ISSN: 2469-5858

Saeed et al. J Geriatr Med Gerontol 2022, 7:127

DOI: 10.23937/2469-5858/1510127
Volume 7 | Issue 5
Journal of Open Access

Geriatric Medicine and Gerontology

Case Series

Diabetic Foot and Geriatric Depression: A Report of Two

Cases
Alan Saeed1, Mohamed Adil Shah Khoodoruth2*, Zerak Al-Salihy2 and Widaad Nuzhah Chut-kai
Khoodoruth3
1
Family Medicine Consultant, Primary Health Care Corporation, Qatar
2
Department of Psychiatry, Hamad Medical Corporation, Qatar
Check for
3
Physician Assistant, Hamad Medical Corporation, Qatar updates

*Corresponding author: Dr. Mohamed Adil Shah Khoodoruth, Department of Psychiatry, Hamad Medical Corporation,
Qatar

Abstract more than 7 mmol/l), which leads over time to serious

damage to the heart, blood vessels, eyes, kidneys and
Background: Research suggests that comorbid diabetes
nerves [1]. Diabetic foot ulcer (DFU) is one of its major
and depression is common. Diabetic foot ulcers and lower
extremity amputation are unfortunately severe complications complications that needs a multidisciplinary approach
of diabetes which can have a serious negative impact on [2]. Diabetic patients have psychiatric symptoms
the quality of life in diabetics. Elderly may even have more such as depression more frequently than the general
significant impairment on their daily life because of chronic population [3]. A Pubmed search for “diabetic foot AND
pain and immobility. A literature search on diabetic foot and
geriatric depression showed that limited studies and case (mental health OR mental illness OR psychiatry)” on 25th
reports have addressed this issue. October 2021 identified 248 items items addressing this
Case report: We report two cases of comorbid diabetic
issue, including 22 case reports/series. Out of these,
foot ulcers and depression in elderly patients to highlight only one report highlighted the case of a 57-years-old
the clinical impact of their quality of life. The first case is white male with chronic diabetic foot and depression
a 67-years-old gentleman known case of diabetes mellitus who committed suicide with an intentional insulin
type 2 and comorbid anxiety and depressive illnesses. We overdose [4].
showed how his mental illness has impacted on his ability to
be adherent to diabetic care. The second case is a 77-years- Depressive symptoms have been found more
old gentleman who developed severe depression secondary prevalent among diabetic foot patients as compared
to diabetic complications.
to non-diabetic patients [5]. It was found that insulin
Conclusion: We advise a multidisciplinary approach, receptors were distributed throughout the brain,
involving the general practitioner, psychiatrist, and
psychologist, in the management of diabetic patients with
including classical regions with regard to mood
foot ulcers in order to optimize wound healing and patients’ regulation [6]. Lyra, et al. [6] also emphasized a possible
quality of life. role of decreased brain insulin signaling due to metabolic
Keywords disorders in the related mechanisms of depressive
symptoms [6]. During follow-up, Pedras, et al. [7] found
Depression, Diabetes complications, Geriatric psychiatry
that depression may make foot ulcers larger and more
severe [7]. Foot problems are significantly associated
Introduction with mental health symptoms in diabetic patients and
Diabetes mellitus (DM) is a chronic, metabolic disease caregivers [8]. This may affect treatment in the foot
characterized by elevated levels of blood sugar (fasting clinic, outcome, and quality of life.

Citation: Saeed A, Khoodoruth MAS, Al-Salihy Z, Khoodoruth WNC (2022) Diabetic Foot and
Geriatric Depression: A Report of Two Cases. J Geriatr Med Gerontol 7:127. doi.org/10.23937/2469-
5858/1510127
Accepted: March 14, 2022: Published: March 16, 2022
Copyright: © 2022 Saeed A, et al. This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited.

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DOI: 10.23937/2469-5858/1510127 ISSN: 2469-5858

