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1 The use of compression hosiery in mixe aetiology ulceration an palliative care Helen Butterfiel The UK has an expaning elerly population, which means that in the future nurses an clinicians who work in community-base units, such as nursing homes an hospices, will increasingly encounter age-relate conitions such as palliative oeema an mixe aetiology ulceration. This article looks at uome soft, (mei UK, Herefor) a new hosiery solution, which is not only easy to apply, making patient self-care more likely, but also provies consistent mil compression in a format that is more cosmetically acceptable to patients. KEYWORDS: Mixe aetiology ulceration Palliative care Compression hosiery Compression therapy is a simple principle that, applie correctly, can have important beneficial effects. Compression can either be applie by banaging, hosiery or hosiery kits an, if use appropriately, can make a funamental contribution to the long-term management of venous leg ulceration, as well as having an enormous effect on patients quality of life (Worl Union of Woun Healing Societies [WUWHS], 2008). There are ifferent compression graes available, with German RAL, French ASQUL an British Stanar being the recognise inepenently teste compression stanars available in the UK. Higher compression values are foun to be more effective in preventing ulcer recurrence (Dowsett, 2011). However, when patients are elerly an unable to tolerate high compression, the lower values of the British Stanar can be a useful resource. Leg ulceration, of venous, arterial an mixe aetiology, is a significant problem in oler people Helen Butterfiel, Leg Ulcer/Dermatology Specialist Nurse, Oxfor an, as this population grows larger (Posnett an Franks, 2008), it is vital that clinicians are familiar with appropriate management strategies. Similarly, oeema is a common complication of many conitions seen at the en of life, where palliative compression may be appropriate to help ease symptoms (Dowsett, 2011). Compression is a simple principle that, if applie correctly, can have important beneficial effects. An unerstaning of leg ulceration, oeema an how compression therapy can help patients is particularly important in the community, where elerly patients may be isolate, lack support an fin it ifficult to access healthcare services. This article looks at the causes an symptoms of venous oeema an ulceration, as well as highlighting appropriate management strategies, incluing an innovative type of hosiery that provies grauate compression in a patient-frienly esign, which can help clinicians with long-term patient concorance in elerly patients with existing comorbiities an en of life care. VENOUS DISEASE Chronic venous isease is a common conition in elerly people, which evelops when valves that normally allow bloo to travel back up to the heart from the lower leg simultaneously preventing a back-flow of bloo into the lower limbs become weaker, usually through age. This causes a buil-up of flui in the lower limb, which if not manage properly, can result in venous stasis an venous hypertension (Scottish Intercollegiate Guielines Network [SIGN], 2010). In turn, this can result in subsequent venous leg ulceration, as the bloo flows backwars an pools in the legs, increasing pressure in the veins. Initially, this can cause certain mil problems, incluing (Eberhart an Raffeto, 2013): Feelings of heaviness in the legs Aching Dilate or unsightly veins. It is also crucial that community clinicians unerstan the psychosocial element of compression therapy, where patients may fin it ifficult to ahere to long-term treatment ue to the commitment involve in banaging regimens, as well as cosmetic consierations (Williams, 2010; Anerson, 2013). If left untreate, mil venous isease can evelop an the patient can encounter more severe problems, incluing (Eberhart an Raffeto, 2013): Swelling Colour changes in the skin Dermatological symptoms, such as varicose eczema an recurrent skin infections Chronic ulcers. 60 JCN 2013, Vol 27, No 4

