Advertisement

The long toenail sign in older adults

  • Author Footnotes
    1 This work was conducted while employed at affiliation sites b, c and e.
    Kirstyn James
    Correspondence
    Corresponding author at: Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland.
    Footnotes
    1 This work was conducted while employed at affiliation sites b, c and e.
    Affiliations
    Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland

    New England Geriatric Research, Education and Clinical Centers, Division of Geriatrics & Palliative Care, Veteran Affairs Boston Healthcare System, Boston, MA, United States

    Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
    Search for articles by this author
  • Ariela R Orkaby
    Affiliations
    New England Geriatric Research, Education and Clinical Centers, Division of Geriatrics & Palliative Care, Veteran Affairs Boston Healthcare System, Boston, MA, United States

    Department of Medicine/Division of Aging, Brigham and Women's Hospital, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
    Search for articles by this author
  • Andrea Wershof Schwartz
    Affiliations
    New England Geriatric Research, Education and Clinical Centers, Division of Geriatrics & Palliative Care, Veteran Affairs Boston Healthcare System, Boston, MA, United States

    Department of Medicine/Division of Aging, Brigham and Women's Hospital, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
    Search for articles by this author
  • Author Footnotes
    1 This work was conducted while employed at affiliation sites b, c and e.
Published:March 21, 2021DOI:https://doi.org/10.1016/j.ejim.2021.03.006

      1. Case description

      A 78 year old male attended a geriatric medicine outpatient clinic accompanied by his son. He described a history of falls, memory impairment and difficulty completing activities of daily living including cutting toenails. He also reported bilateral foot pain. Comprehensive geriatric and frailty assessments were performed. His son described how he was assisting his father with grocery shopping and household cleaning but was not aware his father had developed difficulties in maintaining foot care. Positive findings on physical examination included impaired cognition, difficulty completing a chair stand and a borderline slow gait speed. The final step of the physical examination was to inspect the feet. The patient had difficulty removing his shoes and socks due to hip pain. His toenails were very long and thickened consistent with onychomycosis. Foot hygiene was suboptimal and bony deformities of the feet were present, including hallux valgus and hammertoes.

      2. Discussion

      The “long toenail sign” provides insight into an older adult's overall functional status and risk of frailty.[
      • Orkaby A.R.
      • Schwartz A.W.
      Toenails as the "hemoglobin A1c" of functional independence-beyond the polished wingtips.
      ] Maintaining foot hygiene including cutting toenails, requires bending down which may be difficult in the presence of arthritic conditions. It also requires coordination of the task physically and cognitively. Many older adults have difficulty maintaining their own foot care. Long, thickened toenails can result in pain.[
      • James K.
      • Orkaby A.R.
      • Schwartz A.W.
      Foot examination for older adults.
      ] Foot pathologies and suboptimal foot hygiene are associated with falls, impaired mobility and loss of functional independence.[
      • Menz H.B.
      • Auhl M.
      • Spink M.J.
      Foot problems as a risk factor for falls in community-dwelling older people: a systematic review and meta-analysis.
      ] However, patients may under-report foot problems. Examining an older person's feet can detect remediable conditions such as nail disorders, skin changes and bony deformities. The examination may also reveal long toenails and suboptimal foot hygiene which may indicate a change in ability to complete activities of daily living independently.[
      • Orkaby A.R.
      • Schwartz A.W.
      Toenails as the "hemoglobin A1c" of functional independence-beyond the polished wingtips.
      ] Bony deformities of the foot can result in ill-fitting footwear, potentially leading to pain and skin breakdown. Older age is a known risk factor for the development of fungal nail disorders. These typically present as changes in nail pigmentation and onycholysis. The prevalence of diabetes is higher in older adults, which if complicated by neuropathy can lead to foot pathologies including Charcot foot.[
      • James K.
      • Orkaby A.R.
      • Schwartz A.W.
      Foot examination for older adults.
      ] This Image 1 highlights the importance of foot examination during the assessment of an older or frail patient.
      Image 1
      Image 1Patient's feet with long, thickened toenails consistent with onychomycosis, bilateral hallux valgus and hammertoes.

      Funding

      This material is the result of work supported with resources and the use of facilities at the VA Boston and New England GRECC. The contents do not represent the views of VA or the United States Government.
      Dr. Orkaby is supported by VA CSR&D CDA-2 award IK2-CX001800, NIA R03-AG060169.

      Authors' statement

      All authors had access to and a role in writing the manuscript.

      Declaration of Competing Interest

      None

      Acknowledgement

      The authors wish to acknowledge the contributions of Christian Baglini APRN in the preparation of this manuscript.

      References

        • Orkaby A.R.
        • Schwartz A.W.
        Toenails as the "hemoglobin A1c" of functional independence-beyond the polished wingtips.
        JAMA Intern Med. 2018; 178: 598-599
        • James K.
        • Orkaby A.R.
        • Schwartz A.W.
        Foot examination for older adults.
        Am J Med. 2021; 134: 30-35
        • Menz H.B.
        • Auhl M.
        • Spink M.J.
        Foot problems as a risk factor for falls in community-dwelling older people: a systematic review and meta-analysis.
        Maturitas. 2018; 118: 7-14