Management of Integumentary Conditions in Older Adults

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21 Management of Integumentary Conditions in Older Adults Alan Chong W. Lee “All the carnall beauty of my wife is but skin-deep.” Sir Thomas Overbury, “A Wife” (1613)

OUTLINE Introduction Aging-Related Changes in the Skin Physical Skin Assessment Malnutrition Dehydration Assessment and Prevention Skin Cancer

Common Skin Conditions Candida Cellulitis Herpes Zoster Scabies Common Wound Conditions Pressure Injury/Ulcer Diabetic Neuropathic Ulcers

INTRODUCTION Sir Thomas Overbury eloquently stated that physical beauty is superficial and is not important as one of a person’s essential qualities in a poem titled “A Wife.” A person’s essential beauty is influenced by many physical, environmental, and psychosocial factors in life. For example, sun tanning without proper skin protection throughout one’s life may lead to permanent damage to the exposed skin and greater risk for skin cancer. Immobility, lack of proper nutrition, and depression in compromised older adults increase risks for pressure-related wound injury. Hence, integumentary and wound management in older adults must address physical, environmental, and psychosocial factors to impact overall quality of life (QOL) in older adults. Therefore, physical therapists must become well suited to identify impairments, activity limitations, and community participation restrictions related to integumentary and wound injury in older adults. Aging by itself is not a risk factor for impaired integumentary and wound injury. However, older adults may be at risk for integumentary impairments and delayed wound healing owing to slower cellular responses, thinner skin, and harmful habits such as smoking and sedentary lifestyle. Additionally, comorbid conditions more common in older adults are also commonly associated with

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Arterial and Venous Insufficiency Ulcers Atypical Inflammatory Wounds Burns Quality of Life and Future Directions References

integumentary and wound impairments (e.g., congestive heart failure, diabetes, vascular disease). These comorbid conditions put older adults at higher risk for integumentary and wound impairments. With diligent preventive care and collaborative practice within geriatric and wound care disciplines, most older adults with conditions that put them “at risk” for integumentary and wound injury can enjoy intact and healthy skin into oldest age. This chapter begins with a discussion of normal age-related changes in skin and selected skin conditions prevalent in older adults. The chapter continues with a discussion of physical examination related to malnutrition and dehydration impacting the integumentary system. Dermatologic skin cancer screening of older adults will be covered, followed by a discussion of the role of the physical therapist as a member of the health care team. Common categories of integumentary wounds in older adults are presented, each with a distinct etiology and management approach: pressure ulcers, diabetic/neuropathic ulcers, arterial and venous ulcers, atypical inflammatory wounds, and burns. The chapter concludes with recent recommendations from aging and wound healing practitioners addressing QOL in older adults with integumentary and common wound conditions.

Copyright © 2020, Elsevier Inc.

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AGING-RELATED CHANGES IN THE SKIN As with other organs in the body, the skin undergoes changes with aging. However, these changes do not typically cross the threshold of impairment. Integumentaryrelated impairments most typically occur when extrinsic stresses combined with the presence of comorbid health conditions are added to aging. For example, stress to the skin due to immobility and incontinence increases risks for pressure injury. The skin is composed of two main layers, the epidermis and the dermis, with a basement membrane separating the two layers, totaling 16% of body weight (Fig. 21.1). The epidermis is the thin outermost layer of the skin composed of five sublayers. From deep to superficial, the five sublayers of the epidermis are the stratum germinativum, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The main functions of the skin are thermoregulation, sensation, moisture elimination, vitamin D synthesis, and protection of deeper structures. The epidermis regenerates every 4 to 6 weeks and does not have a blood supply. With normal aging, the epidermis thins and decreases in density of Langerhans cells. Langerhans cells initiate the immune response when foreign cells are present. Consequently, with decreased thickness and immune function, the epidermis becomes less effective at protecting the body from infection and dehydration.1,2 The basement membrane is the interface between the epidermis and dermis. The basement membrane is composed of many projections of the dermis into the epidermis. These projections are known as rete pegs and they provide resistance to shearing forces between the epidermis and dermis. The basement membrane also thins with age because of a flattening of the rete pegs, and this increases vulnerability to shear-related insults to the skin.2–4

Stratum corneum Basement membrane with rete pegs Sweat duct Capillary Sebaceous gland Nerve endings Hair follicle Hair bulb Sweat gland Fat Blood vessels

EPIDERMIS

Papillary dermis DERMIS Reticular dermis

SUBCUTANEOUS TISSUE

FIG. 21.1 Layers of the skin and its underlying tissue. (From Goodman CC. Pathology: Implications for the Physical Therapist. 3rd ed. Philadelphia: Saunders; 2008.)

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The dermis is the thick, deeper layer of the skin responsible for structural integrity of the integument. The dermis provides nutrition, hydration, and oxygen to the epidermis via diffusion. The dermis is primarily composed of the protein collagen, which provides tensile strength, and elastin, which allows the skin to stretch. Collagen and elastin are produced by fibroblasts. As fibroblasts decrease with age, so too does the rate of production of collagen and elastin. Elastin fibers become degraded while collagen bundles become disorganized.2,3,5 The dermis also thins as a normal consequence of aging with fewer blood vessels and nerve endings. As the blood vessels in the skin become thinner, they are more prone to hemorrhages known as senile purpura. Senile purpura is often the site of skin tears, possibly owing to a decrease in pain perception in the area of the purpura.1,6 Finally, Pacinian and Meissner corpuscles found in the dermis degenerate with normal aging and contribute to decreased perception of light touch and pressure sensation. Below the dermis is the subcutaneous layer, composed mainly of adipose tissue but also consisting of blood and lymphatic vessels as well as nerves. The subcutaneous layer facilitates regeneration of the dermis by providing blood supply and it also connects the dermis to underlying structures. As with the more superficial layers of the skin, the subcutaneous layer becomes thinner with age and diminishes in its ability to provide mechanical protection and thermal insulation.1,2 Therefore, all functions of the skin are affected by normal aging. Other lifestyle considerations, particularly sun exposure and cigarette smoking, have an aging effect on skin, including the formation of wrinkles, hyperpigmentation, and change in skin texture. The most significant extrinsic cause of skin degeneration is photo aging, that is, the effect of exposure of the skin to ultraviolet irradiation (Fig. 21.2A). This image of a 64-year-old woman demonstrates the impact of sun damage and aging of the skin with ultraviolet photography. Environmental damage to skin from sunlight is known as dermatoheliosis. The effects of photo aging are seen only in areas exposed to the sun, primarily the face, neck, and hands.1,7 Dermatoheliosis may produce tough, leathery texture on the skin owing to cross-hatching to the dermis. Age spots, once called “liver spots,” are flat, brown spots often caused by years in the sun that show up on areas such as the face, hands, arms, back, and feet, whereas skin tags or flesh-colored growths raised over skin may be found on the eyelids, neck, and body folds (armpits, chest, and groin), especially in women.8 Cigarette smoking increases the incidence of skin wrinkling in smokers when compared to similarly aged nonsmokers. Although the exact cause for increased wrinkling is unknown, it is believed to be a consequence of the cigarette smoke’s toxicity on microvasculature as well as a negative effect on oxidative and enzymatic activity in connective tissue in the dermis.1,9 Although the basic wound healing process does not change in older adults, the lower physiological reserve

