Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study

This was an observational cross-sectional study. The authors followed the STROBE guidelines for the reporting of observational studies [21].

The difference between foot length and internal shoe-length was calculated in mm. The proportion (with 95% confidence intervals) of participants whose foot to shoe length difference was outside the 10 to 15 mm range was calculated. Those with shoes fitting on at least one foot were compared to those with ill-fitting footwear on both feet using the Chi-square test for categorical variables and the T-test or Mann–Whitney U test for continuous variables depending on normal quantile plots. Statistical analyses were carried out using SPSS® Statistics Version 16.

A total of 133 participants were screened, 2 declined to participate and 111 participants were assessed. There were 44 males and 67 females assessed with a mean age of 81.6 years (range 63–99, SD = 7.5). The mean NEADL score was 12.7 (SD = 4.6). The median TUG score, available for 92 participants (83%), was 20 s (IQR = 16–25.7). A walking aid was used by 80% (n = 89) of participants, 43% (n = 48) reported living alone. Over two-thirds (67% (n = 74)) reported wearing slippers at home. Close to half of participants (51% (n = 57)) reported having fallen in the last 6 months. A large proportion (87% (n = 96)) were taking five or more medications.

Table 1 describes the characteristics of shoes worn by the participants. The median UK shoe size for males was a size 9 and for females it was a size 6. On the day of assessment the majority, 59% of men (n = 44) and 46% women (n = 67), wore a walking style shoe. Table 1 shows the distribution of other shoe types by gender.

Two-thirds of participants (67%, n = 74) reported that they wore slippers at home (for comfort and ease of putting on/taking off). According to the Footwear Assessment Form (FAF) no participants’ shoes had 5 or more unsafe features, however, there were several features associated with unsafe shoes noted: 26% (n = 29) had shoes with no fixation, 63% (n = 70) had shoes with a heel counter stiffness > 45°, 81% had shoes with a longitudinal sole rigidity > 45° and 90% (n = 100) of participants had smooth, partly worn or fully worn sole treading on their shoes. A third of participants (34%), had a difference between their self reported shoe size and the actual size of shoes they were wearing.

The mean difference between shoe length and foot length was 18.6 mm (SD: 9.6 mm). Figure 2 shows the distribution of the average difference and Table 1 shows this difference broken down by gender and side of foot. Only 6% of participants (n = 7) (95% CI 2–11%) were defined as having shoes correctly fitting on both feet, i.e. 10-15 mm difference between shoe length and foot length. Correctly fitting shoes on at least one foot was identified in 28% (n = 31) of participants (95% CI 20–36%). Table 2 compares participants who were wearing correctly fitting shoes on at least one foot and ill-fitting shoes. Differences in demographics, functional mobility, functional independence and falls history between the two groups were small and none reached statistical significance. In total, 56% (n = 45) of those with ill-fitting footwear fell in the last six months compared to 39% (n = 12) of those with one shoe within recommend range (p = 0.09).

To the knowledge of the authors, this is the largest study to date to estimate the proportion of older adults attending a geriatric day hospital who were wearing inappropriate shoes. Most participants were wearing footwear that could be described as inappropriate as it was either ill-fitting or had unsafe features. We found a high number of older people to be wearing footwear larger than recommended on both feet. This is consistent with previous studies in older populations [30‐33]. This may put these individuals at risk of trip-related falls [14]. Furthermore, the majority of participants were wearing footwear with several unsafe features including shoes with a heel counter stiffness greater than 45°, shoes with a longitudinal sole rigidity greater than 45° and shoes that had smooth, partly worn or fully worn sole tread pattern. As expected, this sample of participants represents a group with functional limitations, as 80% use walking aids and 87% take at least five or more medications daily. The mean NEADL score of 12.7 showed relatively low levels of independence in instrumental ADLs compared to older adults living in the community [34]. Furthermore, the median time of 20 s to complete the TUG has previously been found to be associated with a high level of frailty in older community-dwelling adults in Ireland [35]. The very high rate of ill-fitting footwear identified in this population is striking both because they are a group that would be considered at high risk of falls and other adverse events, and also because they are a group that has contact with healthcare professionals and should be in receipt of advice from doctors, physiotherapists and occupational therapists. While 56% of those with ill-fitting footwear fell in the last six months compared to 39% of those with one shoe within recommend range, this was not found to be significantly different with the current sample size. As a smaller number than expected wore correctly fitting shoes based on our definition (n = 30), the study was likely underpowered to detect a difference in actual fall events.

Previous footwear studies have identified the difficulty in convincing older adults to purchase appropriate footwear through educational interventions [36]. However, advice and education from health professionals as a behavioural change intervention has been shown to be effective in other healthcare issues such as smoking cessation [37]. Further research into current footwear education interventions being provided to older adults within and outside geriatric services is warranted. The footwear patterns and level of awareness of footwear are unknown among the broader population of community-dwelling older adults in Ireland who do not attend geriatric services. To the knowledge of the authors there are no recent studies investigating footwear patterns and level of awareness of footwear among this population and this is an area for further research.

Previous literature has suggested that podiatry and footwear interventions may prevent falls [38, 39]. The finding in our study that the majority of older adults attending geriatric services wore ill-fitting footwear suggests that podiatric assessment may be warranted in this setting.

The large number of participants who reported wearing slippers at home was an important finding as slippers may be a risk for falls in an older population [11, 12, 14]. The main reasons for selection of footwear for indoor use by older adults have been identified as comfort and low cost, and indoor footwear is also rarely replaced [36]. This method for choosing footwear appears to be consistent with the findings in this study and may contribute to risks of falling for older adults at home. Advice regarding safe and appropriate footwear may be a useful intervention to address this risk and an area for further research.

To the knowledge of the authors, this is the first study to estimate the proportion of older adults attending a geriatric day hospital who were wearing inappropriate shoes. This is a descriptive cross-sectional study of footwear worn by a consecutive convenience sample of older adults who are community-dwelling but who have been referred to a geriatric day hospital for social, rehabilitative and medical assessment and treatment. It provides a detailed description of common potentially problematic footwear characteristics in this group. It may not be generalisable to all community-dwelling older adults but may be relevant in clinical assessment and treatment settings. Furthermore, the sample size of 111 participants is relatively small, leading to a wide 95% confidence interval around the estimate proportion wearing ill-fitting footwear. We did not measure the width of participant’s shoes or feet during this study and thus we are unable to determine whether participants were wearing shoes that were too narrow or too wide for their feet. Not measuring the width of the feet of the participants is a major limitation of this study, particularly considering that the feet tend to become wider and flatter with the ageing process [40]. We were unable to assess the shoes or slippers worn at home by the participants, as we only assessed the shoes that were worn into the day hospital on the day of assessment. In addition, it was not identified if the shoes that were examined in the study were worn when these participants had falls. The use of self-report measures is also a limitation.

Older adults in Ireland who are aged over 65 years make up just over 12% of the population and this number is expected to increase in coming years [41]. The wearing of incorrectly fitting shoes is also strongly associated with pathology of the forefoot and with foot pain [31, 33]. The assessment of such conditions was outside the scope of this study but is an area that should be explored in future research. There is a need for a routine uncomplicated assessment of footwear for older adults, which could help to prevent foot disorders and possibly reduce the risk of falls.