Main Self-Care Deficits Found in Elderly People with Diabetic Foot Ulcer: An Integrative Review

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Theme: Health promotion, well-being, and quality of life Contributions to the discipline: This study contributes to the identification and categorization of the most common self-care deficits in elderly people and the scientific evidence generated provides a foundation for conducting new studies on the theme, as well as assisting in decision-making by nurses to adopt measures that contribute to the self-care of this population group, in addition to guiding this population regarding the necessary care. Furthermore, it contributes to training and qualifying the healthcare team in order to emphasize the need for self-care awareness.

Introduction
The exponential and fast increase in the incidence of diabetes mellitus (DM) has led to consequences for public health, due to the severity of the sequelae caused by the disease. Several individuals with diabetes lose sensitivity and may present foot deformities, which lead to "diabetic foot," defined as the infection, ulceration, and/or destruction of deep tissues associated with neurological abnormalities and varying degrees of peripheral vascular disease in lower limbs. This represents a significant health and economic problem, particularly if it results in amputation and prolonged hospitalization, rehabilitation, as well as loss of productivity and impact on the individual's quality of life (1).
In addition, elderly people with DM are twice more likely to suffer from dementia. Cognitive dysfunction hinders the performance of self-care tasks for patients, such as the management of capillary blood glucose, the administration of insulin doses, and the adoption of an adequate diet. In addition, brain aging, osteoarticular problems, and the presence of cataracts associated with diabetic retinopathy can negatively impact self-care activities and add to the incidence of diabetic foot in this population (2).
In this context and since it is a profession directly related to care, nursing provides self-care teaching, which is a relevant strategy to address the problems related to the disease process and consequent reduction of disabilities caused by diabetic foot syndrome, since the educational interventions employed by nurses stimulate individuals to act in the promotion of their own health (2). This category has been responsible for endeavoring all efforts and strategies for the relief of suffering, during and after the disease, and playing a pioneering role in the development of know-how competence, performing effective care and safe clinical management. As a science, the profession went through distinct moments and gathered strength from Florence Nightingale's care theories, which placed the profession in a new paradigm, as a holder of not only technical but also scientific knowledge, in which nursing knowhow intensifies the need for formal, organized, and scientific education with the consolidation of the administrative, managerial, and intellectual roles (3).
Nursing theories can be described as a set of interrelated concepts, definitions, or premises that present a systematic approach to observing, describing, or predicting phenomena/events to explain or propose the correlations between them (4). They provide a basis for the foundation of care as they guide the development of the systematization of nursing care (SNC) and the application of the nursing process (NP) based on patient-centered premises and foundations and on nursing as a promoter of comprehensive and holistic care, which provides an essential basis for autonomous, resolutive practice based on scientific evidence (5).
Orem's theory is one of the theoretical constructs that have inspired Brazilian nursing practice the most (2). Orem's general theory of self-care consists of three interrelated theoretical constructs: the theory of self-care, the theory of self-care deficit, and the theory of nursing systems, highlighting the importance of patient commitment to self-care (6). Within the scope of this theory, nursing practices directed to individuals are intended to enable them to be fully or partially capable of providing care for themselves or their dependents (7).
Since elderly people are the age group with the highest prevalence of DM and the most vulnerable to the onset of sequelae, there was interest in searching the current literature about the problems found in this population with diabetic foot ulcer (DFU) to identify their self-care deficits, focusing on Orem's self-care theory, based on the following guiding question: What are the factors related to self-care deficits of elderly people with DFU? This is an extremely relevant study given the scarcity of other reviews on this issue. It is hoped that it will contribute to the production of new studies on this subject, as well as to the improvement of the care provided by nurses to this population. Considering the above, the objective was to identify, from the scientific literature, the main self-care deficits present in elderly people with DFU, based on Orem's self-care deficit theory.

