Factors Associated with Activities of Daily Living among Patients

with Diabetic Foot Ulcers

A Pilot Study

Yunita Sari

, Iwan Purnawan

, Agis Taufik

, Annas Sumeru

, Eman Sutrisna

Department of Nursing, Jenderal Soedirman University, Purwokerto, Indonesia

Department of Medicine, Jenderal Soedirman University, Purwokerto, Indonesia

Keywords: Activity of Daily Living, Diabetic, Factors, Foot Ulcer.

Abstract: Patients with diabetic foot ulcers in general have a limited ability to perform activity daily living (ADL).

However, currently, no studies are available that investigated factors associated with ADL among patients

with diabetic foot ulcers. Therefore, the purpose of this study was to investigate factors related with ADL in

patients with diabetic foot ulcers. This was a cross sectional study in patients with diabetic foot ulcers. Data

analysis used Pearson's correlation, independent t-test, and multiple linear regression analysis. Multiple linear

regression analysis showed that factors that had a significant impact on ADL in patients with diabetic foot

ulcer included age and depression. Moreover, the dominant factor for predicting ADL in patients with diabetic

foot ulcer was depression. This is the first study that investigated the factors associated with ADL among

patients with diabetic foot ulcers. Age and depression were related with limited ADL in patients with diabetic

foot ulcers. In the future, Nurses may be able to identify high-risk patients of disability and conduct preventive

interventions.

1 BACKGROUND

Diabetic ulcers are an important cause of morbidity

and mortality in patients with diabetes mellitus (DM).

In a previous study, it was shown that the annual

incidence of diabetic ulcers is 1-4 % with a

prevalence of 10-15 % (Singh, Armstrong, & Lypski,

2005). During their lifetime, each patient with

diabetes mellitus has a 15% chance to get ulcers

(Singh, DG, & BA, 2005). Healed diabetic foot ulcers

still have a risk of about 60% to develop recurrent

ulcers within 3 year (Armstrong, Boulton, & Bus,

2017). Patients with foot ulcer are also at a high risk

of amputation. A total of 73,000 amputations were

performed on patients with DM, most of which are

due to diabetic ulcers (Crews et al., 2016). In addition,

the mortality rate 5 years after amputation is

increased and may reach 80% (Crews et al., 2016).

Diabetic ulcers affect many aspects of patients.

Previous studies have shown that diabetic ulcers

reduce the quality of life, which is mostly due to

reduced mobility. The limited ability to move affects

the patients’ ability to perform every day activities

and tasks and to enjoy leisure activities (Crews et al.,

2016).

In a study by Brod et al. (1998), the effects of

diabetic foot ulcers on patients and their care

caregivers’ life was investigated. The data showed

that diabetic foot ulcers had an effect on the physical,

psychological, social, and economic status of patients

and their caregivers because of the limited ability to

move caused by the wound. In another study, it was

revealed that patients with diabetic ulcers have a

reduced ability to move. The reduction in mobility

causes patients to loose self-esteem due to the

difficulty to take care of themselves (de Jesus Pereira

et al., 2014). Another study showed that the limited

mobility due to diabetic ulcers affected physical

activities, especially those that required the use of the

ankle and foot. The inability of patients to perform

activity daily living (ADL) finally also cause more

physical problems. Previous study showed that the

presence of diabetic foot ulcer interfere their live,

resulted in worsened physical health and even cause

foot complication (Evans & Pinzur, 2005).

The inability of patients to move and to perform ADL

can have various psychological effects. Previous

studies have shown that patients are frustrated, angry,

Purnawan, I., Tauﬁk, A., Sumeru, A. and Sutrisna, E.

Factors Associated with Activities of Daily Living among Patients with Diabetic Foot Ulcers.

DOI: 10.5220/0008328505570562

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 557-562

ISBN: 978-989-758-336-0

557

have a loss of self, and guilt due to their limited ability

to move and feeling being a burden to others to help

them do ADL. In addition, previous studies have

shown that the inability to move due to foot ulcers

may cause unbearable depressions (Kinmond,

McGee, Gough, & Ashford, 2003).