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FIG. 21.2 A, This 64-year-old beach-community resident’s skin chronicles a lifetime of sun exposure. (Photos provided courtesy of David H. McDaniel, MD). B, Xerosis. (From Ignatavicius DD. Medical-Surgical Nursing: Patient-Centered Collaborative Care. 6th ed. Philadelphia: Saunders; 2009.)

of older adults and the increased prevalence of comorbid conditions associated with delayed wound healing make older adults more susceptible to factors that delay wound healing and increase rates of wound infection.10 Understanding the overlapping cascade of inflammation, proliferation, and remodeling as the foundation of wound care is essential for practitioners in the field of aging and wound repair.3 For example, platelets recruit inflammatory cells to form a wound matrix and macrophages to regulate the cytokine environment, assisting proliferative responses and wound closure. Chronic wounds have resident cells that proliferate less and morphologic cellular senescence, resulting in lack of progress in wound healing. Age-related changes in hormonal status affect wound repair and blunt the healing response.3 Overall, wound healing can be delayed by many factors.11–13 Some of these factors are intrinsic, meaning they emerge from internal physiological abnormalities that impair effective wound healing. Other factors are extrinsic, meaning they arise from external forces deterring normal healing processes. Box 21.1 provides a list of common intrinsic and extrinsic factors associated with delayed wound healing. It is important to modify extrinsic risk factors to progress through wound healing and repair in older adults.

PHYSICAL SKIN ASSESSMENT Malnutrition Older adults are susceptible to a host of intrinsic and extrinsic factors that may lead to malnutrition, leading to an increased risk of developing new wounds and impaired ability to heal existing wounds. For example, changes in the digestive system of older adults include decreased production of digestive enzymes and acids, which leads to decreased absorption of nutrients. Impaired dentition may lead to difficulty with chewing, and dry mouth may lead to difficulty swallowing. Chronic illness or impaired mobility can decrease the ability of

older adults to shop, cook, or eat independently. Impaired mental function can suppress appetite, as can many medications, including antidepressants, blood pressure medications, and even over-the-counter medications such as aspirin. Older adults may also have a decreased sense of taste and smell, both of which can significantly decrease appetite. Other extrinsic risk factors for malnutrition in BOX 21.1

Common Intrinsic and Extrinsic Factors Associated with Impaired Wound Healing

Intrinsic Factors Immobility Malnutrition Impaired hydration Obesity Cachexia Infection or colonization Edema around the wound (inhibits oxygen and nutrient transport) Decreased circulatory function Decreased respiratory function Immunosuppressed state (including use of corticosteroids and NSAIDs) Radiation therapy Chronic diseases such as: Diabetes PAD/PVD CAD Renal failure Anemia Cancer

Extrinsic Factors Tobacco use Pressure that impairs circulation in area Desiccation, leading to dryness Presence of necrotic tissue (eschar or slough) Repetitive trauma causing high shear forces Maceration (typically from incontinence or perspiration) Lack of participation in wound plan of care or inappropriate care

CAD, coronary artery disease; NSAID, nonsteroidal anti-inflammatory drug; PAD, peripheral arterial disease; PVD, peripheral vascular disease.

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older adults include low or fixed income, depression, social isolation, and dietary restrictions necessitated by other comorbidities.14 Older adults may experience a nutritional decline that may delay skin and wound healing. Key nutritional indicators are necessary for optimal wound healing, and malnutrition may impact overall clinical outcomes. Malnutrition is defined as unintentional weight loss >10% or >5% over the last 3 months or body mass index (BMI) <18.5 kg/m2.15 The prevalence of malnutrition in patients at hospital admission is 30% to 55%, and patients may continue to lose weight at discharge, increasing the risk for hospital readmissions.16 A focused physical assessment by the physical therapist using valid screening tools for assessing malnutrition for older adults can lead to early identification of malnutrition. For example, the Malnutrition Universal Screening Tool (MUST) can be used to screen community-dwelling older adults, and the Mini Nutrition Assessment (MNA) is designed for older adults aged 65 and older.17 In the screening process, more than two of these six characteristics may identify malnutrition: declining functional status, fluid accumulation, muscle loss, subcutaneous fat loss, unintentional weight loss, and insufficient energy intake.18 Fat and muscle loss, the most prevalent characteristics for chronic illness-related malnutrition, can be assessed through palpitation of anatomical landmarks to help determine the degree of muscle and/or fat loss.19 Fat loss is commonly identified by assessing and palpating six anatomical and body regions including the temporal bone, zygomatic arch, triceps, biceps, ribcage, and midaxillary line to the lumbar region. For example, severe fat loss between the midaxillary line and the lumbar region may display prominent ribs with depressions and protruding iliac crest. Subcutaneous fat loss in triceps can be examined by flexing the elbow at 90 degrees and pinching the triceps without the muscle between fingers. Severe fat loss will allow the fingers to nearly approximate while pinching mostly skin.20 Overall, fat loss is usually more prominent in the upper body. The skilled practitioner may verify if this fat loss is normal for older adults by quantifying the severity and investigating other characteristics such as muscle loss. Typical muscles for identifying muscle loss include the temporalis, pectoralis major, deltoids, trapezius, latissimus dorsi, supraspinatus, infraspinatus, interosseous, quadriceps, and gastrocnemius. For example, assessing both the dorsal and palmar interosseous muscles and thenar region for prominent depressions while the older adult moves the hand or makes an “OK” sign may identify the severity of muscle loss related to nutritional decline. When indicated, referral to the nutritionist and dietitian for optimal nutritional support for older adults must be communicated to the health care team.