Materials and Methods
This is a bibliographic, descriptive, integrative literature review study, which provides the retrieval and systematic summarization of a given theme and leads to practice based on scientific knowledge. The steps proposed in the literature (8) were followed: 1. Identification of the theme and selection of the hypothesis or research question for the development of the integrative review; 2. Establishment of criteria for the inclusion and exclusion of studies/sampling or literature search; 3. Definition of the information to be extracted from the selected studies/categorization of studies; 4. Evaluation of studies to be included; 5. Interpretation of results; 6. Presentation of the review/synthesis of knowledge. The study was conducted based on the following question: What are the factors related to self-care deficits of elderly people with DFU?
The study selection for analysis was performed in January 2022. For the literature search, the Health Sciences Descriptors (DeCS) and the Medical Subject Headings (MeSH) were selected. The search strategy selected was "pé diabético" AND "autocuidado" AND "idoso" and the descriptors in English "diabetic foot" AND "self-care" AND "aged". The descriptor "enfermagem" (nursing) was excluded, as it greatly limited the number of articles found. The following databases indexed in the Virtual Health Library (BVS) were used: Latin American and Caribbean Health Sciences Literature (Lilacs), Medical Literature Analysis and Retrieval System Online (Medline), through the Public Publisher Medline database (PubMed) and Nursing database (BDEnf). Initially, 424 articles were found, using the following filters: scientific articles (original), published between 2011 and 2021, available in full text online and in Portuguese, English, and Spanish.
As inclusion criteria, studies addressing the following descriptors in the abstract were selected: "pé diabético," "autocuidado," and "idoso," that had an absolute number of elderly people in their sample (aged 60 years or above) and were original articles (cross-sectional, case-control, cohort, clinical trials). The exclusion criteria were defined as titles that did not correspond to the guiding question, review articles, theses, dissertations, monographs, books, book chapters, manuals, commentaries, opinion articles, and non-scientific production. Then, the articles were refined by verifying the titles and keywords, and those that mentioned at least two of the descriptors defined in the pre-established criteria were selected.
After the search, all identified articles were loaded into the EndNote basic reference manager and then into the Rayyan software; duplicates were removed, and the review steps were performed (9-10). In the first step, 424 articles were identified, 179 were excluded due to being duplicates, with 245 remaining, of which 4 were found in BDEnf, 21 in Lilacs, 102 in Medline, and 118 in PubMed. The studies pre-selected in Step 1 were restored in full and evaluated in Step 2. All those that failed to meet the inclusion criteria were excluded, and the reasons were registered.
After reading the titles and abstracts, 101 studies were excluded for being duplicates, with 144 remaining, of which 104 were excluded for not meeting the inclusion criteria such as mean age, ineligible methodological design, and not addressing the researched theme, and only one article was excluded for not being found in full. Thus, the present review was composed of 37 studies. The flow diagram of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (Prisma [11]) was used to report the search and selection process of the studies ( Figure 1).
The data obtained were grouped and presented in tables, with information regarding the articles and the self-care deficits found, for a clearer display of the studies included in the integrative review. The findings were summarized to identify the central theme addressed in each analyzed study. For the discussion of the results found, the findings of the studies regarding the adaptive problems experienced by elderly people were integrated.

Results
In the database search step, 245 studies that addressed the theme of self-care in elderly people with diabetic foot were found. Those were analyzed according to the methodological steps. Of these, 101 were selected for full reading, thus the sample of this review was composed of 37 studies.
In the rst step, 424 articles were identi ed.
Inclusion Criteria: Studies published in the format of a scienti c article (original); available in full text; published between 2012 and 2022, presenting two descriptors in the abstract: Diabetic Foot, self-care, and aged. Exclusion criteria: Titles that did not correspond to the guiding question, review articles, theses, dissertations, monographs, books, book chapters, annals, commentaries, opinion articles, and non-scienti c production.
Studies included in the review after reading the title and abstract (n = 38).

Identi cation
Screening Included Table 1 presents an overview of the articles analyzed. They were published from 2012 to 2022, with a prevalence of articles published in 2014 and 2020, with 7 (18.9 %) published each year. Regarding nationality, the country with the highest prevalence of articles on the theme was Brazil, with a total of 7 (18.9 %).
The analysis of the studies that composed the review sample allowed identifying a variety of research methods, with descriptive and cross-sectional exploratory methods being used the most (level of evidence VI). Only two articles were randomized studies with level II evidence.
The level of evidence of 29 (78.4 %) of the articles from the sample of this integrative review was classified as weak (grade 6), except for those with clinical trials, with studies A2 and A14 being classified as level II evidence, and A26 and A38 as level III (Table 1).  In Table 2, to clarify the presentation and organization of the articles' outcomes, a summary is presented, describing the main results and self-care deficits found according to Orem's self-care theory.
Regarding the universal requirements, 69 deficits were found, of which 15 were related to socioeconomic conditions, 26 to skin conditions, 8 to activities, leisure, and rest, 5 to nutrition, 10 to neurological conditions, and 5 to neurological condition deficits. Regarding incidence requirements, 5 deficits were found; on the other hand, regarding those on health deviations, 102 were evidenced, of which 72 were deficits in knowledge of self-care measures for feet and injuries, 24 about knowledge about the need for therapeutic support and treatment, and 6 about health status. Impaired memory and learning, impaired attention, significantly lower levels of self-esteem, self-image, and locus of health control compared to diabetic patients without ulceration, beliefs about symptoms associated with ulceration, barrier belief, stress due to ulcer, diabetes distress, and/or depressive symptoms.