Many studies have been conducted to investigate

the effect of diabetic ulcers on ADL and the effect of

limited ADL due to diabetic foot ulcers on

psychological effects (de Jesus Pereira et al., 2014;

Kinmond et al., 2003). However, currently no studies

are available that investigated the associated factors

of ADL in patients with diabetic foot ulcers.

Investigating ADL is crucial since limited ADL may

have a fatal impact on patients, such as depression

and foot complications. Data regarding factors

associated with limited ADL are important for nurses

so they could take preventive measures to prevent

limited ADL. Therefore, the purpose of this study was

to investigate the factors related with ADL in patients

with diabetic ulcers. To our knowledge, this study is

the first study to assess factors related with ADL in

diabetic patients with foot ulcers.

2 METHODS

2.1 Study Design, Sample and

Procedure

The design of this study was a cross sectional study.

This study was conducted from January 20, 2017 to

November, 2017. Fifty-seven patients were recruited

from Kizu Wound Care Center and Prof Dr. Margono

Hospital, Indonesia using convenience sampling. The

inclusion criteria were: patients with diabetic foot

ulcers, at the age of 35 or older who agreed to be

included in this study. The exclusion criteria were:

patients who did not have mental health or other

conditions that hampered completion of the

questionnaire.

Four nurses conducted the surveys using the face-

to-face method. Before data was obtained, patients

were informed about the aim and protocol of the

study. Patients were also informed that the

involvement in this study was not obligatory. They

could decline at any time. The protocol of this study

was approved by ethical committee of the medical

faculty, Universitas Jenderal Soedirman, Purwokerto,

Indonesia.

Independent variables in this study included age,

education, employment status, gender, marital status,

income, smoking, blood glucose level, body mass

index (BMI), and ADL, grade of wound, and number

of wounds.

2.2 Measures

ADL was obtained by using Barthel index (BI)

questionnaires. The BI consisted of 10 aspects of

ADL, including the ability to do personal toileting,

getting on and off from the toilet, feeding, moving

from wheelchair to bed and return, self-bathing skills,

walking on a level surface, ascending and descending

on stairs, dressing, controlling bowels, and

controlling bladder. The total score ranged from 0

(total dependence) to 100 (total independence). A

higher BI indicated a higher level of ADL and a lower

BI indicated a lower level of ADL. The Barthel Index

is widely used in Indonesia. The Cronbach alpha of

BI in Indonesia was 0,938 (Iskandar, 2016).

The data of depression was adapted from

questionnaires by Rochmayanti (2017) and consisted

of 8 questions. The minimum value was 0 and the

maximum value was 8. A higher value indicated

worse depressive symptoms. In a previous study, it

was revealed that the Cronbach’s coefficient alpha for

these questionnaires was 0,7999 and that all items

were valid (Rochmayanti, 2017).

2.3 Data Analysis

In this study, descriptive statistics were used to

express descriptive variables. Then, the Cronbach’s

alpha method was used to determine reliability. Data

analyses were performed using SPSS version 20. The

Pearson correlation, independent t-test, and multiple

linier analyses were used.

For analysis of multiple linier regression,

backward elimination was performed. Data was

considered statistically significant when P<0.05.

Adjusted R2 was used to determine the variance of

ADL.

3 RESULTS

3.1 Patient Characteristics

Demographic profile of respondents, characteristics

of the wound, and ADL data are presented in Table 1.

The age of most respondents was less than 65 years

old, with a low educational background, female,

having a job, were married, low income, normal BMI,

having a controlled blood glucose. Regarding wound

characteristics, most patients had grade 2 ulcers, and

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

558

had one ulcer, which occurred less than 6 months ago.

Most patients had symptoms of depression.

3.2 Bivariate and Multiple Regression

Analyses

ADL data of participants showed that most patients

had a disability, which were severe (21%), moderate

(14%), and mild (28.1%), respectively. The mean

score of ADL was 81 ± 25. The Pearson correlation

showed that age, glucose levels, depression, and

Table 2: Patient ADL’s ability.