Dehydration Older adults are at greater risk of dehydration than younger people and this can lead to serious health complications including increased time to wound healing. It is

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generally accepted that the increased risk of dehydration among older adults is not a direct consequence of aging but rather the result of age-associated factors such as increased physical dependence, multiple medical comorbidities, and self-limiting hydration habits.21,22 Commonly used assessments of dehydration in older adults may include dry mucous membranes, rapid pulse, furrowed tongue, decreased fluid intake, urine color or volume, and feeling thirsty but should not be used alone because combining several symptoms and tests (expressing fatigue, missing drinks between meals) may improve diagnostic accuracy.23 Furthermore, the commonly accepted test of skin turgor at the sternum is not reliable in older adults because of the previously discussed changes in skin elasticity.21,23,24 Other measures of dehydration are obtained from lab values, including increased concentration of serum sodium, increased serum osmolality, and increased ratio of blood urea nitrogen to creatinine.25 The incidence of xerosis, or dryness of the skin, increases as people age. Xerosis, depicted in Fig. 21.2B, occurs when the moisture level of the stratum corneum is below 10%.1,26 The precise cause of xerosis is not known; however, age-related changes including waterloss dehydration as well as environmental and genetic factors contribute to the severity of this problem. Xerosis can negatively impact the quality of life for older adults by producing pruritus (itching), burning or stinging, and an uncomfortable sensation of tightness in the skin. As xerosis becomes more severe, it can lead to redness or cracking of the skin.1 Older adults should be encouraged to keep hydrated and to use a moisturizing lotion to prevent or manage dry skin and moisturize the skin. Overall, a collaborative approach to proper skin assessment and proper education of older adults on optimizing nutrition and hydration are key factors to healthy skin.

Assessment and Prevention Fragile skin in older adults can be associated with the intrinsic and extrinsic factors in aging-related changes in older adults (see Box 21.1). Older adults describe fragile skin as paper thin skin that can be easily traumatized by falls and lead to skin tears. Approximately one in five falls may result in scrapes, bruises, or blisters. As mentioned earlier, the epidermal proliferative capacity is reduced with aging owing to changes in the basal keratinocyte microenvironment. The flattening of epidermal rete pegs at the epidermis–dermis junction of the skin can contribute to impaired skin integrity in older adults through separation of the epidermis and dermis with shearing, friction, or blunt trauma. In addition, skin structure with increased wrinkling, rough dryness, laxity, and reduced elasticity predispose older adults to skin tears. The etiology of skin tears is multifactorial. For example, cachexia with loss of muscle and fat is common in patients with cancer as well as patients on prolonged anticoagulant

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therapy and may make them susceptible to skin tears. Anticoagulant medications to treat chronic medical conditions can predispose older adults to skin tears and bruising. However, certain unintentional consequences of drugs or polypharmacy can be remedied by educating older adults about the increased risk of injuring fragile skin. Older adults may experience skin tears anywhere on the body, though the most common locations are the arms and hands, followed by the lower extremities.1,27 The risk of skin tears increases with dependence in activities of daily living such as requiring assistance with transfer and with the removal of tapes and adhesives from the skin.1,28 Visual impairment increases the risk of skin tears because of bumping into objects.1,27,29 Preventing skin tears means protecting the skin from trauma. Older adults should be encouraged to apply lotion twice per day and to wear loose, long-sleeved shirts and pants and skid-free footwear. Avoidance of soaps and lotions containing alcohol and excessive washing with soap, which reduces intrinsic skin lubrication, is also important.30,31 The environment can be modified to limit risk of skin tears by eliminating superfluous furniture, providing adequate lighting (including nightlights), and padding edges on furniture, wheelchairs, and bedrails.29,32 Skin tears are commonly underreported in long-term care residents. Hence, practitioners should be educated on classification and types of skin tears (Table 21.1). Although Payne and Martin developed the first classification system, another tool developed in Australia called the Skin Tear Audit Research (STAR) Classification System exists and was reported to be implemented within the United Kingdom.28 Caregivers should be educated in and assessed for proper transfer technique to prevent friction, shear, or trauma. Protective sleeves to secure dressings should be used instead of applying adhesive tape directly to an older patient’s skin.31,32 In T AB L E 2 1 . 1

Category

Payne-Martin Skin Tear Classification System Amount of Tissue Loss

I

Skin tear without tissue loss

II

Partial tissue loss

III

Skin tears with complete tissue loss

Description Linear type (epidermis and dermis layers separated in an incision-like lesion) Flap type (an epidermal flap that covers the dermis, and wound edges are within 1 mm of separation) Scant tissue loss: <25% epidermal flap lost Moderate to large tissue loss: >25% epidermal flap lost Epidermal flap completely gone

(From Baranoski S. Meeting the challenge of skin tears. Adv Skin Wound Care. 2005;18[2]:74–75.)

addition, older adult residents with frequent skin tears or mobility issues should have routine skin inspections. Using a universal system to classify skin tears in health care may assist in developing evidence-based guidelines and practice to improve the quality of life and reduce health care burden from skin tears in older adults.

Skin Cancer Dermatologic skin cancer ABCDE screening33 as well as calculating older adults’ risk of melanoma by using valid tools such as the melanoma risk assessment34 is available for physical therapists. For example, practitioners should educate older adults to assess their skin regularly for skin cancer in sun-exposed areas, including top of head, posterior neck and ears, tip of nose, upper back, shoulders, and exposed extremities. Suspicious skin areas with (A) asymmetry, (B) irregular borders, (C) dark colors, (D) diameter >0.5 mm, and (E) elevated skin should be screened for skin cancer by a dermatologic specialist in a timely manner. Furthermore, information on the benefits, harms, and description of the evidence on skin cancer screening for health professionals (the PDQ)35 can be helpful to discern appropriate care for older adults. General practitioners should be aware of free and secure resources to access dermatology specialist consultation through the Internet known as AccessDerm.36 AccessDerm, with the support of the American Academy of Dermatology (AAD), has provided consultations to underserved patients, which have included diagnoses of a previously undiagnosed melanoma and Kaposi sarcoma. In addition, the AAD provides information on free SPOTme skin cancer screenings in local areas in the United States when users sign up for email alerts on the AAD website.36 Skin cancer is common in older adults and increases with age. The three most common types of skin cancer include basal cell carcinoma, squamous cell carcinoma, and melanoma (Fig. 21.3).33 Although melanoma makes up 4% of skin cancers compared to basal cell (80%) or squamous cell (16%) carcinoma, it is more deadly with rapidly spreading malignancy. Squamous cell carcinoma tends to be scaly, ulcerate, and metastasize, whereas basal

FIG. 21.3 Melanoma. (From Goodman CC. Pathology: Implications for the Physical Therapist. 3rd ed. Philadelphia: Saunders; 2008.)