Health deviation requirements
Knowledge about the need for therapeutic support and treatment (13, 15-23, 28-40, 42-44, 46-48) Low and medium levels of knowledge about self-care, no measurement of the ankle-brachial index, no palpation of peripheral pulses, patients without diabetes education, no foot examination, difficulty with insulin treatment, increased number of hospitalizations, increased self-care scale score, diabetes decompensation, self-monitoring of blood glucose, poor glycemic control, nursing care, podiatrist appointment last year, no monitoring of blood glucose level, insufficient self-management of the ulcer, not performing laboratory tests for lipid profile at the recommended frequency, poor preventive activities by medical doctors and not providing education on foot self-care, unaware of correct nail cutting, willingness to perform self-care, their understanding of ulceration and their perceived personal control over ulceration, diabetic foot ulcers were already in poor condition at the first time patients had an appointment with the clinic.
Source: prepared by the authors.

Discussion Elderly People with Diabetes and Self-Care in the Prevention of Foot Injuries
The results presented indicate a prevalence of the elderly population group considering the other age groups, given that the present review aimed to identify self-care deficits in this group. Elderly people with diabetes have a shorter life expectancy and are particularly burdened by foot diseases that can lead to amputation and other disabilities in addition to physical and psychological suffering. In Malaysia, it was reported that 55.3 % of patients with diabetes experience diabetic foot problems and 38.3 % of them were among the elderly (35).
People with diabetes need to adopt regular foot self-care behaviors to prevent and delay potential complications, such as avoiding skin dryness, damage between the toes and calluses on the feet that can reduce blood circulation and lead to early occurrence of trauma and complications. However, several factors in the elderly population can have an impact, including physical limitations, health status, as well as cognitive and psychosocial aspects. Thus, the aging of the world population and the exponential sharp increase of elderly diabetics make DFU a challenge for health professionals (14).
The study conducted in 2017 on the self-care behavior of diabetic elderly people reported that the adoption of foot care can help mitigate problems in these body segments by 49-85 % (14). Analysis of respondents through a set of validated questionnaires showed that participants were aware of the importance of foot care for the prevention of complications, but the professional and skin care subscales received only moderate scores. The same study pointed out that only a limited number of elderly people with diabetes seek medical advice when they experience the onset of the disease; most only seek professional assistance for treatment when the disease becomes severe.
Adherence to self-care behavior is considered low in people with diabetes, so the underlying determinants need to be identified (49). In a study conducted in Cuba, misinformation on foot selfcare measures prevailed (84.3 %), with higher percentages in the 61-70 years group (100 %) versus 65 % in the 50-60 years group. Most patients qualified as having poor foot self-care habits (86.6 %). It was noted by the researchers that in the 61-70 age group, this category rose to 96 %; however, in the 50-60 age group, 5 patients had good and regular habits (2 and 3 representing 10 % and 15 %, respectively). The variable "foot self-care" showed a prevalence of patients with poor evaluation (82.1 % [12]).
DFU can be reduced through adequate guidance on podiatric care, as early identification of tissue at risk of ulceration can enable appropriate preventive care, thus reducing the incidence of foot ulceration. Such results were shown in a study that evidenced a substantial decrease in the incidence of DFU, in which 185 patients with diabetes at high risk for foot disease received intensive nursing education and, after two years of follow-up, the incidence of DFU was significantly reduced. More ulcers were healed, and fewer surgical procedures were required in patients who were monitored (47). However, the rates of foot examinations and prevention activities carried out by health professionals are low. According to the literature, only 14 % of respondents have ever received guidance on foot care and only 26 % have had their feet examined by a professional (43).
In a Colombian study, diabetic foot prevention activities performed by medical doctors were found to be precarious, as 59.5 % of patients reported not having received guidance on foot self-care.
Only 106 (40.5 %) reported having received guidance on foot self-care. Similarly, 57.1 % of patients reported that the outpatient medical doctor had not examined their feet, i.e., in the last year, only 42.9 % of patients had had their feet examined. Similarly, 68.3 % were not asked about dysesthesia and intermittent claudication in 74.8 % of the total group of patients surveyed (27).
This reality contrasts with what is recommended by the International Diabetic Foot Group guidelines, which highlight the cost-effectiveness of prevention activities to reduce the prevalence of ulcers and amputations. It has been shown that patients at high risk of diabetic foot injuries need timely diagnosis and education for appropriate diabetes self-care behaviors and foot self-examination. In light of the above, every clinician providing care to a patient with DM should question them regarding risk factors for diabetic foot (dysesthesias, intermittent claudication, ulceration, and amputation), perform a primary foot examination (inspection, protective tenderness with the Semmes Wein-