ADL Disability

(number of

ersons)

No disability

(number of

ersons)

Bowels 6 52

Bladde

9 48

Groomin

13 44

Toilet use 17 40

Feeding 12 45

Beed to chair

and bac

23 24

Mobility 22 25

Dressing 19 28

Stairs 23 24

Bathin

19 38

Table 3: Multiple correlation coefficient.

Variables t/F

Value

Age -0.361 0.006

Education 1.684 0.098

Gende

0.693 0.491

Employment -

0.,664

0.510

Income -

0.714

0.478

Body mass index -0.001 0.995

Grade of woun

s -0.301 0.023

Number of ulce

s -0.143 0.290

Duration of ulce

-0.50 0.96

Blood glucose

level

0.335 -0.335 0.011

Depression -0.592 P<0,001

Table 4: Multiple regression analyses.

Variable Depression

Depression -0,174 P<0,001

Age -0,245 0,035

Multiple correlation coefficient (R) = 0.690,

Adjusted coefficient of determination (R2) = 0.4

Table 1: Characteristics of patients.

Variables Values Percentage

Age

Less than 65 42 73, 4

More than 65

15 26, 3

Education

No education 2 3.6

Low education 30 52,6

High education 25 43, 8

Employment

Employed 30 52,6

Unemployed 27 47, 4

Gender

Male 20 35,1

Female 37 64,9

Marital Status

Married 52 91,2

Not married

8.8

Income

Low 22 38,6

Moderate 11 19,3

High 24 42,1

Body mass index

Slim 2 3,5

Normal 39 68,4

Excess weight 16

Smoking

Yes 3 5.3

No 54 94,7

Blood glucose

Less than 200

31 54,4

Above 200 mg/dl 26 45,6

Grade

Grade 2 40 70,2

Above grade 2 17 29,8

Number of ulcers

One 42 73,7

More than one 15 26,3

Duration of ulcers

Less than 6

50 87,7

Above 6 months 7 12,3

Blood glucose

Less than 200

31 54,4

Above 200 mg/dl 26 45,6

Depression

No depression 2 3.5 %

At least one

55 96,49%

ADL

Severe disability 12 21.0

Moderate

disability

8 14,0

Mild disability 16 28,1

No disability 21 36,9

Factors Associated with Activities of Daily Living among Patients with Diabetic Foot Ulcers

559

grade of wound were significantly associated with

ADL in patients with diabetic ulcers. In addition, the

number of wounds and BMI were not significantly

different. Independent t-test showed that there were

no difference between gender, income, duration of

ulcers, marital status, income, smoking, and

employment status and ADL in patients with diabetic

ulcers (Table 1).

In the table 2 shows the ADL characteristics

among the study participants. Among the daily living

activities, most of the study participants had a

disability in bed to chair and back, and stairs. The

Pearson correlation showed that age, blood glucose

level, depression, and the wound grade were

significantly associated with ADL in patients with

diabetic ulcers, whereas the number of wounds and

BMI were not significantly different. Independent T-

test indicated no differences between gender, income,

duration of ulcers, marital status, income, smoking,

and employment status with ADL in patients with

diabetic ulcers (Table 3).

The independent variables in multiple linear

regression analysis included age, education, grade of

wounds, depression, and blood glucose level. Age (t

= -2.174, p=0.035) and depression (t = -3.967, p <

0.001) were determined as significant predictors for

depression in patients with diabetic ulcers (Table 4).

The multiple correlation coefficient (R) was 0.735,

and the adjusted R2 was 54 % (F = 14.97, p < 0.001).

4 DISCUSSION

To our knowledge, this is the first study to examine

the factors associated with ADL in patients with

diabetic ulcers. Our data showed that depression and

age were main predictors for limited ADL in patients

with diabetic ulcers. Moreover, in this study, we

showed that diabetic patients who were elderly and

had depressive symptoms were at risk for having a

limited ability to perform ADL.

