aging changes that increase the risk of wounds and

Aging Changes that Increase the Risk of Wounds and Decrease

Wound Healing

Joan Chang, DO Center for Healthy Aging

BACKGROUND/BIO

Medical school- Philadelphia College of Osteopathic Medicine Internal medicine residency @ Good Samaritan Hospital in Baltimore, Maryland Geriatric fellowship @ Johns Hopkins School of Medicine Board certified in Geriatric Medicine, and Hospice and Palliative Care

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DISCLOSURE

• None

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Goals

1. Understand changes in aging skin 2. Understand comorbidities that can lead to

chronic wound 3. Recognize palliative wound

CASE

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Mrs. H is an 81 year old female admitted to your nursing home with contractures, tube feeding, and multiple PrU of the buttocks and lower extremities. She had history of dementia x 8 years and has been hospitalized multiple times for medical issues that included UTI, pneumonia, GT replacement, and anemia with gastrointestinal bleed. She’s had a PEG tube now for 1.5 years. This is her third nursing home admission. The daughter who is HCP insists that everything be done to keep her alive. They take detailed notes of all conversations and care rendered, and frequently document their mother’s wounds with their cell phone camera.

Changes in Aging Skin 3

Adapted from Nagwa et al Ind J Derm 2012: 57 (3); 181-186

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• Thinning of the epidermis

• Flattening of the dermal-epidermal junction

• Disorganization of collagen and elastin

19 year old skin 74 year old skin

Changes in Aging Skin

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Changes in Aging Skin

Intrinsic vs Extrinsic factors

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Intrinsic Changes in Aging Skin • Increased Reactive 02 Species (ROS), decreased antioxidative

capacity • Increased matrix metalloproteases (MMPs) • Decreased Langerhans Cells, aberrant function of T, B Cells

[immunosenescence] • Flattening of the dermal-epidermal junction (rete • ridges) • Dermis: reduced fibroblasts, macrophages and mast cells • Reduced vascularity and elastin • Loss of Extracellular Matrix (ECM) components: collagen and

glycosaminoglycans 9

Levine,J et al. Wound healing in the geriatric population. Today’s Wound Clinic. Nov/Dec 2013. 14-18.

Intrinsic Changes in Aging Skin

• Diminished sensation to light touch and pressure (Meissner & Pacini corpuscles)

• Reduced sebum secretion • Decreased ability to produce Vitamin D3 • Decreased pilosebacious units, sweat glands and

subcutaneous fat • Advanced glycation end products (AGE’s) and

increased fibroblast death (apoptosis)

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Levine,J. “Pressure Ulcers and Wound Care” Geriatrics Review Syllabus. Ed. Samuel C. Durso, Ed.Gail M Sullivan. American Geriatrics Society, 2016 (9th edition),

Extrinsic Changes in Aging Skin

• Environmental insults through oxidative stress • Generation of free radicals and reactive

oxygen species (ROS) • ROS stimulates the lipid peroxidation reaction

cascade and the release of pro-inflammatory mediators

• Most important: UV radiation, Cigarette Smoke, Ozone(03), Airborne particulate matter

• Photo aging

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Levine,J et al. Wound healing in the geriatric population. Today’s Wound Clinic. Nov/Dec 2013. 14-18.

Extrinsic Changes in Aging Skin

• Cigarette Smoke (CS) has over 4,000 chemicals including pro-oxidants, free radicals, and nitric oxide

• Directly induces oxidative stress and other adverse chemical reactions

• Ozone (03) is a gaseous oxidant that also directly induces oxidative stress, decreases antioxidants such as Vitamin C, E, and Glutathione (GSH)

• Polycyclic aromatic hydrocarbons (PAHs) adsorbed to airborne particulate matter (PM) may activate xenobiotic metabolism and induce ROS and MMPs

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Co-Morbidities that Impact Skin

• Altered nutritional status • Altered hormone levels (Estrogen, Testosterone,

GH) • Anemia • Atherosclerosis, decreased perfusion • Venous insufficiency • Diabetes with microvascular and neurologic

changes • Any source of edema: CHF, Venous stasis, and

hypoalbuminemia

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Co-Morbidities that Impact Skin • Any source of hypoxia: COPD, OSA, etc. • Low output state: CHF, shock • Incontinence with Moisture Associated Skin

Damage(MASD) • Colonization of skin with fungus and pathogenic,

multiple resistant bacteria • Pharmacologic compromise: corticosteroids,

immunomodulators • Obesity, lymphedema

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Cumulative Results of Co-morbidities and Age

• Xerosis (dry skin), pruritis • Decreased reserve: Homeostenosis, affects

thermoregulation and H20 balance • More susceptible to injury including shear

forces, ischemia, pressure related trauma, maceration

• More susceptible to infection • Prolonged wound healing

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Gould, Lisa, et al. Chronic Wound Repair and healing in Older Adults: Current Status and Future research. J Am Geriatr Soc 63:427–438, 2015.