Orem's Theory and Its Self-Care Requirements
It should be noted that nursing theories are used as a basis to substantiate care and are considered a relevant strategy to aid in the educational interventions employed by nurses and consequently reduce the disabilities caused by diabetic foot syndrome and stimulate patients to act in the promotion of their health as they guide the development of the SNC and implementation of the NP.
Orem's theory is one of the theoretical constructs that have inspired Brazilian nursing practice the most (2). Among its three interrelated theoretical constructs, there are the self-care theory and the universal, development, and health deviation requirements.

Self-Care Deficits of Universal Requirements
The articles that presented universal deficits point out that elderly people were less confident in protecting and checking their feet daily for any abnormality such as redness, cuts, blisters, and dry skin. The barriers to performing these tasks may be explained by geriatric conditions such as visual impairment and other medical conditions that limit the ability to adequately inspect and protect the feet. The highest self-care subscale scores in this study were for footwear, hygiene, and safety. This finding is supported by previous research showing that self-efficacy is significantly associated with foot self-care behavior of elderly people with diabetes (12).
A study (17) performed with 60 patients hospitalized for diabetic foot used the questionnaire on capacities and self-care activities of patients with diabetic foot as an instrument, which highlighted that, when it came to foot care, 58.3 % had an inadequate level; 50 % of users had lesions, that is, calluses, fungal infections, and bad odor. This is due to their poor condition and the use of cloth, plastic, and leather sandals, the latter being traditionally used.
In the primary health care system of a city in the countryside of São Paulo, a study was performed to evaluate the feet of individuals with DM (43), it was found that 94 % of the respondents had no lesions on their feet; in the sensitivity test, 88 % had preserved sensitivity and 77 % had preserved pedic pulse, showing that, in both tests, a percentage of patients already present alterations in the exams, allowing timely guidance to be provided.
Thus, the effect of intensive nursing education on the prevention of DFU in patients at high risk for diabetic foot is not only possible but also highly beneficial for the patient, so that they can have their feet inspected regularly. At the end of the follow-up, the onset of DFU was prevented and the participants were educated about sensory neuropathy, which leads to a deficit or loss of the skin's self-protection mechanism (47).
Motor neuropathy alters the plantar pressure load, and autonomic neuropathy reduces the perspiration of the foot skin, making the skin dry and easily damaged or cracked. Visual inspection of the skin for signs of dryness is often vital to prevent skin integrity cracking. Checking the skin will provide an early warning of impending problems and such inspections should be encouraged and guided by healthcare professionals in their care (47).

