Health Tips

Throughout our entire life, we may accidentally knock ourselves over and get minor injuries on our body surface. While that may be trivial for young people, skin injuries in elderly should be taken seriously. This is because the skin is the body’s largest organ and, like other organs, becomes compromised with aging. 

Elderly skin has decreases in water content, subcutaneous tissue, blood flow, and integrity between skin layers. Their skin also has less tensile strength, making it prone to injury with even the slightest pressure or abrasion. Many elderly patients also have at least one chronic disease that may complicate the wound healing process.Thus, the elderly patient is at high risk for skin breakdown, slower healing and complications from wounds.

Types of wounds

Wounds may look almost the same for many, but for those who are familiar with wound care, identifying different types of wounds can be helpful as it informs which wound dressings to use. The most common types of wounds in the elderly are:

• Pressure ulcers:  Pressure ulcers often occur where bony prominences underlie soft tissues, such as on the heels, ankles, lower back area, buttocks and hips. Immobile elder patients who are lying on bed long-term while being put on feeding tubes are also more likely to get pressure ulcers. It was known that the incidence of pressure ulcers increases significantly with advancing age and is most likely to occur in patients older than 85 years of age.

Image credit to https://www.dermnetnz.org/search.html?q=pressure%20ulcer%20dermnet

• Vascular ulcers: Vascular ulcers are usually the results of deficiency in blood supply of a particular skin area. Depending on the type of blood vessels involved, they can be further classified into arterial or venous ulcers. 

  • Arterial ulcers arise because of restricted blood flow of an artery. Therefore, these ulcers are often pale in color with minimal exudate, i.e. fluid secreted from the wound. Arterial ulcers commonly occur on toes or heels and can be painful, sometimes with dead tissues, and can be difficult to heal because of lack of oxygen supply to the wound area.

  • Venous ulcers are caused by venous insufficiency, i.e. the wall of the veins in the leg are not functioning well, which results in extreme swelling. It was found that older age, female gender, obesity and family history of venous diseases may increase the risk of an elderly getting venous ulcers.

Image credit to https://www.dermnetnz.org/search.html?q=vascular%20ulcer

• Neuropathic ulcers: Neuropathic ulcers are common among elderly with uncontrolled diabetes, autoimmune diseases, infectious diseases such as Lyme disease, herpes zoster, hypothyroidism and tumours. These conditions destroy the nerves in the skin, which leads to a lack of protective sensation on the skin, i.e. the elderly do not feel pain even when the skin is injured. As a result, the elderly go about their daily routine and the skin areas receiving repeated stress may form a callus or blister, which can ultimately lead to ulcers. 

Image credit to https://www.dermnetnz.org/search.html?q=diabetic%20foot%20ulcer

Treating chronic wounds

It is perfectly fine if the wound is formed and healed over time. However, many elderly patients often suffered from chronic wounds, which are wounds that fail to heal properly. Care of the chronic wound requires attention to four basic processes: debridement, moisture balance, infection control, and protected healing.

Debridement

Debridement is the removal of dead tissues on the wounds. It is an important process as dead tissues delay wound healing and may serve as a medium for bacterial infection.  Debridement can occur several ways:

• Surgical debridement involves use of a sharp instrument to cut away dead tissue. This is usually done by the doctors.

• Autolytic debridement is the process in which the body’s own enzymes liquefy the dead tissue. This process can be enhanced by maintaining a moist wound environment, such as using a hydrogel.

• Enzymatic debridement uses dressings impregnated with enzymatic agents like collagenase to liquefy the dead tissue. Some of the products used are clostridiopeptidase A , honey and fibrinolysin with DNAse. 

• Mechanical debridement includes using wire gauze to peel the dead tissues from the wound, which can be very painful. Other methods include scrubbing, whirlpool (use low pressure water force to cleanse and debride the skin) and wound irrigation (use non-antiseptic cleansing solutions such as saline water to irrigate and debride the wound). 

Moisture balance

A moist wound environment promotes healing, hence it is crucial to maintain the moisture of skin. However, when the wound is inflamed, there may be a lot of exudates that can damage and macerate surrounding tissues. Moisturizing the skin at this stage would do more harm than good. Therefore, wounds that are too dry may require a dressing that adds moisture, while wounds with heavy exudate may need an absorptive dressing. In other words, the moisture level of the wound should partly guide your decision on which wound dressing to use. 

Other types of wound dressings are also available for selection, such as foams, hydrofibre, charcoal, and silver. 

Today, there are many composite dressings available in the market. They contain the combination of 2 or more dressing materials mentioned above, which provides convenience and cost-effectiveness for the consumers.

Infection Control

One of the reasons why wound care is essential is to prevent infection. An infected wound can not only cause delay in wound healing, but can lead to sepsis, which is fatal in frail elderly patients. Signs of infection include redness of the wound, swelling, warmth, pain and may also include odour or pus formation. However, a wound without these symptoms can still be suspected of infection. An infected wound is usually managed by applying antiseptics such as hydrogen peroxide and povidone-iodine (Betadine®). Some wound care dressings that contain silver are useful for skin infections as well. In the incidence where the skin infection develops into a deeper region (osteomyelitis or cellulitis), the elderly patient should be given antibiotics pills. 

Image credit: https://www.watsons.com.my/hydrogen-peroxide-100ml/p/BP_44550

Image credit: http://my.betadine.com/

Protection 

To protect the wound when applying dressing, never place gauze and/or adhesive dressings directly on the wound; instead, apply a secondary dressing, such as silicone-coated dressing directly on the wound, followed by gauze or adhesive dressings. Small amounts of lotion can be applied to the edges of the adhesive bandage to loosen the adhesive product and minimize discomfort on removal. To minimise pain on removal, extend the protective/secondary dressing at least one inch away from the wound. 

Professional opinion matters

Wound care may seem intimidating at first. Not only because of the overwhelming product selection, but more often than not we are afraid of hurting the elderly patient when helping them manage their wound. Just keep in mind that practise makes perfect, and professional opinion is your greatest ally. You should always consult a doctor or pharmacist before purchasing any wound care products. This article shall not supersede any professional opinions by a healthcare professional.

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697592/

2. https://www.moh.gov.my/moh/resources/Penerbitan/Garis%20Panduan/Garis%20Panduan%20Umum(KKM)/Wound_Care_Manual.pdf

3. https://www.pharmaceutical-journal.com/cpd-and-learning/learning-article/how-to-select-a-wound-dressing/11039846.article

4. https://pubmed.ncbi.nlm.nih.gov/23748122/

Written by

Ms Joyce Toh