AMANDA PALMER discusses some of the major health issues experienced by our older clients and how these can impact on wound healing.
Where once a simple wound from a car door, coffee table or dog claw would heal easily, as a person ages there is an increased risk of delay and potential deterioration.
During the initial assessment of an older client with a wound, it is important not only to identify but also to actively consider how the following co-morbidities may impact on the potential progress of the wound.
Diabetes affects the ability of the body to manufacture insulin and can also mean it becomes resistant to insulin. This results in the altered ability to take up, store and utilise energy. The impact of diabetes on wound healing is complex and significant.
There is an increased likelihood of hyperglycaemia (high blood sugars) in people with significant wounds because the inflammatory response causes an increased rate of glucose production. Antibiotic use will also affect glycaemic control. Tight control of hyperglycaemia will reduce the risk of infection and promote healing.
When a person with diabetes has episodes of hyperglycaemia, damage is caused by processing the excess glucose. The result of this is delayed wound healing due to impaired angiogenesis (formation of new blood vessels), damage to nerves (neuropathy) and blood vessels (ischaemia) and poorly regulated cellular functions including phagocytosis (debris clearing) that not only break down dead tissue but start to damage the new developing tissues.
Nerve damage to the feet causes dry skin on the feet and lower legs increasing the risk of cracking and bacterial infection. It changes foot, toes and foot arch shape and changes the pressure points of the feet as a person walks. This results in movement of the fat pads that normally provide some protection against pressure damage and can lead to callus build up and trauma to areas of the foot not used to the change in weight and function. Sensory nerves alert the body to pain, heat, cold and touch. Damage to these nerves can lead to unrecognised trauma occurring i.e. burns, sharp objects stuck in foot and so on.
Altered pain sensations are often described as like burning or tingling, numbness, or like wearing a thin sock, sharp jabbing pain, extreme sensitivity, skin, hair and nail changes. Neuropathy can disguise the symptoms of infection and inflammation or ongoing trauma because the brain does not receive the appropriate nerve triggers.
Ischaemia means a reduced blood supply to the tissues. This results in nerve and tissue damage and ultimately death. A person with ischaemia in the feet and lower legs will experience pain due to lack of oxygen. This is noticeable when demand increases, such as walking, elevating the foot, lying in bed. The lack of an adequate blood supply will make healing wounds more complex and in extreme cases impossible because of poor oxygen levels and reduced nutrient availability to cells.
Ischaemic wounds are at high risk of infection due to the reduced ability of the immune system to respond to bacteria. Gangrene and other rapidly developing infections can quickly become life or limb threatening. Ischaemic feet can be purple when dependent and requires urgent intervention to improve the blood supply. Ischaemic limbs also get pale and cold on elevation; toenails and hairs stop growing. Palpation of the foot pulse is an indication of blood flow, but will not necessarily mean the flow is sufficient for effective wound healing or compression bandages or hosiery.
Renal or liver disease
These affect the homeostasis within the body by affecting nutrient use and metabolism, haemoglobin levels and blood pressure, all of which will have an effect in wound healing. Renal failure in people with diabetes results in a significant rate of lower leg ulceration and amputation due to ischaemia. Even with successful re-vascularisation the amputation rate can be more than one in three people.
Systemically obesity is associated with the development of heart disease, arthrosclerosis, type 2 diabetes, cancer, hypertension, dyslipidemia, stroke respiratory problems, low iron and reduced haemoglobin production resulting in reduced oxygenation of tissues. At a local level there is increased pressure ulcer risk due to hypovascularity (reduced blood supply). Poor perfusion in subcutaneous adipose tissue and reduced mobility increases the risk of pressure injury development and infection.
Breakdown of surgical wounds is caused by increased tension on the wound edges causing micro-ischaemia. Skin folds harbour bacteria due to the warm moist environment and allow normal skin flora to become problematic. Friction and shear results in skin breakdown. The adipose tissue secretes adipokines that negatively influence the systemic immune system and therefore wound healing. There is an increased risk of haematoma formation and venous leg ulcer formation. Weight loss can reverse many of these factors.
Increasing age is not a risk factor for wound healing but is associated with an increased likelihood of disease processes, multiple medications, malnutrition, reduced mobility and lifestyle issues that could be significant. Age is associated with reduced collagen production that affects skin’s elasticity and structure. Older skin becomes less able to hold moisture and dries more readily, leading to cracking and therefore increased infection risk.
Over time sun damage causes thinning of the epidermis, resulting in skin that blisters, tears and grazes more easily. There is also an increase of pre-cancerous skin changes and skin cancer (basal cell or squamous cell carcinoma) development that can initially appear as areas of dermatitis, eczema or small ulcers.
These include around 80 diseases, including cancer, lupus, scleroderma, rheumatoid arthritis, diabetes, Crohn’s disease, eczema, endometriosis, Grave’s disease, multiple sclerosis, psoriasis, vasculitis and so on. These diseases arise from an abnormal immune response of the body against substances and tissues normally present in the body. Typical treatment is with immunosuppressing medications.
These diseases are often complex, with both the disease and its treatment adversely affecting wound healing – the most significant of which is the chronic state of activity of neutrophils and leukocytes that cause tissue damage.
These diseases include heart attack (MI), stroke (CVA), angina, heart surgery, trans-ischaemic attack (TIA) and congestive heart failure. These result in an inefficient heart pump, compromising pressure in the lower extremities making venous return problematic. This results in oedema and venous ulcers. Arthrosclerosis/ arteriosclerosis/ peripheral vascular disease causes blockages, narrowing and hardening of the arteries and ischaemia. Regular exercise of 30 minutes a day, which includes pushing through the pain – i.e. walking a further 10–20 steps beyond when the pain starts – and quitting smoking has been demonstrated to improve the blood supply in around two to three months.
Deep vein thrombosis
DVT causes long-term complications including pain, swelling and heaviness, lipodermatosclerosis, venous hypertension and ulceration. At five years post DVT most people will show signs of post-thrombotic syndrome, spider veins, varicose veins, oedema, pigmentation, lipodermatosclerosis or ulceration. There might not be a known episode of DVT but incidents of surgery or significant lower limb injury can result in a DVT forming that resolves without apparent issue at the time.
It is not necessarily possible to influence the impact of chronic disease on wound healing, but by recognising it and understanding its influence the management of wounds can be better tailored to the individual’s needs. Attention to factors such as infection, mobility and diet can have a significant impact on the overall outcome.
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