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cell carcinoma is shiny, translucent, and rarely metastasizes. For example, squamous cell carcinomas are the most commonly encountered cancer arising from venous leg ulcers and basal cell carcinoma is much rarer.37 Risk factors for skin cancer include men and women older than age 65 years, patients with atypical moles, patients with more than 50 moles, family history of skin cancer, and a history of severe sunburns. Physical therapists should educate older adults on common skin cancer prevention strategies including wearing protective clothing (long sleeves, wide-brimmed hat, and sunglasses), avoiding excessive sun rays between 10 a.m. and 2 p.m. or seeking shade, using and reapplying waterresistant sunscreen with an SPF >30, using self-tanning products, avoiding tanning beds, and performing regular skin self-exams. The referral of an older adult to a boardcertified dermatologist if new or suspicious spots on the skin are detected is imperative.38 Other AAD recommendations for antiaging skin tips for older adults include preventing dry skin by avoiding bar soaps and bath oil during bathing, avoiding fragrant skin care products, using a humidifier to reduce dry air, wearing gloves for housework and gardening outdoors, wearing skin protective clothing, and examining skin regularly.39 Therefore, physical therapists can positively influence aging older adults to manage common dermatologic changes and skin integrity conditions. The role of physical therapists is to collaborate with specialists in dermatology and primary care to detect abnormalities in the skin and provide preventive educational strategies with early surveillance of skin risk factors for older adults.

COMMON SKIN CONDITIONS Candida

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appear macerated and erythematous with papules and pustules due to prolonged exposure to moisture damage.1 Standard treatment for candida consists of topical antifungal agents alone or in combination with topical steroids.1 The most common pathogen is Candida albicans, which is involved with moisture-associated skin damage; however, the more serious C. auris infection is emerging as a multi-drug-resistant pathogen isolated from fluid and skin samples.

Cellulitis Cellulitis, illustrated in Fig. 21.5, is a rapidly spreading infection of the dermis and subcutaneous layer most commonly seen in the face and extremities. Typically, cellulitis occurs in older adults in the presence of edema, obesity, and openings in the skin1 but can occur at any site where the skin has been broken: cracks, cuts, blisters, insect bites, burns, injection sites, surgical incisions, or catheter insertion sites. The infection can be caused by the normal flora of the skin but may also be caused by exogenous bacteria, most commonly, group A Streptococcus or Staphylococcus. In older adults, group G Streptococcus may occur more frequently with underlying chronic illness.40 Signs and symptoms of cellulitis include pain, increased warmth, erythema, and edema. When edema is present anywhere in the body, there is a higher risk of cellulitis in that area, and obese people are at highest risk for cellulitis in the folds and rolls of the skin. The prevalence of health care charges from 1998 to 2013 owing to cellulitis was reported to have more than doubled, and admissions for cellulitis are quite seasonal. For example, during the peak month of July, the incidence was 34.8% higher than the baseline month of February in one study.41 Cellulitis is most commonly treated with oral antibiotics, but in severe

Candida, illustrated in Fig. 21.4, is a superficial yeast infection that most commonly affects older adults and the immunocompromised. Candida presents most often in the groin, axilla, or breast folds; affected skin may

FIG. 21.4 Candida. (From Paul A. Volberding, MD, University of California San Francisco)

FIG. 21.5 Cellulitis. (From Gould BE. Pathophysiology for the Health Professions. 3rd ed. Philadelphia: Saunders; 2006.)

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cases, intravenous antibiotics may be considered. Most patients’ conditions respond well to these treatments. However, if cellulitis progresses to serious illness by uncontrolled contiguous spread and systemic infection, emergent medical care is necessary to prevent sepsis and potential life-threating illness in older adults.

Herpes Zoster Herpes zoster, also known as shingles, is illustrated in Fig. 21.6. Herpes zoster results from the reactivation of the varicella zoster virus, which lies dormant in nerve ganglia after chickenpox. Age is one of the most significant risk factors for developing shingles. One study reports that incidence increases with age by a factor of >10, from 0.74 per 1000 person-years in children aged <10 years to 10.1 per 1000 person-years in persons aged 80 to 89 years, with much of the increase beginning at age 40 to 60 years. Approximately 50% of people who live to age 85 years will have experienced zoster.42 Shingles can be identified by complaints of tingling or pain in a unilateral dermatome followed in 1 to 2 days by erythema and vesicles. The vesicles break down into crusted plaques, and patients remain contagious for chickenpox until all of the vesicles have crusted over. It typically takes 2 to 3 weeks from the initial onset of dermatome pain to the resolution of the zoster plaques.43 Shingles occurs most commonly in the thoracic, cranial, lumbar, and sacral dermatomes. Once identified, shingles are treated with oral antiviral agents such as valacyclovir and famciclovir to minimize the duration of the disease and incidence of

postherpetic neuralgia (PHN).1,44 Areas of skin affected by vesicles can be treated by topical application of emollients, and PHN symptoms are commonly managed through oral agents such as gabapentin and tricyclic antidepressants.1 Physical therapists may be involved in the management of PHN and educate older adults about a shingles vaccination. Since 2016, 33.4% of adults aged 60 years and older reported receiving Zostavax, a shingles vaccine in use since 2006. This is an increase from the 31% reported the previous year. In 2018, the Centers for Disease Control and Prevention (CDC) will collect data on vaccination of adults aged 50 years and older using Shingrix (recombinant zoster vaccine) as preferred over Zostavax (zoster vaccine live) for prevention of herpes zoster and related complications.44 The CDC recommends two doses of Shingrix separated by 2 to 6 months for immunocompetent adults aged 50 years and older.

Scabies Scabies, illustrated in Fig. 21.7, is very contagious and common to long-term care and other settings where people live in close proximity to each other. The rate of scabies occurrence varies in the recent literature from 0.3% to 46%.45 Scabies is caused by a mite that lays its eggs in burrows on the skin. In 3 to 4 days the larvae hatch, come to the skin, and repeat the process. Several weeks after the initial infection, itching will be reported as a result of the immune response to the mites and their wastes; once the itch is scratched a secondary infection may result. Scabies infections can be recognized by

FIG. 21.6 Herpes zoster. (From Goodman CC. Pathology: Implications for the Physical Therapist. 3rd ed. Philadelphia: Saunders; 2008.)