Case 1 Case 2
The patient is a 67-years-old gentleman with a past The patient is a 77-years-old gentleman with a past
medical history of Diabetes Mellitus Type II for the past medical history of Diabetes Mellitus for more than
15 years. He is on oral hypoglycemic drug -Metformin 20 years, in addition to ischemic heart disease, heart
1000 mg - Sitagliptin 50 mg XL twice daily and Gliclazide failure and dyslipidemia. His daily medications consist
120 mg XL daily. However, he has a poor compliance to of vildagliptin 50 mg- Metformin 500 mg twice daily,
his medications as demonstrated from his medication dapagliflozin 10 mg, insulin glargine 55 Units nocte, aspirin
refill history which shows that he did not resupply 100 mg, carvedilol 6.25 mg twice daily, rosuvastatin 10
his drugs for the past 6 months. He is also a known mg nocte, and pantoprazole 40 mg. He lives with his
case of anxiety and depression for which he is taking family and is neither a non-smoker nor drinks alcohol.
Escitalopram 10 mg and Risperidone 2 mg once daily. In March 2020, he presented with persistent right
Nonetheless he has a poor compliance to his psychiatric foot infected wounds, mixed arterial and neuropathic
appointments and poor adherence to his medications. defects with clear signs of self-neglect and poor hygiene
He lives with his family and smokes two packs per and interdigital toe fungal infection. Following which he
day but does not drink alcohol or use recreational was treated with two courses of antibiotics and daily
products. He did not attend his three-month routine wound care until some gangrenous signs evolved as
appointments at the diabetic clinic, nor performed his a result of poorly controlled diabetes and peripheral
regular blood investigations (HbA1c, renal and liver vascular disease. Consequently, he was referred to
function tests). Table 1 shows the patient’s pertinent hospital where he had surgical debridement three
times with nerve block anesthesia and intravenous
laboratory findings. The patient has no record of
antibiotic. However, the treatment had limited help as
neither diabetes retinal screening nor regular foot care
he had to undergo the right foot second toe amputation
treatment March 2021 attended the health center for
under general anesthesia on 31st March 2020. Following
diabetic foot wound dressing care and review. Upon
the surgery, he presented to the health center with
examination both feet had signs of advanced diabetic
penetrating wound and the treating doctor suspected
foot complications such as no arterial perfusion, absent
it to be associated with osteomyelitis. He was then
dorsalis pedis and loss of vibration and touch sensation
referred to the hospital but the patient signed discharge
(Figure 1). against medical advice.

Table 1: Shows pertinent laboratory findings of Case 1.

Parameters March 2018 June 2021 Normal values

HbA1C (%) 8.6 10.7 4%-5.6
Urea (mmol/L) 7.6 9 2.1-8.5
Creatinine (micromol/L) 133 145 65.4-119.3
Microalbumin/Cr ratio (mg/mmol) 3.4 4.6 0-2.5

Figure 1: Shows gangrenous third toe with auto-amputation and combined diabetic neuropathic and ischemic ulcer.

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DOI: 10.23937/2469-5858/1510127 ISSN: 2469-5858

Before March 2021, the patient was independent in to be less common in older cohorts (specifically lower
his care except for food preparation and laundry. After in populations > 60 years) [10]. In a population of
March 2021, he had a complicated foot ulcer along with patients with diabetic ulcers, Udovichenko, et al. [11]
prolonged infection which resulted in the amputation found 39% of patients with depression, more often
of his right second toe (Figure 2). This rendered him in females [11]. Similar to venous wounds, Iversen, et
more dependent on his family for his daily care. Table al. [12] showed for diabetic wounds that the risk of
2 shows his laboratory results which indicate a gradual developing a diabetic foot ulcer was almost 2-fold for
deterioration of his glycemic control and renal function. patients reporting a HADS score of 8-10, and 3-fold for
On the patient’s latest consultation, he presented HADS scores of ≥ 11, compared with HADS scores of <
with clear signs of depression and behavioral changes 8, after adjusting for age, gender, and serum glucose
in terms of being abusive to the nursing staff and losing at baseline. Symptoms of depression at baseline were
his temper easily. Upon assessment of his mental associated with an increased risk of developing diabetic
health score for depression along with the collateral foot ulcer in a dose-response manner during this 11-
history from his son and other members of the family, year follow-up [12].
he scored 27 on PHQ-9, indicating severe depression. Based on our literature review, it is likely that
He was urgently referred to the psychiatrist for further establishing a bidirectional relationship between
management as his mental health was affecting his depression and diabetes is not as straight-forwards as
basic self-care and compliance to his medications along establishing a unidirectional one, where the evidence
with adherence to his appointments in the hospital. consistently suggests that diabetics are twice as likely
Discussion as to be depressed compared to non-diabetics [13-15].
It has been theorized that diabetes precedes depression
Depressive disorders and diabetes are interrelated, and leads to depression whether through a direct effect
widely prevalent across the world and contribute of hyperglycemia, possibly leading to altered glucose
to the major disease burden globally [9]. We have transport, or as a result of the psychological stress
demonstrated in the above two case vignettes that resulting from the knowledge of the diagnosis or from the
elderly patients with Type II Diabetes Mellitus suffering rigors of the pharmacological and non-pharmacological
from foot complications are more prone to develop treatment [16-18]. Nonetheless, recent cohort studies
depression. A systemic review by Roy, et al. [10] has have suggested that depression may be a risk factor for
shown that the prevalence of depression is higher diabetes [14,17,19].
in people with diabetes. In fact, the prevalence of
depression is increased in female gender and younger When depression is diagnosed in a diabetic patient,
and/or older age. However, depression has been found the common sense would be to treat both diseases