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3 Venous leg ulcers are one of the severest complications of venous isease an are the most common type of lower leg ulceration (SIGN, 2010), usually affecting oler people. Chronic venous leg ulceration involves consierable morbiity an can have a particularly eleterious effect on quality of life (Persoon et al, 2004; SIGN, 2010). It is also true that healing a venous leg ulcer is only the first stage in what will often be a long-term management plan, incluing compression, as recurrence rates vary (Anerson, 2013). ARTERIAL DISEASE Arterial problems evelop when the flow of bloo through the arteries is impaire. The main cause is buil-up of fatty eposits (atheroma) that form plaques on the insie of the artery wall, narrowing the lumen of the artery over time an impeing bloo flow (Dowsett, 2006). This, in turn, impairs the supply of oxygen an nutrients to the lower limb, resulting in poorly perfuse tissues an, eventually, ulceration. Accoring to the SIGN guielines (2010), up to 22% of leg ulcers are cause by peripheral arterial isease, which is inicate by a history of intermittent clauication, cariovascular isease, or stroke (SIGN, 2010). The absence of symptoms (see below) oes not necessarily exclue arterial isease, but it can be rule out by performing ankle brachial pressure inex (APBI) measurements using a Doppler assessment compression therapy may be safely use in leg ulcer patients with an ABPI greater than or equal to 0.8 (SIGN, 2010). Symptoms of arterial isease inclue (SIGN, 2010): Ulcers (a punche-out appearance) Pain, cramping, aching in the lower limb Lack of hair growth beneath the knee Poor toenail growth Cool feet Weak or absent pulse in the lower limb arteries Slow capillary refill time in foot Increase pain on elevation of legs. As well as the initial evelopment of ulcers, the lack of oxygen elivere to the lower limbs means that when they o occur, they may be particularly har to heal. MIXED AETIOLOGY ULCERATION As the name suggests, mixe aetiology ulcers have a number of causes, often isplaying both venous an arterial insufficiency, although they can also involve iabetes mellitus an rheumatoi arthritis (Ousey an McIntosh, 2008). Mixe aetiology ulcers often occur as a result of chronic venous problems in the lower limb being exacerbate When treating mixe venous an arterial ulcers, the aim is to achieve a balance between safety an efficacy. by arterial insufficiency, although Anerson an King (2006) note that the arterial bloo supply will not yet be sufficiently compromise to cause critical ischaemia. MANAGEMENT When treating mixe venous an arterial ulcers, the aim is to achieve a balance between safety an efficacy. Stevens (2004) notes that in the past there has been little evience on the management of mixe arterial ulcers, although some areas have evelope compression guielines base on local practice an a European Woun Management Association (EWMA) position ocument that etaile the principles of compression therapy (Stacey et al, 2002). Many of these local guielines outline the benefits of using a reuce compression regimen in mixe aetiology ulcers with an APBI between 0.5 an 0.8 (Stevens, 2004). compression can have benefits. The aim of reuce compression is to lessen venous pressure an lower limb oeema, but not to significantly compress the arteries an impee arterial bloo flow. As mentione above, reuce compression is useful in patients with an ABPI of between 0.8 an 0.5 (Anerson an King, 2006), but they shoul be regularly monitore for pain or a reuction in their ABPI. British stanar class 1 an 2 compression hosiery can be useful (Anerson an King, 2006), as there is low pressure exerte at rest, but higher pressure on exertion (Stacey et al, 2002). Compression in elerly patients Accoring to the SIGN guielines, patients regularly cite problems with pain, iscomfort an lack of appropriate avice as reasons for non-concorance with compression therapy (SIGN, 2010). In elerly patients, concorance issues can be exacerbate, ue to mobility (patients with poor mobility may fin it har to apply compression themselves) an in some cases, cognitive impairment. Compression banaging requires a time commitment from patients as well as the willingness to unergo regular application. Compression banaging is also epenent on the availability of clinicians who are able to apply it an monitor the patient s suitability. Similarly, oler patients may fin it ifficult to access healthcare facilities on a regular basis in orer to have compression banaging applie. In some cases, a user-frienly form of compression, such as easy-toapply hosiery, can be beneficial, as it is easier for oler patients to use themselves, although this must be carefully monitore by an appropriately traine clinician. Applying full compression to an ulcer with mixe aetiology can be angerous, impeing bloo flow to the affecte area an potentially resulting in amage or even amputation (Vowen an Vowen, 2001). Therefore, assessment by an experience clinician is vital. However, applying reuce The appearance of compression banaging can also be an issue for oler people, as it can be bulky an easily visible, even uner clothing, an restrict their normal footwear. Palliative care The aim of palliative care accoring 62 JCN 2013, Vol 27, No 4