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Management of Integumentary Conditions in Older Adults BOX 21.2

Pressure Ulcer Staging

Stage Stage 1

Stage 2

Stage 3

FIG. 21.7 Scabies. (From Christsensen BL. Adult Health Nursing. 5th ed. St. Louis: Mosby, 2005.) excoriation and papules around the groin, abdomen, axillae, and wrists. Scabies often goes undetected in cognitively impaired older adults because of the inability to report symptoms. Treatment for scabies includes a topical scabicide such as permethrin, and all bed linens should be washed in the hottest possible water (i.e., 140°F to 200°F or 60°C to 90°C).1,46,47

COMMON WOUND CONDITIONS According to the U.S. Centers for Medicare and Medicaid Services (CMS), it is estimated that nearly 15% of all Medicare beneficiaries (8.2 million older adults) experienced chronic nonhealing wounds at an annual cost of nearly $32 billion in 2014.48 Surgical infections were the largest-prevalence category (4.0%) followed by diabetic infections (3.4%). The highest costs occurred for hospital outpatients followed by hospital inpatients.48 Pressure injury and ulcers across hospitals in 34 states declined from 2011 to 2014,49 largely owing to early identification and management of pressure injuries. Overall, pressure injury/ulcers, diabetic neuropathic ulcers, and arterial and venous ulcers, discussed next, represent common wound conditions in older adults addressed by physical therapists as part of integumentary care.

Pressure Injury/Ulcer Pressure injury and ulcers are most common among older adults and are a source of premature mortality in some patients, interfering with functional recovery complicated by pain and infection.50 Each year, more than 2.5 million people in the United States develop pressure ulcers.51 In 2008, the CMS announced it would not pay for additional costs incurred for hospital-acquired pressure ulcers.52 In 2016, the National Pressure Ulcer Advisory Panel (NPUAP) replaced the term pressure ulcer with pressure injury in the NPUAP injury staging system and added use of Arabic numerals instead of the previous Roman numerals.53 Box 21.2 provides a description of pressure

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Stage 4

Deep-tissue pressure injury

Unstageable pressure injury Medical device–related pressure injury Mucosal membrane pressure injury

Description Nonblanchable localized area of intact skin with erythema that does not resolve within 30 minutes of complete pressure relief Partial-thickness skin loss with exposed dermis but no slough, eschar present at this level Full-thickness skin loss involves fascia with adipose tissue; however, damage does not expose tendon, bone, or joint capsule Full-thickness skin loss extending through the fascia, muscle, tendon, ligament, cartilage, or bone Nonblanchable purple or maroon discoloration of intact skin that may indicate damage to the underlying tissue Ulcers completely covered with slough, eschar, or necrotic debris to the extent that the wound base is not visualized Generally conforms to the pattern or shape of device and should be staged using the staging system. Pressure injury found on mucous membranes with a history of a medical device in use at the location of the injury; due to the anatomy of the tissue these injuries cannot be staged

ulcer staging and additional pressure injury categories. Stage 1 pressure injury is a nonblanchable localized area of intact skin with erythema (redness). In people with darker skin tones, the stage 1 pressure injury may appear differently. Stage 2 pressure injury involves partial-thickness skin loss with exposed dermis. Full-thickness skin loss is classified as stage 3 pressure injury and involves damage extending down to, but not through, underlying fascia with adipose (fat) visible in the ulcer. Stage 4 pressure injury involves full-thickness skin loss penetrating through the fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.53 Pressure injury develops as soft tissue is compressed from sources of intense and/or prolonged pressure or shearing forces, restricting the blood supply and causing tissue damage. The most common wound locations in older adults are over bony prominences, most notably the sacrum and coccyx, heel, malleolus, trochanter, ischial tuberosity, elbow, knee, scapula, and occiput.53 However, pressure ulcers may occur in other locations as sources of external pressure compress soft tissues. Examples of these injuries are on the leg where it is pressed against a bed rail or across the thigh where a urinary catheter was pulled tight. Hence, additional pressure injuries occur from medical device–related pressure as well as mucosal membrane

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pressure found on mucous membranes that is not stageable.53 Other pressure injuries include unstageable obscured full-thickness skin loss and deep tissue pressure injury. Overall, pressure injury and ulcers are affected by microclimate of the skin and support surface, nutrition, perfusion, comorbidities, and condition of the soft tissue. Prevention of pressure injury and ulcers in older adults includes assessing risk, providing proper skin care for those at risk, and educating patients.53 The NPUAP recommends risk assessment tools such as the Norton scale54 or the Braden scale55 be used routinely (at admission and at regular intervals thereafter) with at-risk persons to ensure systematic evaluation of individual risk factors. Proper skin care, educational programs, and a rehabilitation program to maintain or improve mobility and activity status are important prevention strategies. Once an ulcer is present, early treatment is critical. In addition, pressure reduction is essential in preventing and treating pressure ulcers. There are many options for wheelchair cushions, mattresses, mattress overlays, positioning aids, and orthotics to assist with off-loading.56 Recent literature suggests the need for the correct support surface for specific situations to reduce and prevent pressure injuries. For example, a small trial found that sheepskin placed under the legs significantly reduced redness and that profiling beds were better than standard beds in terms of healing existing stage 1 pressure injuries.56 On the other hand, foam overlays are no longer used for pressure redistribution. Although physical therapists have training in most of these products, advanced training is beneficial in determining the optimal choices for a given patient. Therefore, the physical therapist may wish to consult other physical therapists, an occupational therapist, or a durable medical equipment provider with more experience in that area. Clinical guidelines to prevent and treat pressure ulcers include proper skin and tissue assessment, preventive skin care, prophylactic dressings, early mobilization/repositioning, adequate nutrition, cleansing, debridement, assessment of infection/biofilms, and use of biophysical agents.57 Nutritional evaluation including serum albumin and prealbumin levels are needed, although decreased levels may reflect production of inflammatory cytokines, not actual nutritional status. In addition, practitioners should educate caregivers not to massage an area at risk over bony prominences while applying moisturizing lotions or creams because this may increase the risk of breakdown. Overall, improvements in continence care through scheduling toileting every 2 hours and use of skin-protectant barrier creams to help maintain skin health and pressure relief are key to reducing pressure injury.50

