrasive sloughing lotion might be too rough. If the skin is relatively intact, however, use the sloughing lotions and the other moisturizing lotions just like you would with anybody else. Sloughing lotion might be good on the bottoms of the feet because it’s more gentle than a callus file.
Because elderly people usually can’t reach their feet, they really need our help, both my help and the nail professional’s. Many health maintenance organizations don’t cover what’s called routine foot care, unless the patient is diabetic or has severe circulation problems. This is where the nail professional fits in. She should promote the fact that she can provide expert routine foot care. My wife (who is a nail professional) is here in my office, and that’s how we work it. The patients who aren’t covered by medical insurance can go to her; she can give them a better (and less expensive) service than I can.
NAILS: Are there some long-term, cumulative benefits for elderly pedicure clients?
Dr. Mix: Yes. For one thing, keeping the nails trimmed properly prevents them from being injured further.
NAILS: What are some of the injuries their toenails might suffer?
Dr. Mix: If the toenail gets too thick or long, it will hit the top or the end of shoe, and every step puts pressure on the matrix bed and the nail bed. Each little tiny step causes a micro-injury, so to speak. Add up all the micro-injuries incurred over several weeks or months and the client ends up with one big injury to her toe. So the client gets thickening or lifting of the nail plate. Keeping the nails properly trimmed promotes good health and healthy nails.
NAILS: Some clients may have had foot surgery. What kinds of “modified feet” will a nail technician see, and how should she accommodate her services to give them a safe pedicure?
Dr. Mix: Unless it’s immediately after a foot surgery, I don’t see any reasons for changing the pedicure service at all. Again, practice gentleness in your service.
NAILS: What are some of the common types of foot surgery for an elderly client?
Dr. Mix: Ingrown toenail surgery and permanent avulsion (removal) of the nails are not uncommon. Moisturizers on the nail bed are great for these cases. Even using a little bit of the sloughing lotion is good, because the area around the incision will have a tendency to build up more dead skin. You’ll also see hammer toe surgeries and bunions. In general, it isn’t a problem to perform pedicures on clients who’ve had these types of operations.
NAILS: Besides excessive cutting, what are some things that a nail technician should not do?
Dr. Mix: If anything needs cutting, the client should be referred to a podiatrist. No type of cutting instrument should ever be used, particularly on the elderly. Foot paddles, however, are fine. The rule of thumb is to soften and smooth the callus, not remove it.
NAILS: Is it true that with routine pedicures, calluses will become less and less coarse and hard?
Dr. Mix: Yes. If you can get the client in for routine pedicures (every few weeks to start with and then maybe once a month), you’re doing a great service for elderly clients. The real secret to a good pedicure is to trim the nail and clean out along the margins. The rest of the pedicure [the pampering portion] is just the icing on the cake. You’ve got to take care of those nails so they are comfortable when they walk out. A good pedicure should make that client feel like she is walking on a cloud. So often I see patients whose nails aren’t trimmed properly. Their nails are trimmed straight across, which is wrong. By trimming toenails properly, you’ll get a pedicure addict.
When working with a thickened toenail, the thinner you can make it, the better. I use a drill for smoothing and thinning the nails. Drills don’t injure people; people injure people by improperly using a drill. If a nail technician takes a course on how to use a drill, she could use it to thin a toenail without harming the client. Education of drill use is the most important thing. Also, letting the drill do the work, not forcing the drill down onto the nail plate is crucial.
You want a drill bit that’s the roughest you can get to cut, because it creates less heat and uses less pressure to take down the nail. The more pressure you have to apply to the drill, the easier it is for the bit to slip. When using a drill on a toenail, you can slip and hit the tissue without danger (the soft tissue around the toenail really is fairly hard to cut) as long as you aren’t applying pressure. It is the pressure with speed that will cut the soft tissue.
Another thing to consider when servicing the feet of the elderly is cuticle pushing. On toes, I don’t recommend it at all. You should use a cuticle softener and rub it into the skin, with either a 2-inch x 2-inch gauze pad or your finger.
NAILS: Why shouldn’t cuticles on toes be pushed back?
Dr. Mix: I see patients in my practice coming from nail professionals who have done this during pedicure services. These patients have infections around the base of the nail. The nail technician will push back the cuticle and it is so easily injured, particularly on the elderly, that it creates a portal of entry for infection.
NAILS: Can even an orangewood stick cause the injuries?
Dr. Mix: yes, because that skin is so thin back there. That’s why I just recommend using cuticle creams or mousses. If you’re doing routine pedicures, that skin will go away. Plus, you also have to get your client to take care of her feet herself by applying lotion between appointments to keep the skin soft.