In this study, we used the BI as an index to assess

ADL. In previous studies, the BI has been widely

used to assess the ADL. The BI has been widely

translated into other languages, and the results

indicated that this index was highly valid and reliable

(Khoei, Akbari, Sharifi, Fakhrzadeh, & Larijani,

2013; Minosso, Amendola, Alvarenga, & de Campos

Oliveira, 2010; Pei et al., 2016).

It is recommended to use BI to assess ADL. The

ability of patients in performing ADL used this index

so that high-risk patients could be readily identified,

and therefore early intervention could be conducted

as soon as possible.

In our study, we found that most patients with

diabetic ulcers had limitations in doing ADL. Our

study corresponded with a previous study by Obilor

& Adejumo, (2015). In their study, the authors stated

that patients with diabetic ulcers had a more limited

ability in performing ADL when compared with

diabetic patients without ulcers. In another study by

Obilor & Adejumo (2015) it was shown that patients

with diabetic ulcers had limited ADL. Moreover, in a

recent study, it was shown that limited ADL also

occurred in other types of chronic wounds, such as

venous ulcers (Szewczyk et al., 2005). A study by

Minosso et al. (2010) showed that 55% of patients

with venous ulcers had a limited ability to perform

ADL.

In this study, we showed that depression was the

most prominent factor leading to limited abilities. The

results of our study were in line with the findings of a

previous study in which was revealed that comorbid

psychiatric issues, such as depression, can affect the

ability to perform ADL (Mendes de Leon & Rajan,

2014). Another study reported that there was a strong

association between depression and limited mobility,

transferring, and dressing (Mendes de Leon & Rajan,

2014). A study by Piccinni et al. (2012) found that

participants with moderate or severe depression had a

worse score on ADL measures when compared to

participants with mild/low levels of depression.

Depression not only caused limited ADL, but can also

lead to worse ADL. Depression can worsen ADL

after help was provided to care recipients, and

patients felt more helpless over their condition

(Piccinni et al., 2012).

Our study demonstrated that age was one

predictor for ADL in patients with diabetic ulcers.

The results of our study were in line with the data

presented in previous studies that showed that elderly

persons aged 60 years and above were dependent in

at least one ADL component using the BI (Gupta,

Yadav, & Malhotra, 2016). Many studies have shown

that the more advanced the age, the higher the

percentage of persons with functional disabilities

(Hu, Hu, Hsu, Hsieh, & Li, 2012). Based on this

study, the elderly population with diabetic foot ulcers

should become the priority of nurses in the prevention

of functional disabilities.

Since depression and age are predictive factors of

ADL in patients with diabetic ulcers, nurses should

intervene so that patients with diabetic foot ulcers can

recover their ability to gain functional independence.

Health education to patients and practice of range of

motion can help patients with diabetic ulcers to regain

independence in certain aspects of daily activities.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

560

Patients also need to be taught how to utilize assistive

devices to help with their movements.

There were several limitations to this study. First,

this study was conducted in a small sample size and

the analyses may have yielded significant findings if

the study involved additional areas in the sampling

frame. Therefore, future studies that involve a large

sample size are needed. Second, the design of this

study was a cross sectional study, which may have

resulted in the inappropriateness of drawing a causal

relationship between variables and ADL. Therefore,

future studies should use a cohort design so that

drawing a conclusion of causal relationship could be

made. However, this study also had significant

strengths that are worth noting. For example, the

originality of this study is high as this is the first study

to assess the associated factors related with ADL in

patients with diabetic ulcers. The data of our study

provided critical evidence to the nurses in hospitals

regarding the urgency to assess the ADL in patients

with diabetic ulcers so that nurses could identify high

risk patients. Therefore early intervention could be

conducted to patients.

5 CONCLUSIONS

This is the first study to investigate associated factors

of ADL in patients with diabetic ulcers. We

demonstrated that depression and age were predictors

of ADL. Based on this study, nurses should identify

high-risk patients of disability and conduct preventive

interventions according to related factors.

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