prevalence of 50% with diabetes.58 The pathophysiology of diabetes leading to a series of vascular, immune, sensory, neurological, and orthopedic changes in older adults can lead to neuropathic foot ulcers. Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States, with approximately 5% with foot ulcers each year and 1% requiring amputation. On a large scale, the annual cost of diabetes in the United States in 2012 was $245 billion, and it has been estimated that about 27% of health care costs of diabetes can be attributed to DPN.58 In addition, atherosclerosis of large and small vessels results in ischemia of the feet. This arterial compromise damages tissue and limits the healing ability, with occlusive events leading to gangrene. Consequently, diabetic neuropathic ulcers have traits in common with arterial insufficiency and pressure injury on weight-bearing skin of both the dorsum and plantar foot. In addition, diabetes impairs the immune system, allowing bacteria to become entrenched more easily in the wound, making infection harder to fight and leading to limited phagocytosis. Consequences of diabetes, such as nephropathy and impaired vision from retinopathy, can complicate the prevention and treatment of diabetic foot ulcers in older adults. Overall, DPN is an important risk factor for skin breakdown, amputation, and reduced physical mobility. The nonenzymatic glycation predisposes ligaments to stiffness, and loss of coordination and sensation lead to mechanical stresses during ambulation.59 The diabetic unholy triad affects sensory, autonomic, and motor nerves, and each has sequelae that contribute to diabetic neuropathic ulcers. Sensory neuropathy prevents the older adult from feeling when something is harming the foot. Practitioners quantifiably test sensation with monofilaments (Fig. 21.8). The 5.07 monofilament

Diabetic Neuropathic Ulcers Diabetes is a pandemic health care problem affecting 366 million people globally.58 Diabetic peripheral neuropathy (DPN) is the most common complication with a lifetime

FIG. 21.8 Semmes-Weinstein monofilament test. (Courtesy of Erica LaPierre, PT, 2009; VNA of CNY, Syracuse, NY.)

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tests for sensitivity to 10 grams of pressure, called protective sensation. This threshold of sensation is only 2% of normal sensation.60 If a person does not feel 10 grams of force, he or she is more likely to develop an ulceration from pressure from a sock seam or wrinkle, friction from a sandal strap, or even a steel nail through the sole of the shoe. People with diabetes should have their sensation tested with a 5.07 monofilament at least once a year.61 To maximize the diagnostic value of testing, a three-site test involving the plantar aspects of the great toe, the third metatarsal, and the fifth metatarsal should be used; ankle reflexes are not a reliable way to assess DPN.62,63 Screening is easily taught and vital in identifying DPN early and can be performed by most health care providers. Autonomic neuropathy results in reduced perspiration and oil production. The skin on the feet becomes very dry, creating cracking and a route for bacterial entry. Feet with autonomic neuropathy have a greater occurrence of a loss of vasomotor tone, contributing to impaired tissue perfusion.63 Motor neuropathy leads to muscle atrophy. Musculoskeletal problems arise as structural deformities such as hammertoes then develop from muscle imbalances. Altered foot pressure distribution occurs so that the metatarsal heads press more firmly down onto the walking surface, and the dorsal interphalangeal joints are raised, pressing onto the top of the shoe. The skin breaks down more easily from pressure and friction owing to the skin thinning from arterial insufficiency. The first metatarsal–phalangeal joint stiffens with diabetes, creating a condition called hallux rigidus. Without first metatarsal– phalangeal joint extension, extreme pressure is placed on the plantar hallux, increasing diabetic neuropathic ulcer risk. Diabetes also thins the protective fat pads of the foot, further increasing pressure on the metatarsal heads and the heel. The prevention and treatment of diabetic neuropathic ulcers must include systemic and local approaches. Metabolic control of diabetes is critical and a key position published by the American Diabetes Association (ADA).64 Consistent blood sugar control reduces the progression of the diabetic complications. The person’s diet must support glycemic control and meet any other needs the person may have, such as proper wound healing. An educational dietary consultation may be necessary to keep tight glycemic control and limit hyperglycemia. Future prospective studies should assess the effect of decreased hemoglobin A1c (HbA1c) levels (the ADA recommends <7%),64 a reflection of glycemia over 2 to 3 months in the blood, in diabetic wound healing because poor wound healing is associated with hyperglycemia.65 On the weightbearing tissue, off-loading is important in relieving pressure for anyone with a foot injury or open sore due to DPN. Non–weight-bearing gait is the best option, yet it is the most difficult to achieve with an older person owing to the strength, balance, and endurance demands. Total contact casting has been considered the gold standard for off-loading, but in recent years, other methods

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(healing shoe, walking boot, and felt pad) have shown comparable results.64 Most recently, the evidence for the stress threshold for safe exercise prescription in people with DPN is emerging with proper assessment of all the risk factors in integument, nervous, musculoskeletal, and vascular systems.66 Although weight-bearing exercise and ambulation with proper foot wear in patients with DPN is recommended, cautionary advice for physical therapists includes special considerations for older adults with DPN to address coexisting medical conditions and functional impairments in hearing, vision, gait, and balance, and limit postural instability and falls in older adults.66 Overall, physical activity should be encouraged in older adults with DPN with proper screening, assessment, and careful consideration of safety with physical therapist supervision.66 Lastly, the U.S. Federal Drug Administration (FDA) has issued an ongoing safety review regarding becaplermin (Regranex), a topical recombinant form of human platelet-derived growth factor to treat neuropathic ulcers, owing to a likely increased risk of death from cancer in patients who had used three or more tubes of Regranex, who had a mortality rate five times higher than patients who did not use Regranex.67

Arterial and Venous Insufficiency Ulcers Both arterial and venous insufficiency may manifest in the lower extremity of older adults as ulcerated wounds (Figs. 21.9 and 21.10). According to the American Heart Association (AHA),68 the risk factors for peripheral arterial disease (PAD) include age >70, history of smoking and/or diabetes, hypertension, stroke, known atherosclerosis and history of claudication, abnormal pulses, obesity, inactivity, and high blood cholesterol. The factors

FIG. 21.9 Venous insufficiency ulcer. (From Kamal A, Brockelhurst JC. Color Atlas of Geriatric Medicine. 2nd ed. St Louis: Mosby Year Book; 1991.)

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FIG. 21.11 Ankle–brachial index test: blood pressure cuff placement and Doppler ultrasound placement to measure systolic pressure through dorsal pedal pulse. (Courtesy of Erica LaPierre, PT, 2009; VNA of CNY, Syracuse, NY.)