4 to the Worl Health Organization (WHO) is to offer symptom relief an help the person to live as active a life as possible until eath (WHO, 2013). Palliative oeema at the en of life can occur as a irect result of a number of conitions, some of which may be terminal, incluing (International Lymphoeema Network [ILF], 2010): Avance cancer Chronic heart failure Avance neurological isease Avance liver isease En-stage renal isease En-stage chronic respiratory isease Human immunoeficiency virus (HIV)/acquire immunoeficiency synrome (AIDS). Oeema is a significant problem at the en of life, with up to 67% of patients with avance cancer, for example, experiencing oeemarelate pain (Bager et al, 1988). Oeematous limbs can also cause relate pain, for example hip an back pain (ILF, 2010). Reuce or mil compression can form part of a number of enof-life management strategies, helping, for example, with reucing oeema through manual lymph rainage an the management of skin conitions (ILF, 2010). Compression can also improve en-of-life patients quality of life through cosmetic appearance an improve freeom of movement, Table 1: Compression classes an prouct coes Style Compression class 1 (ccl 1) = 14 17mmHg Below knee, open toe Below knee, close toe Thigh length with silicone top-ban, open toe Thigh length with silicone top-ban, close toe Compression class 2 (ccl 2) = 18 24mmHg Below knee, open toe Below knee, close toe Thigh length with silicone top-ban, open toe Thigh length with silicone top-ban, close toe Compression class 3 (ccl 3) = 25 35mmHg Below knee, open toe Thigh length with silicone top-ban, open toe both complications of palliative oeema. Compression can form part of exercise routines, where light compression in particular can help with muscle strength an tone an, more generally, with increase venous an lymphatic return (ILF, 2010). Crucially, responsibility for compression in palliative care shoul never be passe to the patient (ILF, 2010). En-of-life patients may fin removal of banages an garments ifficult an attempts to apply these moalities themselves coul result in physical harm such as islocation, fracture an skin tears (ILF, 2010), as well as psychological istress. Constant monitoring is vital, especially if the en-of-life patient is unable to communicate well. Hosiery The aim of compression hosiery is to control oeema by applying pressure evenly aroun the limb, thereby increasing the rate of venous return (Anerson, 2013). Active leg ulcers are usually controlle with the higher pressures of compression banaging, an maintaine once heale in RAL grae hosiery to reuce recurrence rates (Dowsett, 2011). However, once ulcers have heale, patients are often prescribe compression hosiery, which provies lower levels of compression, to maintain the heale state. Prouct coe DT511/1-5 (S-XXL) DT512/1-5 (S-XXL) DT611/1-5 (S-XXL) DT612/1-5 (S-XXL) DT521/1-5 (S-XXL) DT522/1-5 (S-XXL) DT621/1-5 (S-XXL) DT622/1-5 (S-XXL) DT532/1-5 (S-XXL) DT632/1-5 (S-XXL) Accoring to a Cochrane review of hosiery an patient concorance, higher rates of compression are more effective, but are rarely maintaine by patients (Nelson an Bell-Syer, 2012). The researchers also foun that any compression is better than none at all. Therefore, it is recommene that patients shoul wear the highest rate of compression hosiery they can tolerate, but the minimum shoul be a UK (British Stanar) Class 2 garment (Anerson, 2013). In the past, cosmetic consierations have playe a part in patient concorance with compression hosiery, with many proucts being bulky, cosmetically unappealing an ifficult to apply. As a result, manufacturers have evelope ifferent styles an colours an hosiery is available in a number of formats, incluing (Anerson, 2013): Below-the-knee garments Full-leg garments Socks. Manufacturers have also evelope a number of hosiery styles to make application easier, incluing inner an outer layers, an proucts that have zips. These formats represent an unerstaning by manufacturers an clinicians that patients affecte by mixe aetiology ulceration, mil venous isease, or palliative oeema at the en of life, nee compression hosiery that is easy to apply. uome soft uome soft is a new range of British Stanar compression hosiery that promotes patient comfort through the use of soft, sheer fabric. It has a silicone top-ban (Figure 1), which stops slippage an oes away with having to wear prescribe suspeners. Its soft fabric also gives it the look of a non-meical stocking, making it far more cosmetically acceptable to the patient. The range has a simple selection metho, so clinicians can easily choose the right size an option for their patients. JCN 2013, Vol 27, No 4 63

