Aging Changes that Increase the Risk of Wounds and Decrease Wound Healing. Joan Chang, DO Center for Healthy Aging

Transcription

1 Aging Changes that Increase the Risk of Wounds and Decrease Wound Healing Joan Chang, DO Center for Healthy Aging

2 BACKGROUND/BIO Medical school- Philadelphia College of Osteopathic Medicine Internal medicine Good Samaritan Hospital in Baltimore, Maryland Geriatric Johns Hopkins School of Medicine Board certified in Geriatric Medicine, and Hospice and Palliative Care 2

3 DISCLOSURE None 3

4 Goals 1. Understand changes in aging skin 2. Understand comorbidities that can lead to chronic wound 3. Recognize palliative wound

5 5 CASE 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.

6 Changes in Aging Skin 3 19 year old skin 74 year old skin 4 Thinning of the epidermis Flattening of the dermal-epidermal junction Disorganization of collagen and elastin Adapted from Nagwa et al Ind J Derm 2012: 57 (3);

7 7 Changes in Aging Skin

8 Changes in Aging Skin Intrinsic vs Extrinsic factors 8

9 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

10 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) Levine,J. Pressure Ulcers and Wound Care Geriatrics Review Syllabus. Ed. Samuel C. Durso, Ed.Gail M Sullivan. American Geriatrics Society, 2016 (9th edition), 10

11 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 Levine,J et al. Wound healing in the geriatric population. Today s Wound Clinic. Nov/Dec Photo aging 11

12 Extrinsic Changes in Aging Skin Cigarette Smoke (CS) has over 4,000 chemicals including prooxidants, 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 Levine,J. Pressure Ulcers and Wound Care Geriatrics Review Syllabus. Ed. Samuel C. Durso, Ed.Gail M Sullivan. American Geriatrics Society, 2016 (9th edition), 12

13 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 13 hypoalbuminemia Levine,J. Pressure Ulcers and Wound Care Geriatrics Review Syllabus. Ed. Samuel C. Durso, Ed.Gail M Sullivan. American Geriatrics Society, 2016 (9th edition),

14 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 Levine,J. Pressure Ulcers and Wound Care Geriatrics Review Syllabus. Ed. Samuel C. Durso, Ed.Gail M Sullivan. American Geriatrics Society, 2016 (9th edition), 14

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

16 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 16

17 Pressure Ulcer before Death in Advanced Dementia Mitchell et al. The clinical course of advanced dementia. New England Journal of Medicine 361: p ;

18 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 18 Mengell, C. Improving practice in wound care for patients with dementia.. Nurs Times Sep 21-27;100(38):29

19 Skin and Dying Process Skin changes at EOL Reduce tissue perfusion Decrease tolerance to external insult Impaired removal of metabolic waste 19 Communication among members of team and patient s circle of care Expectation of EOL goals Discussion of SCALE Sibald et al. SCALE: Skin Changes at Life s End Final Consensus Statement: Oct Advances in Skin & Wound Care: May Volume 23 - Issue 5 - p

20 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 20

21 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 21

22 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 Alvarez, OM et al, Incorporating wound healing strategies to improve palliation, J Palliat Med Oct;10(5):

23 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) 23

24 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. 24

25 Reference 1. Alvarez, OM et al. Incorporating wound healing strategies to improve palliation in patients with chronic wounds. J Palliat Med Oct;10(5): Gould, L, et al. Chronic Wound Repair and healing in Older Adults: Current Status and Future research. J Am Geriatric Soc Mar;63(3): Levine, J, et al. Wound healing in the geriatric population. Today s Wound Clinic. Nov/Dec 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 Sep 21-27;100(38): Mitchell, S, et al. The clinical course of advanced dementia. New England Journal of Medicine 2009; 361: p Nagwa, et al Ind J Derm 2012: 57 (3); Sibbald et al. SCALE: Skin Changes at Life s End Final Consensus Statement: Oct Advances in Skin & Wound Care May;23(5):