T ABLE 2 1 .2

FIG. 21.10 Arterial insufficiency ulcer. (From Black JM. MedicalSurgical Nursing: Clinical Management for Positive Outcomes. 8th ed. Philadelphia: Saunders; 2008.)

leading to venous disease include immobility, ineffective calf muscle pump, venous valve dysfunction from trauma, deep vein thrombosis, and phlebitis.69 Therefore, common arterial and venous insufficiency leg ulcers occur below the knees.70 Although most leg ulcers are caused by venous disease alone (72%), arterial insufficiency ulcers are the second most common, ranging from 10% to 30% of lower leg ulcers. Within the venous wounds, 10% to 15% are of mixed arteriovenous etiology with a compromised ankle–brachial index (ABI ¼ 0.5 up to 0.85) (Fig. 21.11).70 Normal ABI values are between 0.9 and 1.0, and the lower ABI values (<0.5) indicate further compromised arterial insufficiency and difficulty for the wound to heal.3 Common sites for arterial insufficiency ulcers are over toe joints, under heels, over malleoli, and on anterior shins, whereas venous ulcers occur above the medial and lateral ankles and below the knees.3 Furthermore, arterial ulcers have minimal drainage with a dry, red wound base, whereas venous ulcers are shallow and have moderate to copious drainage with a yellow gelatinous wound base. Other signs and symptoms of arterial insufficiency ulcer include atrophic skin, diminished or absent pedal dorsal pulses, and pain with activity. Venous insufficiency ulcers tend to have less pain, more edema, and hemosiderin staining due to iron permanently staining the lower calves in a brownish-ruddy color. Table 21.2 provides a differentiation of arterial and venous ulcers.3 The skin relies on steady blood flow from the circulatory system for nourishment, hydration, oxygen, and

Wound Differentiation Between Arterial Versus Venous Ulcers

Differentiation

Arterial Ulcers

Venous Ulcers

Location

Tips of or between toes, over the phalangeal heads, or over the lateral malleolus Minimal to slight exudate Discrete punched out Pale

Near or above medial or lateral malleolus, above malleoli Moderate to heavy exudate Irregular borders Hyperpigmentation

None None Likely

Likely Strong None

Drainage Wound margins Wound appearance Edema Odor Pain

(From Gist S, Tio-Matos I, Falzgraf S, Cameron S, Beebe M. Wound care in the geriatric client. Clin Interv Aging. 2009;4:269–287.)

removal of waste products to remain healthy. In both arterial and venous insufficiency, the systemic circulatory dysfunction manifests itself locally on the lower legs. Simply put, arterial ulcers are due to poor “pipes” in the arterial system, whereas venous ulcers are due to poor “plumbing” in the venous system. For example, arterial insufficiency may cause arteriosclerotic development of plaques that restrict the arterial flow to the body region as well as microthrombi in some of the capillaries in patients with venous leg ulcers. This problem may be located in the small vessels, large vessels, or both. Regardless of the reason for the circulation compromise, the result is the same. Localized ischemia starves the tissue of vital nutrients and oxygen. The tissue begins to necrose, and cells are unable to clear waste products. Therefore,

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wounds will not heal well owing to poor tissue perfusion. Further, systemic antibiotics will not be able to reach the involved area, so topical treatment may be more appropriate. Prevention and management of arterial insufficiency is crucial for wound healing and preventing recurrence. This includes smoking cessation to slow progression of atherosclerosis and decrease the risk of cardiovascular events, and medical management of the underlying disease (e.g., atherosclerosis, peripheral vascular disease, diabetes, hypertension, hypercholesterolemia). The treatment of arterial ulcers is based on adequate perfusion with risk factor modification and a daily walking program.70 Compared to the FDA-approved drugs of pentroxifylline (Trental) and cilostazol (Pletal) for promoting blood flow in patients with arterial ulcers or claudication; a supervised exercise program with treadmill or track walking was able to improve the mean change in maximal walking distance greater than the medication alone.70 To achieve these gains, as the patients improve their walking ability, the exercise workload should be increased to ensure that there is always the stimulus of claudication pain during the workout. As a caution, the practitioner must be watching for the possibility that cardiac signs and symptoms (dysrhythmia, angina, or ST-segment depression) may appear in patients while doing the treadmill or track walking program.70 Other surgical treatment for arterial ulcers is recommended for patients with rest claudication who are at risk for limb loss.3 It is the position of the American Physical Therapy Association (APTA) that procedural interventions like sharp selective debridement, which is a component of wound management, is performed exclusively by the physical therapist. Therefore, it would be prudent to review the specific state practice acts with regard to procedural interventions and selected interventions that can be performed by the physical therapist assistant under the direction and supervision of the physical therapist.71 Lastly, some patients with arterial and venous ulcers (mixed) should wear compression bandages or stockings only with careful and close monitoring by physical therapists.72 In venous insufficiency ulcers, the superficial veins, deep veins, or perforator veins may be compromised. Veins have valves that keep the blood flowing in one upward direction. They open for the pulse of blood upward, then close to prevent backflow into a lower segment.73 Valves may become damaged through thrombophlebitis, deep vein thrombosis, or other trauma. As a result, blood flow becomes bidirectional and downward. Venous hypertension results in vessel bulging, stretching the gaps between vessel wall cells. The microtrauma stimulates leukocyte aggregation, occluding the vessel. Other cells leak from the vessel. Fibrin cuffs form around the vessel wall. The leukocyte occlusion and fibrin cuffs impair perfusion of oxygen from the blood to the tissue. Erythrocytes also leech into the tissue, breaking down to leave iron deposits behind, described earlier as hemosiderin staining. The fluid that escapes from the vessels causes swelling in the lower leg(s). This edema compresses

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capillaries, further restricting local tissue oxygenation. The gastrocnemius–soleus muscles compress the veins when contracting, and this muscle pump action promotes venous return. Thus, when the muscle pump is insufficient through loss of ankle range of motion, inactivity, or loss of muscle tone, the body is less able to counteract the effects of gravity. Blood can pool in the veins, causing venous hypertension and resulting in vein distention and tissue hypoxia.73 Without adequate compression to mimic a competent venous system, the underlying problem escalates the condition, worsening the venous insufficiency ulcer. Venous leg ulcers affect up to 3% of people aged 65 years and older, and these chronic wounds recur at rates of up to 69%.74 Compression of venous legs must be used for the rest of one’s life to reduce the risk of recurrence. Compression stockings at a strength of 30 to 40 mmHg are considered the gold standard of treatment and the most commonly used form of compression to prevent venous insufficiency ulcer recurrence. Compression stockings must be replaced approximately every 6 months, as the elastic degrades and the compressive force weakens. When stockings are worn beyond their lifespan, wounds often recur from the lack of venous support. Older adults with chronic venous insufficiency can further reduce the risk of new ulcerations by elevating the legs and modifying activity (e.g., limiting sitting and standing still) as much as possible while maintaining a prescribed exercise program because gravitational ulcers require elevation.69 Although managing edema is paramount, venous insufficiency ulcers must be managed with proper moisture-capturing dressings and compression to optimize wound healing for older adults.75