Management of Wound in Older Adults

• Clinical assessment of “at risk” status • Offloading: repositioning and surfaces • Maintain awareness of devices, lines • HOB elevation: consideration of priorities (i.e.

ventilators and TFs require >30 degrees but PU prevention requires <30 degrees

• Document your wounds and interventions! • Consider palliative care principles

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Pressure Ulcer before Death in Advanced Dementia

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Mitchell et al. The clinical course of advanced dementia. New England Journal of Medicine 361: p 1529-1538; 2009

How Dementia Impacts Wound Care • Incontinence with chronic MASD and fecal contamination • Severe immobility: • Need for advanced support surfaces • Difficulty with transportation, need for skilled home nursing

• Nutritional Risk: • Dysphagia, depression, inability to feed self • Tube feeding

• Infectious aspects of institutional environments: • C Diff, Multi-resistant organisms • Isolation procedures

• Perception and expression of pain • Ethical aspects of care: • Informed consent for procedures • Health Care Proxy, AD’s

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Mengell, C. Improving practice in wound care for patients with dementia.. Nurs Times. 2004 Sep 21-27;100(38):29

Skin and Dying Process

• Skin changes at EOL • Reduce tissue perfusion • Decrease tolerance to external insult • Impaired removal of metabolic waste

• Communication among members of team and

patient’s circle of care • Expectation of EOL goals • Discussion of SCALE

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Sibald et al. SCALE: Skin Changes at Life’s End Final Consensus Statement: Oct 2009. Advances in Skin & Wound Care: May 2010 - Volume 23 - Issue 5 - p 225-236

Recognizing Palliative Wound

• When there is little/no realistic chance of healing

• Wound is unresponsive to therapy • The process of achieving healing is

inconsistent with overall goals of care • The dying process

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The Palliative Approach to Wound Care

• Identify the goals of care: cure vs comfort • Consider AD’s, values, and ethical issues • Educate the patient and family • Emotional support and promote comfort • Prevent further skin deterioration and infection • Optimize pain management and other symptoms • Engage the entire care team, including physician and family • Reconsider futile, heroic, measures: Repeated hospital

transfers/ Sharp debridements/ Operative procedures/ Skin grafts

• Burdens vs benefits of procedures

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Palliative Care of Wounds: “SPECIAL”

• S=Stabilize the wound • P=Prevent new wounds • E=Eliminate odor • C=Control pain • I=Infection prophylaxis • A=Absorbent wound dressings • L=Lessen or reduce dressing changes

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Alvarez, OM et al, Incorporating wound healing strategies to improve palliation, J Palliat Med. 2007 Oct;10(5):1161-89

Challenges of Palliative Wound Care

• Association of palliative wound care with “giving up”

• Family reluctance • Physician reluctance • Lack of information about the severity and/or

irreversibility of illness • Cultural/political attitudes toward death, terminal

care, and pressure injuries (commonly viewed as a failure of the caregivers)

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Summary

• With increase in life expectancy and more people living with chronic illness we’re caring for a frail population with increase risk of developing wounds

• Interdisciplinary approach to wound care • Recognition of palliative wound has the

potential to curtail suffering and decrease healthcare costs.

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Reference

1. Alvarez, OM et al. Incorporating wound healing strategies to improve palliation in patients with chronic wounds. J Palliat Med. 2007 Oct;10(5):1161-89

2. Gould, L, et al. Chronic Wound Repair and healing in Older Adults: Current Status and Future research. J Am Geriatric Soc. 2015 Mar;63(3):427–438.

3. Levine, J, et al. Wound healing in the geriatric population. Today’s Wound Clinic. Nov/Dec 2013. 14-18.

4. Levine, J. “Pressure Ulcers and Wound Care” Geriatrics Review Syllabus. Ed. Samuel C. Durso, Ed.Gail M Sullivan. American Geriatrics Society, 2016 (9th edition)

5. Mengell, C. Improving practice in wound care for patients with dementia.. Nurs Times. 2004 Sep 21-27;100(38):29.

6. Mitchell, S, et al. The clinical course of advanced dementia. New England Journal of Medicine 2009; 361: p 1529-1538.

7. Nagwa, et al Ind J Derm 2012: 57 (3); 181-186 8. Sibbald et al. SCALE: Skin Changes at Life’s End Final Consensus Statement: Oct

2009. Advances in Skin & Wound Care. 2010 May;23(5):225-36

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aging changes that increase the risk of wounds and

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