Self-Care Deficits of Development Requirements
Regarding development deficits, the literature shows that 50.4 % of patients have mobility problems, 28.2 % have self-care problems, and 47.6 % have regular activities problems (51). In addition to finding a significant association between adherence to foot care and mobility problems, self-care, and regular activities (p < 0.05). A significant association was also found between lack of adherence to exercise and poor mobility, self-care, regular activities, pain, and anxiety (p < 0.05). Non-adherence to diet was associated with poor mobility (p < 0.05). In this study, patients who had a non-adherence index also had lower quality of life.
According to descriptive results in one study (29), 42.1 % of the elderly participants suffered from some other disease other than diabetes, 26.3 % were current smokers and 30.8 % were alcoholics. Ulcers are associated with an increased risk of all-cause mortality, fatal myocardial infarction, and fatal stroke. These patients have insulin resistance, central obesity, dyslipidemia, and hypertension. The finding that 26.3 % of participants were current smokers needs to be carefully considered due to the vasoconstrictive effects of nicotine on late or non-healing ulcers and the increased risk of diabetic foot amputation.
When analyzing the self-care and social support variable, it was possible to note that patients who live alone, who live with their partner, and with their family presented a higher percentage in the partially adequate self-care category: 2 (50 %), 4 (44.4 %), and 10 (55.6 %), respectively; and 3 (33.3 %) of those who live with a partner presented adequate self-care (21).
Regarding the level of education, it is worth noting that participants with higher education, when compared to those with secondary education, obtained significantly higher foot care behavior scores than those with low education. Thus, it emphasizes that less educated people tend to be less knowledgeable about health, lead-| AÑO 23 -VOL. 23 Nº 3 -CHÍA, COLOMBIA -JULIO-SEPTIEMBRE 2023 | e2336 ing to unhealthy behaviors compared to those with higher levels of education (34).
It was also possible to note that patients with DFU are more likely to have depression and anxiety compared to those without foot complications, while patients with DM are twice more likely to have anxiety and depression when compared to the general population. Anxiety is associated with DM duration (< 10 years), comorbid conditions, and HbA1c level > 7 %, while depression is associated with patients' age (< 50 years), being female, being a current smoker, foot ulcer duration, and comorbid conditions. Depressive symptoms are associated with ulcer recurrence in DM patients aged 60 years old. Depression at the first ulcer occurrence is associated with a 2-fold increase in mortality within 5 years and an increased amputation rate (29).

Self-Care Deficits of Health Deviation Requirements
Regarding health deviation deficits, the mean number of years since diagnosis of the participants studied was 17.1 (SD = 12.6). In the group with less than 11 years since diagnosis, the category "partially adequate self-care" prevailed (n = 6; 37.5 %); but in the group with 11 to 20 years, the category "no self-care capacity" was more frequent (n = 3.5 %). In people with more than 20 years since diagnosis, there was still a higher percentage of "partially adequate self-care". The category that presented the highest percentage was "partially adequate self-care" in all groups, with 5 (71.4 %) in the group with 21 to 30 years, but in the group with 10 to 20 years, there were 2 (40 %) that presented the category "self-care deficit" (21).
In this same study, when evaluating the relationship between selfcare and hospitalization in elderly people, it was found that the main cause of hospitalization of elderly diabetics was due to diabetic foot, followed by patients with metabolic decompensation (21).
It was found that 51.7 % of patients with diabetes received foot care education from a nurse, 80 % knew the negative effect of diabetes on the feet, 69.2 % had no foot problems after diagnosis, 40 % attended a health care institution in case of any foot problem, 76.7 % performed leg and foot gymnastics, 63 % performed leg and foot gymnastics regularly daily, and 30.8 % performed foot examination daily (45).
The aforementioned study also found that patients' knowledge about diabetic foot and diabetes self-care behaviors increased significantly as the duration of diabetes increased, but they failed to convert this knowledge into foot-care behaviors. This result suggests that the patients included in the study had difficulty converting their knowledge into behaviors due to their older mean age (45). Therefore, when evaluating the effect of the operating group in teaching foot self-care for the prevention of diabetic foot, with the participation of 209 people with diabetes, several aspects were considered in the intensive nursing teaching. Dry and cracked foot skin was addressed and patients were instructed to wash their feet correctly, including care for adequate water temperature and how to keep the feet dry. In addition, patients were advised on the choice of adequate shoes and socks and their awareness of self-protection was improved. Therefore, patients were encouraged to perform an inspection of their feet and consequently to practice daily self-care (6).

Conclusions
The findings of the selected studies evidenced that participants had a low level of knowledge on the theme, in addition to limitations to self-care in elderly people, who are affected by the long-term complications of diabetes. In addition, the progression of the disease associated with gaps in communication and guidance from health professionals could be noted in the studies that had a large number of participants who stated that they had never received foot care guidelines, which resulted in serious consequences in the onset and healing of DFU.
It should be stated to patients that adequate foot care in diabetes is essential to prevent the occurrence of wounds. In this sense, Orem's self-care theory proved to be compatible with the study, enabling the identification and classification of the main self-care deficits and their categorization, which can ease care and improve the self-care perspective.
Therefore, the importance of carrying out the present study is highlighted, which contributes to the identification and categorization of the most common self-care deficits in elderly people. The scientific evidence hereby produced provides a basis for further studies on the theme, in addition to assisting nurses in decision-making to adopt measures that promote self-care in this population group, besides guiding this population regarding the necessary care. It also contributes to training and qualifying the team to emphasize the need for self-care awareness.