Atypical Inflammatory Wounds Some wounds are created out of inflammatory or autoimmune conditions. Vasculitis is an inflammation of the blood vessels, which may degrade soft tissue and lead to ulcer formation. These exquisitely painful wounds are most commonly located on the lower leg and triggered by underlying infections with palpable purpura. Rheumatoid arthritis can cause leg wounds directly, as well as via small-vessel vasculitis owing to immune complex formation.76 The inflammation must be halted with medications for the body to progress beyond this phase and begin wound healing. Other wounds are autoimmune in nature. Pyoderma gangrenosum is a poorly understood disease with an unknown etiology, though it is no longer considered to be infectious in origin.77 It is found almost exclusively in people with a systemic autoimmune disorder, such as Crohn disease, ulcerative colitis, or rheumatoid arthritis. Wounds have an inflammatory appearance and typically enlarge with debridement or other treatments that increase inflammation. These atypical inflammatory wounds present with irregular raised wound margins with round erythema on the legs and chronic wound sites. These atypical wounds may require tissue biopsy and systemic corticosteroids, which necessitates collaborative medical and physical therapy management.

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Burns Aging is associated with delays in thermal sensation, leading to a greater risk of burns, especially while bathing. Animal models in older mice demonstrate slower wound healing from scald wounds78 owing to limited chemokines as well as comorbid diabetic burn injuries with fewer bone marrow–derived angiogenic cells, diminished hypoxiainducible factor 1 expression, and dampened homing responses.79 Older adults, especially those with diabetes with sensory neuropathy, should be encouraged to test water temperature with the hand instead of the more sensory-impaired feet. Even better, turning the water heater to a lower temperature or using safety products (e.g., bath mats, tub thermometers, and color-changing rubber duckies that indicate an unsafe water temperature) may reduce the risk of burns. Burns that extend to large and deep areas of the skin require serious medical attention. Older adults over age 65 have twice the fire death rate as the population as a whole. Adults over age 85 have a fire death rate 3.5 times that of the general population.80 Older adults may not react as quickly to extinguish a fire or move away from a source of potential burn injury. Furthermore, older adults may take more prescription drugs that may dull the senses and their vision, exposing the individual to risks for fire and burn injury. More importantly, some older adults may have careless attitudes that may increase their risk of experiencing a fire or burn injury. Educating older adults on the leading causes of fire and burns from cooking and scald burn injuries due to faulty electrical wiring, portable heating source, boiling baths, or showers may help alter dangerous attitudes and change unsafe behaviors in older adults. The key to preventing burn injury in older adults is to educate on safety risks and provide resources to older adults.80 In addition, serious burn injuries should be managed in designated burn centers with available specialty care.81 Therefore, skin and burn management in older adults must be identified, prevented, and treated in a timely manner by physical therapists. BOX 21.3

QUALITY OF LIFE AND FUTURE DIRECTIONS Older adults who sustain an acute wound injury and who have chronic wounds report physical problems, mental health problems, and cognitive problems.82 The effect of chronic wounds on quality of life is particularly profound in older individuals.82 Using the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF),83 physical therapists need to address the profound effect on QOL of acute and chronic wounds because individuals seen in outpatient wound centers have an average of eight comorbid conditions.82 Recently, exercise has been shown to be paramount in cutaneous wound healing from rodent and human studies.84 Exercise is a relatively low-cost intervention and it has been shown to speed healing in both aged and obese mice and in older adults.84 Although little is known about the mechanisms by which exercise speeds wound healing, physical therapists can play a major role in proper supervision of exercise and prevention of harm in older adults with comorbidities and integumentary wound conditions. By addressing the appropriate activity imitations and participation restrictions with proper dosage of exercise and functional activities, physical therapists can assist older adults with improving their QOL and proper wound healing. Recently, with the health care burden focusing on changing older adults’ demographics and chronic medical conditions, key gaps in wound care knowledge and research priorities were addressed by an international meeting of stakeholders in the fields of aging, and wound repair and regeneration in 2015.82 From this meeting, key research questions and outcomes were generated for future studies82 (Boxes 21.3 and 21.4). Therefore, it would be prudent for physical therapists to collaborate with a wound care interdisciplinary team to develop appropriate care plans based on research needs and

Research Questions for Wound Healing in Older Adults

Category Epidemiology and quality of life Basic biology of wound healing, chronic wounds, and aging

Research Questions What is the burden of illness due to chronic wounds in populations of older adults? What is the frequency of multiple wounds and recurrent wounds in older adults? What causes acute injuries to become chronic wounds? How can immune cells in the wound environment, or recruitment of immune cells to the wound, be modulated to harness benefit? What strategies can be used to reverse macrophage impairment? What factors regulate or activate macrophage phenotypes in wound repair? What are the mechanisms underlying endothelial and epidermal stem cell activation and homing to the wound site? What are the roles of proliferation and apoptosis in acute versus chronic wounds? What are reasons for delayed chemotaxis and lack of neutrophil function in chronic wounds? How does neutrophil depletion delay wound closure with advanced age? What are the mechanisms for matrix metalloproteinase overproduction with aging in chronic wounds?

(From Gould L, Abadir P, Brem H, et al. Chronic wound repair and healing in older adults: current status and future research. J Am Geriatr Soc. 2015;63 [3]:427–438.)

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Management of Integumentary Conditions in Older Adults

Potential Outcomes for Clinical Studies of Wound Healing in Older Adults

Synergy between age and comorbidities Pathology of tissue left behind in the wound Costs of nonhealing wounds Goals for healing at the time of wound presentation Effects of standardized clinical decision support based on electronic medical records Quality of life Functional status Morbidity Pain Level of independence Sepsis Prevention of amputation and mortality Palliative care versus healing (From Gould L, Abadir P, Brem H, et al. Chronic wound repair and healing in older adults: current status and future research. J Am Geriatr Soc. 2015;63 [3]:427–438.)

recommendations. By following this chapter’s recommendations on skin and wound management for older adults, practitioners can develop solid clinical judgment based on the current evidence and future needs for research in aging and wound healing. Therefore, the carnal beauty of older adults’ skin is truly deeper than what meets the eye.

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