Figure 1. Silicone top-ban. Pe Figure 2. Below-knee uome soft. C ar e uome soft is available in a wie range of British Stanar sizes.

Other benefits of uome soft inclue: British Stanar elastic hosiery with a hypoallergenic silicone top-ban (Figure 1) available on W ou n uome soft combines ieal wearing properties an appropriate

PERFORMANCE INDICATORS uome soft is British Stanar grauate elastic compression hosiery, which is available on prescription.

5 Figure 1. Silicone top-ban. Pe Figure 2. Below-knee uome soft. C ar e uome soft is available in a wie range of British Stanar sizes. The knee-length stocking comes in both open- or close-toe versions (open-toe only for ccl3). Other benefits of uome soft inclue: British Stanar elastic hosiery with a hypoallergenic silicone top-ban (Figure 1) available on W ou n uome soft combines ieal wearing properties an appropriate British Stanar meical compression, while maintaining the look an feel of a non-meical stocking. The fabric is soft, sheer, comfortable an easy to apply, thus promoting patient concorance. PERFORMANCE INDICATORS uome soft is British Stanar grauate elastic compression hosiery, which is available on prescription. It is available in five sizes, an in below-knee or thighlength varieties (Figures 2 an 3). The thigh-length is the only British Stanar stocking with a grip top. op le Lt INDICATIONS uome soft is a roun-knit fabric inicate for mil venous conitions an palliative oeema. Specific inications for each class available inclue: Class 1: superficial varices or threa veins if RAL grae compression is too high for palliative limbs or mixe aetiology Class 2: varices or post healing of an ulcer when RAL grae compression cannot be tolerate Class 3: varices an the formation of moerate venous oeema. (uome soft shoul not be use in avance peripheral arterial occlusive isease or pre-gangrenous conitions. Caution shoul also be exercise in suppurative skin conitions, if the patient is intolerant to any component fabrics or in avance peripheral neuropathy.) 64 JCN 2013, Vol 27, No 4 Manufacturers have also evelope a number of hosiery styles to make application easier. all thigh-length garments Easy application, silky feel Open- or close-toe the open-toe variant comes with Easy-On Slipper Three compression classes (ccl 1, ccl 2, ccl 3) Below-knee an full thighlength available in all classes (Figures 2 3) Machine washable Latex-free Simple size selection Combines ieal wearing properties an appropriate British Stanar meical compression, while maintaining the look an feel of a nonmeical stocking Offers a seamless, two-way stretch stocking which is highly elastic an non-slip. Figure 3. Thigh-length uome soft. HOW TO USE uome soft shoul be worn uring the ay an remove at night. CONCLUSION The UK has an expaning elerly population, which means that in

Table 2: Sizes (circumference [cm]) (also, see Figure 4) Size S M L XL XXL cg thigh 42-57 48-64 54-71 60-78 66-85 cc calf 28-34 32-38 36-42 40-46 44-50 cb ankle 19-21 22-24 25-27 28-30 31-34 the