Figure 2: Shows amputation of right second toe secondary to complicated foot ulcer along with prolonged infection.

Table 2: Shows pertinent laboratory findings of Case 2.

Parameters March 2021 July 2021 Normal values

HbA1C (%) 8.4 9.6 4%-5.6
Urea (mmol/L) 6.2 9.3 2.1-8.5
Creatinine 125 131 65.4-119.3
(micromol/L)
Microalbuminurea 3.2 6.4 0-2.5
(mg/mmol)

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at the same time. Petrak, et al. [20] recommended of anxiety/depression and adherence to self-care. Int J Low
treating depression as a priority, as the response Extrem Wounds 19: 165-179.
to medication is usually seen within 2-4 weeks for 3. Ahmad A, Abujbara M, Jaddou H, Younes NA, Ajlouni K
antidepressants, while the improvement in the glycemic (2018) Anxiety and depression among adult patients with
diabetic foot: Prevalence and associated factors. J Clin
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to settle [20].  When compared to standard cognitive
4. Walsh SM, Sage RA (2002) Depression and chronic
behaviour therapy (CBT) and diabetes-specific CBT
diabetic foot disability: A case report of suicide. Clin Podiatr
(additional training in working with T2DM patients for Med Surg 19: 493-508.
general practitioner and clinical health psychologist),
5. Rotella F, Mannucci E (2013) Diabetes mellitus as a risk
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the management of depression in diabetes [21]. We Fronti Psychiatry 10: 57.
thus advise a multidisciplinary approach, involving the 7. Pedras S, Carvalho R, Pereira MG (2018) A predictive
general practitioner, psychiatrist, and psychologist, in model of anxiety and depression symptoms after a lower
the management of diabetic patients with foot ulcers in limb amputation. Disabil Health J 11: 79-85.
order to optimize wound healing and patients’ quality 8. Hoban C, Sareen J, Henriksen CA, Kuzyk L, Embil JM, et al.
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Conclusion 9. Mukherjee N, Chaturvedi SK (2019) Depressive symptoms
We advise a multidisciplinary approach, involving and disorders in type 2 diabetes mellitus. Curr Opin
Psychiatry 32: 416-421.
the general practitioner, psychiatrist, and psychologist,
in the management of diabetic patients with foot 10. Roy T, Lloyd CE (2012) Epidemiology of depression and
diabetes: A systematic review. J Affect Disord 142: S8-S21.
ulcers in order to optimize wound healing and patients’
quality of life. We also recommend further cohort and 11. Udovichenko O, Maximova NV, Amosova MV, Yunilaynen
OA, Berseneva EA, et al. (2017) Prevalence and prognostic
clinic studies on depressive symptomatology and their
value of depression and anxiety in patients with diabetic
management among our elderly diabetic population foot ulcers and possibilities of their treatment. Curr Diabetes
with major depression. Rev 13: 97-106.

Acknowledgements 12. Iversen MM, Tell GS, Espehaug B, Midthjell K, Graue M, et

al. (2015) Is depression a risk factor for diabetic foot ulcers?
The authors would like to thank the patients for 11-years follow-up of the Nord-Trøndelag Health Study
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13. Mezuk B, Eaton WW, Albrecht S, Golden SH (2008)
Declaration of Conflicting Interests Depression and type 2 diabetes over the lifespan: A meta-
The authors declared no potential conflicts of analysis. Diabetes Care 31: 2383-2390.
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between depressive symptoms and diabetes. JAMA 299:
Ethical Approval 2751-2759.
15. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K, et al.
Ethical approval to report this case was obtained
(2006) The prevalence of co-morbid depression in adults
from the Medical Research Center of Hamad Medical with Type 2 diabetes: A systematic review and meta-
Corporation (MRC-04-21-828). analysis. Diabetic Med 23: 1165-1173.

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relationship of depression and diabetes: A systematic
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