6 Table 2: Sizes (circumference [cm]) (also, see Figure 4) Size S M L XL XXL cg thigh cc calf cb ankle the future, community nurses an clinicians who work in communitybase units, such as nursing homes an hospices, will increasingly encounter age-relate conitions such as palliative oeema an mixe-aetiology ulceration. It is vital, therefore, that not only o these clinicians have the necessary knowlege, but that they also have access to the correct equipment to provie this population with evience-base care. uome soft provies a hosiery option that is not only easy to apply, making self-care more likely, but also consistent mil compression in a format that is cosmetically acceptable to patients. In the author s opinion, innovative proucts such as uome soft can help to promote patient concorance in an elerly population, Figure 4. uome soft circumferences. enabling more patients, who otherwise might not have tolerate the higher compression classes of RAL, to be care for at home. JCN REFERENCES Anerson I (2013) Compression hosiery to reuce leg ulcer recurrence. Nurs Times 109(6): Anerson I, King B (2006) Mixe aetiology ulcers. Nurs Times 102(16): 45, 47, Bager C, Mortimer PS, Regnar CFB (1988) Pain in the chronically swollen limb. Prog Lymphol 11: Dowsett C (2006) Fact file assessing mixe venous an arterial leg ulcers. Nurs Times 102(44): 58 Dowsett C (2011) Treatment an prevention of recurrence of venous leg ulcers using RAL hosiery. Wouns UK 7(1): Eberhart RT, Raffetto JD (2013) Chronic Venous Insufficiency. Available at: circ.ahajournals.org/content/111/18/2398. full (accesse 21 August, 2013) IlF (2010) The Management of Lymphoeema in Avance Cancer an Oeema at the En of Life. ILF, Lonon Ousey K, McIntosh C (2008) Lower Extremity Wouns: a problem-base learning approach. Wiley an Sons, Oxfor Nelson EA, Bell-Syer SEM (2012 Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev 8: CD Persoon A, Heinen MM, van er Vleuten CJ, e Rooij MJ, van e Kerkhof PC, van Achterberg T (2004) Leg ulcers: a review of their impact on aily life. J Clin Nurs 13(3): Posnett J, Franks PJ (2008) The buren of chronic wouns in the UK. Nurs Times 104(3): Scottish Intercollegiate Guielines Network (2010) Management of Chronic Venous Leg Ulcers: a national clinical guieline. SIGN, Einburgh. Available at: pf/sign120.pf (accesse 10 July, 2013) Stacey MC, Falanga V, Marston W, Moffatt CJ et al (2002) The use of compression therapy in the treatment of venous leg ulcers: a recommene management pathway. EWMA J 2(1): 9 13 KEY POINTS Compression therapy is a simple principle that, applie correctly, can have beneficial effects. Leg ulceration, of venous, arterial an mixe aetiology, is a significant problem in oler people. Oeema is a common complication of many conitions seen at the en of life. It is crucial that community clinicians unerstan the psychosocial element of compression therapy, where patients may fin it ifficult to ahere to long-term treatment ue to the commitment involve in banaging regimens, as well as cosmetic consierations. Manufacturers have evelope a number of hosiery styles to make application easier, incluing inner an outer layers, an proucts that have zips. This article looks at an innovative type of hosiery that provies grauate compression in a patient-frienly esign. uome soft provies a hosiery option that is not only easy to apply, making self-care more likely, but also mil compression in a format that is cosmetically acceptable to patients. Stevens J (2004) Diagnosis, assessment an management of mixe aetiology ulcers using reuce compression. J Woun Care 13(8): Worl Health Organization (2013) Palliative Care. WHO, Geneva. Available at: www. who.int/cancer/palliative/en/ (accesse 17 August, 2013) Williams A (2010) Issues affecting concorance with leg ulcer care an quality of life. Nurs Stan 24(45): Vowen P, Vowen K (2001) Doppler assessment an ABPI: Interpretation in the management of leg ulceration. Worlwie Wouns. Available at: www. worlwiewouns.com/2001/march/ Vowen/Doppler-assessment-an-ABPI. html (accesse 21 August, 2013) Worl Union of Woun Healing Societies (2008) Principles of Best Practice: compression in venous leg ulcers. A consensus ocument. MEP, Lonon JCN 2013, Vol 27, No 4 65

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